Follow-Up Activities for Product-Related Injuries-Interviews

Fireworks

Questionnaire # ________

U.S. Consumer Product Safety Commission
2019 Fireworks Study
Patients Treated 6/21/19 - 7/21/19
Before contacting the victim, please review the NEISS emergency room information on the assignment
cover sheet. Information about the type of firework (e.g., firecracker, Roman Candle, sparkler, mortar,
etc.) should be found in the comment area.
If victim is under the age of 18, ask for parent or guardian. If victim is 18 or older, interview him/her
directly.
Text in BOLD contains instructions to the interviewer and should not be read to the respondent.
Record all responses to open-ended questions in the space provided. Try to record responses as close to
verbatim as possible. If respondent doesn't know the answer, record "Don't know" or "DK." If the question
is not applicable in a given case, record "N/A."
If you have any questions, please call:
Yongling Tu (301) 504-7841

Q.1 Before beginning interview, please enter the tkno (task number).
__________________________

Q.2 Before beginning interview, please fill in the following question based on victim information
given:
Is victim 16 years old or older?
Yes
No

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Q.3 Contact questions
Hello. May I speak with ______________? (OR: Hello. May I speak with the parent or guardian of
_______?)
Hello. I am calling for the U.S. Consumer Product Safety Commission. In cooperation with (hospital
name) we're conducting a study on fireworks injuries to try to reduce the number and severity of such
injuries. Will you help us by answering some questions about the fireworks injury that happened to
you/(victim's name) recently? It will take about 20 minutes. Your participation is voluntary and your
answers will be strictly confidential.
Did I reach you on a cell phone?
Yes
No

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Yes
No

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Q.4 Is it safe to talk with you now?

Q.5 The person responding is: To be filled in by caller
The victim
Parent or Guardian of injured person
Other

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Q.6 Please specify "Other" respondent.
__________________________________________________________________________________________

Q.7 Did you witness the incident?
Yes
No

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Q.8 How did you find out about the incident?
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.9 Did the injury occur on the job or in connection with [your/the victim's] employment?
Yes
No

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Q.10 Read the following before asking the question: The next few questions ask about the actual
fireworks incident. This information is very valuable in preventing injuries from happening again;
your answers are strictly confidential.
In your own words, please tell me how the incident happened. Include what happened just before
the incident.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.11 Please describe [your/the victim's] injury in your own words.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.12 Were [you/the victim] admitted to the hospital because of this injury?
Yes
No
Don't know

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Q.13 How long was the hospital stay? (days)
__________________________________________________________________________________________

Q.14 After discharge from the hospital, did [you/the victim] require any additional visits to the hospital or a
doctor to treat the fireworks injury?
Yes
No
Don't know

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Q.15 After the emergency room visit, did [you/the victim] require any additional visits to the hospital or a
doctor to treat the fireworks injury?
Yes
No
Don't know

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Q.16 Was the purpose of the return visit(s) to: Read the list, select ALL that apply.
Change the bandage or dressing.
Remove stitches or a cast.
Surgery.
Some other reason
Don't know

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5

Q.17 Please specify "Other Reason for Return Visit"
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.18 Have [you/the victim] fully recovered from the injury?
Yes
No
Don't know

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Q.19 How long did it take to recover from the injury? (Please record units of measurement along with
numeric value, e.g., months, years)
__________________________________________________________________________________________

Q.20 How long from the injury will it take to fully recover? (Please record units of measurement along
with numeric value, e.g., months, years)
__________________________________________________________________________________________

Q.21 How much time will be lost from work or school as a result of this injury? (Please records units of
measurement along with numeric value, e.g., years, months, days)
__________________________________________________________________________________________

Q.22 Please describe any long-term effect of the injury, including any permanent loss of function or
activity restriction.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.23 Where did the incident take place? Read the list.
Yard
Porch or deck
Street
Open field
Other
Don't know

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Q.24 Please specify "Other incident location".
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.25 At about what time of day did the incident take place? Leave blank if unknown.
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.26 Were [you/the victim] injured at a public fireworks display, for example, a fireworks show put on by
your city or town?
Yes
No
Don't know

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Q.27 Were [you/the victim] injured by the public display itself or by fireworks that were being used by other
spectators? Read the list.
The public display fireworks
Fireworks that you or other spectators used
Other
Don't know

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Q.28 Please specify "Other" cause of injury.
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.29 Please describe the public display firework that injured you in as much detail as you can recall.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.30 Were [you/the victim]: Read the list.
Injured by fireworks that were lit by someone else
Using or lighting the fireworks that caused the injury
Other
Don't know

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Q.31 Please specify "Other" (identity of victim in relation to person who lit firework)
__________________________________________________________________________________________

Q.32 Was the person who lit the firework that caused the injury younger than 18?
Yes
No
Don't know

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Q.33 How old was that person? (in years)
________________________________________

Q.34 Was the person who lit the fireworks?: Read the list.
18 to 25 years old?
25-64 years old?
Age 65 or over?
Don't know

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Q.35 Do you think that the fireworks was thrown or aimed at or near [you/the victim] on purpose?
Yes
No
Don't know

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Q.36 Did the fireworks do what [you/the victim] expected it to do?
Yes
No
Don't know

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Q.37 What did the firework do that was unexpected?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.38 Were [you/the victim] injured by a firecracker, a device intended to produce a "bang" on the ground,
but which doesn't move?
Yes
No
Don't know

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Q.39 Was it:

Read the list.

An M-80
An M-500
An M-1000
A Silver Salute
A quarter stick
A half stick
A tennis ball bomb
A bird banger or rope salute
A large firecracker larger than 1/4 inch in diameter and 1.5 inches in length with no warning or brand name labeling
A small firecracker about 1/4 to 1/2 inch in diameter, sold in strips, bundles, or in bags with warning and brand name
labels
Other
Don't know

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5
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7
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9
10
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12

Q.40 Please specify "Other" firecracker type.
__________________________________________________________________________________________

Q.41 Were you injured by:

Read the list.

A Roman Candle (a candle shaped device that fires colored balls and makes small explosions)
A rocket or bottle rocket (a 1/4" to 1" diameter firework attached to the top of a stick, which flies like a missile after
lighting).
A sparkler (a stick 9 to 36 inches long that emits sparks after lighting)
A pest control or wildlife control device (a device like a large firecracker sold to control birds and other wildlife)
A multiple tube device, "cake" or multiple shot repeater (a cluster of tubes which each shoot firework into air)
A "reloadable" mortar or aerial shell device (at least one mortar tube and 6 or more shells)
A fountain type firework (cone or cylinder which emits a shower of sparks into air)
Other
Don't know

Q.42 Please specify "Other" firework type.
__________________________________________________________________________________________
__________________________________________________________________________________________

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7
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9

Q.43 Please describe the fireworks in as much detail as you can recall.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.44 What brand were the fireworks?
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.45 Did you see the label on the fireworks or the package of fireworks?
Yes
No

Q.46 Did the label or package have the words:

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Read the list.

Consumer Display
Professional
Novelty
Other
Don't know

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Q.47 Please describe "Other" package labeling.
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.48 Were there any other markings on the label or the package? Please describe.
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.49 The following questions ask about the source of the fireworks. If the person being
interviewed has admitted to have used or lit the fireworks in a prior question, then use "you"
in these questions; otherwise, use "the person who lit the fireworks."
Please read: The next few questions ask where the fireworks that caused the injury were obtained.
The U.S. Consumer Product Safety Commission is trying to find out as much as possible about how
people obtain fireworks that cause injuries. This information is very valuable in preventing injuries
like [yours/victim's] from happening again. Your answers are strictly confidential.
How did [you/the person who lit the fireworks] get them? Was it from:
Read the list.
A friend or relative
A stand that only sells fireworks
A store
Mail order
Internet
Somewhere else
Don't know

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7

Q.50 Please specify web site address.
______________________________________________________________________

Q.51 Please specify "somewhere else" where fireworks were purchased.
__________________________________________________________________________________________

Q.52 Please give us as many details as you can about where the fireworks were obtained, including the
name of the business, street address, town, or city.
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.53 Do you know how many were purchased?
Yes
No

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Q.54 How many?
__________________________________________________________________________________________

Q.55 Do [you/the person who lit the fireworks] have any more of these fireworks?
Yes
No
Don't know

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Q.56 How many?
__________________________________________________________________________________________

Q.57 Did [you/the person who lit the fireworks] get the impression that the fireworks were legal or illegal?
Got the impression that they were legal
Got the impression that they were not legal
Did not get any impression

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Q.58 What information was provided about whether the fireworks were legal or illegal?
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.59 How was this information provided? Read the list.
I/the person was told at the place where the fireworks were obtained
It was in the catalog
It was on the web site
Other

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Q.60 Please specify "Other" information source (regarding legality of fireworks)?
__________________________________________________________________________________________

Q.61 Is there anything else that you think that we should know about the incident or the injury?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.62 Is it possible that alcohol or illegal drugs contributed to the accident?
Yes
No
Don't know

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Q.63 Please explain (how alcohol or drugs may have contributed to the accident).
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.64 The following race and ethnicity questions will help the U.S. Consumer Product Safety Commission
better focus its outreach and education efforts related to fireworks safety.
Are [you/the victim] Hispanic or Latino?
Yes
No
Don't know
Refused

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Q.65 What race or races do you consider yourself to be? Read the list and ask the respondent to
select ALL categories that apply. If the respondent replies "Other", you'll be prompted for a
verbatim answer.
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
Other
Don't know
Refused

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8

Q.66 Please specify "Other" race. If respondent states "biracial" or "multiracial" please prompt for
specifics (country of origin, nationality, etc). Otherwise, simply state "biracial" or "multiracial."
______________________________________________________________________

We appreciate your time. The information you have given us will be very helpful. Thanks again.
Goodbye.

Q.67 When would be a good time to contact you?
__________________________________________________________________________________________
__________________________________________________________________________________________

Q.68 What phone number should I use when I call you?
Thank you. Terminate call.
________________________

Thank you for your time.

Q.69 Date
__________________

Q.70 Duration
____________

Q.71 Interviewer
________