Follow-Up Activities for Product-Related Injuries-Interviews

NEISS TV Tipovers for Children Younger than Five

Questionnaire # ________ (1-4)

Q.1 Interviewer: Instructions to the interviewer are in bold blue text.
Please do not read "Don't Known/Unknown" choices unless instructed to read the choices.
Please do not read "Refused" choice on any question.

Q.2 Interviewer: Please enter Task Number
__________________________

Q.3 Contact Questions

(5-17)

Q.4 Hello, may I speak with the parent or guardian of __________?
I'm calling for the Consumer Product Safety Commission. We are presently performing a study on
childhood television tipovers. I understand that (Victim's Name) was in an accident involving a
television and would like to ask you some questions about the accident.
Interviewer:
Be prepared to answer/assure with the following:
- that the identity will be kept confidential
- that the purpose of the study is to prevent future incidents and injuries
- there is a particular interest in the circumstances surrounding the childhood TV tipover
(18)

 1 Agreed
 2 Refused
[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 88]

Q.5 Do you know how this incident happened?
[REQUIRE ANSWER]
(19)

 1 Yes
 2 No
 3 Refused
[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 11]

Q.6 Is there someone else who knows more about the details of the incident?
[REQUIRE ANSWER]
(20)

 1 Yes
 2 No
 3 Refused
[S - IF THE ANSWER IS 2 OR 3, THEN SKIP TO QUESTION 88]

Q.7 Is he/she available?
[REQUIRE ANSWER]
(21)

 1 Yes
 2 No
 3 Refused
[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 4]
[S - IF THE ANSWER IS 3, THEN SKIP TO QUESTION 88]

Q.8 Record name and phone number if different.
___________________________________________________________________________________

(22-71)

Q.9 When would be a good time to contact him/her?
[REQUIRE ANSWER]
__________________________________________________________________________________

(72-121)

[D - IF THE ANSWER TO QUESTION 7 IS 2, THEN SKIP TO QUESTION 88]

Q.10 TV Tipover Scenario Questions

Q.11 Please give a brief summary of the reason for the emergency room visit.
Interviewer: Please probe for the following information if they fail to mention it in their
summary
- TV involvement in incident or injury
- Prompt for injury and treatment given
- Specify the primary body part injured
[REQUIRE ANSWER]
________________________________________________________________________________

(122-1121)

Q.12 Interviewer: If the incident did not involve a television, end the interview.
[REQUIRE ANSWER]
(1122)

 1 Continue
 2 End the Interview
[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 87]

Q.13 What was the child doing prior to the incident?
[REQUIRE ANSWER]
_______________________________________________________________________________

(1123-1372)

Q.14 In what condition was the child found, after the TV fell?
Interviewer: Please probe for items such as
- Who found the child?
- Were they found under items such as the TV or furniture?
[REQUIRE ANSWER]
_______________________________________________________________________________

(1373-1622)

Q.15 What happened after the child was found?
Interviewer: Please probe for items such as
- Was child treated at home first?
- How long before child taken to the emergency room?
[REQUIRE ANSWER]
_______________________________________________________________________________

(1623-1872)

Q.16 Were any other children present when the incident occurred?
Interviewer: We are interested in finding out about children in the same room as victim
during the TV falling.
[REQUIRE ANSWER]
(1873)

1
2
3
4

Yes
No
Don't know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 18]

Q.17 What relationship were the other children to (name of victim) ?
Interviewer: Probe for ages of other children.
[REQUIRE ANSWER]
_______________________________________________________________________________

(1874-2123)

Q.18 What fell?
Interviewer:
What items/objects fell/tipped over during the incident. We are interested in finding out what
fell.
Instruction: Read choices except for Refused. Item did not have to strike the child.
[REQUIRE ANSWER]
(2124)

1
2
3
4
5

Television only
Television and furniture (other items could have fallen as well)
Television and other items (no furniture fell)
Television did not fall (End the interview)
Refused (End the interview)

[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 20]
[S - IF THE ANSWER IS 4 OR 5, THEN SKIP TO QUESTION 87]

Q.19 Please describe what other items fell?
[REQUIRE ANSWER]
_______________________________________________________________________________

(2125-2374)

Q.20 Which best describes the interaction of the child with the TV or furniture right before the TV or
furniture fell?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(2375)

1
2
3
4
5
6
7
8

Climbing on the TV or furniture
Pulling on the TV or furniture
Pushing on the TV or furniture
Pulling on Cords or Wires Attached to TV
Did not touch or interact with TV or furniture
Other interaction with TV or furniture
Don't Know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 5 OR 7 OR 8, THEN SKIP TO QUESTION 22]

Q.21 Please describe how the child interacted with the TV or furniture.
[REQUIRE ANSWER]
_______________________________________________________________________________

(2376-2625)

Q.22 Did anyone else touch or interact with the TV or furniture right before the TV or furniture fell?
[REQUIRE ANSWER]
(2626)

1
2
3
4

Yes
No
Don't Know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 26]

Q.23 Which best describes the interaction with the other person and the TV or furniture right before the
TV or furniture fell?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(2627)

1
2
3
4
5
6
7

Climbing on the TV or furniture
Pulling on the TV or furniture
Pushing on the TV or furniture
Pulling on Cords or Wires Attached to TV
Other interaction with the TV or furniture
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6 OR 7, THEN SKIP TO QUESTION 26]

Q.24 Please describe how the other person interacted with the TV or furniture.
[REQUIRE ANSWER]
_______________________________________________________________________________

(2628-2877)

Q.25 TV Specific Questions

Q.26 What type of television was involved in the incident?
Instruction: Read choices except for Refused.
Interviewer:
Flat screen deals with the curvature of the screen whereas newer flat panel deals with the
depth of the TV.
TUBE - CRT can also be flat screen, older TVs usually CRT.
Flat panel - usually the newer tvs which are thin in depth.
[REQUIRE ANSWER]
(2878)

1
2
3
4
5
6

Tube (CRT)
Flat panel (plasma, LCD)
Projection (rear projection)
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 5 OR 6, THEN SKIP TO QUESTION 28]

Q.27 Please describe the "other" type of television.
[REQUIRE ANSWER]
_______________________________________________________________________________

(2879-3128)

Q.28 What is the approximate screen size (measured diagonally) of the TV involved in incident?
Please specify units.
Interviewer: Height and width if the diagonal measurement is unknown.
[REQUIRE ANSWER]
_______________________________________________________________________________

(3129-3178)

Q.29 What is the approximate depth of the TV from the front of the screen to the back of the TV?
Interviewer: Don't read choices unless respondent is unsure, then interviewer could prompt.
Don't read the refused choice.
[REQUIRE ANSWER]
(3179)

1
2
3
4
5
6

Less than 6 Inches
6 inches to Less 12 inches
12 inches (1 Ft) to Less than 24 inches (2 Ft)
More than 24 Inches (2 Ft)
Don't Know
Refused

Q.30 What type of signal does the TV receive?
Interviewer: This is the signal the TV receives without any type of converter box.
[REQUIRE ANSWER]
(3180)

1
2
3
4

Analog
Digital
Don't Know
Refused

Q.31 What is the name brand of the TV involved in the incident?
[REQUIRE ANSWER]
_______________________________________________________________________________

(3181-3230)

Q.32 What is the Model and Model number?
[REQUIRE ANSWER]
_______________________________________________________________________________

(3231-3280)

Q.33 What is the approximate age of the TV?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(3281)

1
2
3
4
5
6

New or less than 1 year old
1 to less than 5 years old
5 to less than 10 years old
10 years or more
Don't know
Refused

Q.34 Which of the following best describes the base of the TV?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(3282)

1
2
3
4
5

Built-in swivel base (moves, turns)
Stationary Base (does not move)
Other
Don't Know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 4 OR 5, THEN SKIP TO QUESTION 36]

Q.35 Please describe the "other" type of base.
[REQUIRE ANSWER]
_______________________________________________________________________________

(3283-3382)

Q.36 Did the base of the TV itself break or fail in some way?
Interviewer: Asking about the base of the TV itself and not about a wall-mount or furniture
breaking.
[REQUIRE ANSWER]
(3383)

1
2
3
4

Yes
No
Don't know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 38]

Q.37 Please describe how the base of the TV broke or failed.
[REQUIRE ANSWER]
_______________________________________________________________________________

(3384-3633)

Q.38 Which location describes where the TV was located at the time of the incident?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(3634)

1
2
3
4
5
6
7

Living room or Family room or Den
Bedroom
Kitchen
Dining room
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6 OR 7, THEN SKIP TO QUESTION 40]

Q.39 Please describe the "other" location.
[REQUIRE ANSWER]
_______________________________________________________________________________

(3635-3734)

Q.40 About how high was the television positioned measured from the floor to the bottom of the
television? Please specify units of measurement.
[REQUIRE ANSWER]
_______________________________________________________________________________

(3735-3784)

Q.41 TV Placement/Mount Questions

Q.42 Which describes the placement of the TV in the room prior to the incident?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(3785)

1
2
3
4
5

Freestanding (inside or on furniture, on the floor or countertop)
Wall-mounted (on the wall or some type of mount)
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 4 OR 5, THEN SKIP TO QUESTION 44]
[S - IF THE ANSWER IS 2, THEN SKIP TO QUESTION 49]

Q.43 Please describe the "other" type of placement.
[REQUIRE ANSWER]
_______________________________________________________________________________

(3786-4035)

Q.44 Prior to the incident was the TV
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(4036)

1
2
3
4
5
6
7

Inside of furniture (such as an entertainment center, cabinet, etc.)
On top of furniture (such as a tv stand, dresser, etc.)
On the floor
On a countertop
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2, THEN SKIP TO QUESTION 57]
[S - IF THE ANSWER IS 3, THEN SKIP TO QUESTION 70]
[S - IF THE ANSWER IS 4, THEN SKIP TO QUESTION 47]
[S - IF THE ANSWER IS 6 OR 7, THEN SKIP TO QUESTION 72]

Q.45 Please describe other.
[REQUIRE ANSWER]
_______________________________________________________________________________

(4037-4286)

Q.46 Interviewer: Was the "other" a type of furniture?
[REQUIRE ANSWER]
(4287)

 1 Yes (go to furniture section)
 2 No
[S - IF THE ANSWER IS 1, THEN SKIP TO QUESTION 57]

Q.47 Did the item the TV was in or on break or fail in some way?
[REQUIRE ANSWER]
(4288)

1
2
3
4

Yes
No
Don't know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 72]

Q.48 Please describe how it broke or failed.
[REQUIRE ANSWER]
_______________________________________________________________________________

[D - IF THE ANSWER TO QUESTION 47 IS 1, THEN SKIP TO QUESTION 72]

(4289-4538)

Q.49 Before the incident, what type of wall mount was the TV attached to
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(4539)

1
2
3
4
5
6
7

Fixed against the wall (does not tilt, extend or articulate from wall)
Against the wall but can swivel and tilt from wall
Fixed shelf attached to wall (does not swivel)
Swivel shelf attached to wall (angle can be adjusted)
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6 OR 7, THEN SKIP TO QUESTION 51]

Q.50 Please describe the "other" type of wall mount.
[REQUIRE ANSWER]
_______________________________________________________________________________

(4540-4789)

Q.51 Please specify the brand name of the wall mount.
Interviewer: If brand name is unknown, where purchased? Please state "purchased at
(retailer)" in answer.
[REQUIRE ANSWER]
_______________________________________________________________________________

(4790-5039)

Q.52 What type of material is the mount made from?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(5040)

1
2
3
4
5
6
7

All Metal
All Plastic
Combination of Metal and Plastic
Wood
Other
Don't Know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6 OR 7, THEN SKIP TO QUESTION 54]

Q.53 Please describe the "other" type of material mount made from.
[REQUIRE ANSWER]
_______________________________________________________________________________

(5041-5290)

Q.54 Did the mount break or fail in some way?
[REQUIRE ANSWER]
(5291)

1
2
3
4

Yes
No
Don't know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 72]

Q.55 How did it break or fail?
[REQUIRE ANSWER]
_______________________________________________________________________________

(5292-5541)

[D - IF THE ANSWER TO QUESTION 54 IS 1, THEN SKIP TO QUESTION 72]

Q.56 Furniture Questions
Q.57 What type of furniture was the TV placed in or on during the incident?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(5542)

1
2
3
4
5
6
7

Entertainment Center
TV stand or cart
Dresser or Chest of Drawers or Bureau
Shelving or Bookcase or Cabinet
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 6 OR 7, THEN SKIP TO QUESTION 59]

Q.58 Please describe the "other" type of furniture.
[REQUIRE ANSWER]
_______________________________________________________________________________

(5543-5792)

Q.59 What is the brand name of the furniture?
Interviewer: If brand name is unknown, where purchased? Please state "purchased at
(retailer)" in answer.
[REQUIRE ANSWER]
_______________________________________________________________________________

(5793-5842)

Q.60 What is the model and model number?
[REQUIRE ANSWER]
_______________________________________________________________________________

(5843-5892)

Q.61 Was the furniture stationary or can it move due to having wheels?
[REQUIRE ANSWER]
(5893)

1
2
3
4
5

Stationary
Wheels
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 4 OR 5, THEN SKIP TO QUESTION 63]

Q.62 Please describe the "other" type of movement of the furniture.
[REQUIRE ANSWER]
_______________________________________________________________________________

(5894-6143)

Q.63 Did the furniture fail or break in some way?
[REQUIRE ANSWER]
(6144)

1
2
3
4

Yes
No
Don't know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 65]

Q.64 How did the furniture break or fail?
[REQUIRE ANSWER]
_______________________________________________________________________________

(6145-6394)

Q.65 What type of surface was the furniture on?
Instruction: Read choices except for Refused.
[REQUIRE ANSWER]
(6395)

1
2
3
4
5
6
7
8
9

Carpeting
Hardwood
Tile
Lineoleum
Rug on carpet
Rug on hard surface (hardwood, tile, or lineoleum)
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 8 OR 9, THEN SKIP TO QUESTION 67]

Q.66 Please describe the "other" type of surface the furniture was on.
[REQUIRE ANSWER]
_______________________________________________________________________________

(6396-6495)

Q.67 Were there any anti-tipping or safety devices as part of the television or installed with the furniture?
[REQUIRE ANSWER]
(6496)

1
2
3
4

Yes
No
Don't know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 74]

Q.68 Please describe the types of devices installed?
[REQUIRE ANSWER]
_______________________________________________________________________________

[D - IF THE ANSWER TO QUESTION 67 IS 1, THEN SKIP TO QUESTION 74]

Q.69 General TV Tipover Questions

(6497-6746)

Q.70 What type of surface was the TV on?
Instruction: Read choices except for Refused.
(6747)

1
2
3
4
5
6
7
8
9

Carpeting
Hardwood
Tile
Lineoleum
Rug on carpet
Rug on hard surface (hardwood, tile, or lineoleum)
Other
Don't know
Refused

[S - IF THE ANSWER IS 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 8 OR 9, THEN SKIP TO QUESTION 72]

Q.71 Please describe the "other" type of surface the TV was on.
_______________________________________________________________________________

(6748-6847)

Q.72 Was there any anti-tipping or safety devices as part of the television?
[REQUIRE ANSWER]
(6848)

1
2
3
4

Yes
No
Don't Know
Refused

[S - IF THE ANSWER IS 2 OR 3 OR 4, THEN SKIP TO QUESTION 74]

Q.73 Please describe the types of devices installed.
[REQUIRE ANSWER]
_______________________________________________________________________________

(6849-7098)

Q.74 Have there been any other incidents with this TV tipping or falling? If so, please describe briefly
how many incidents and what happened in each incident.
[REQUIRE ANSWER]
_______________________________________________________________________________

(7099-8098)

Q.75 Is there anything else about the incident that the CPSC should know about?
_______________________________________________________________________________

Q.76 Victim Specific Questions

(8099-9098)

Q.77 I'm now going to ask some information about
What was

(Victim's Name)

(Victim's Name)

.

's age in months at the time of the accident?

Interviewer: Please be as accurate as you can. Developmentally, a two-year old child who
is 24 month-old is different from a 2 year-old child who is 35 months-old.
[REQUIRE ANSWER]
_______________________________________________________________________________

(9099-9148)

Q.78 Please give their height at the time of the incident.
Interview: Please be sure to ask and capture the units for the measurement.
[REQUIRE ANSWER]
_______________________________________________________________________________

(9149-9198)

Q.79 Please give the weight at the time of the incident.
Interview: Please be sure to ask and capture the units for the measurement.
[REQUIRE ANSWER]
_______________________________________________________________________________

Q.80 How long was

(Victim's Name)

(9199-9248)

under medical care specifically after the accident?

Interviewer: Probe for whether they were hospitalized, required rehabilitation, or periodic
check-ups/follow-up visits.
[REQUIRE ANSWER]
_______________________________________________________________________________

Q.81 What is the long term medical outlook for

(Victim's Name)

(9249-9748)

?

[REQUIRE ANSWER]
_______________________________________________________________________________

(9749-9998)

Q.82 Due to the cultural diversity in the United States, we sometimes have difficulty
communicating
important product safety information to consumers. The following race and ethnicity
questions
will help us better focus our outreach and education efforts related to consumer product
safety.
OMB defines Hispanic or Latino as "a person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin regardless of race.

Q.83 Do you consider yourself to be Hispanic or Latino?
(9999)

1
2
3
4

Yes
No
Don't know
Refused

Q.84 Race categories as defined by the Census 2000:
"White" refers to people having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
"Black or African American" refers to people having origins in any of the Black racial groups
of Africa.
"Asian" refers to people having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent.
"American Indian or Alaska Native" refers to people having origins in any of the original
peoples of North or South America (including Central America), and who maintain tribal
affiliation or community attachment.
"Native Hawaiian or Other Pacific Islander" refers to people having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Q.85 Interviewer: Please read race choices aloud and ask respondent to select ALL categories
that
apply. If respondent replies with anything other than the first 5 categories, select "Other" and
in next question, enter their answer verbatim.
What race or races do you consider yourself to be?
(10000-10005)

1
2
3
4
5
6
7
8

White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Don't know
Refused

[S - IF THE ANSWER IS NOT 6, THEN SKIP TO QUESTION 87]

Q.86 Please specify "other" race.
Interviewer: if respondent states 'biracial' or 'multiracial', please prompt for specifics (country
of origin, nationality, etc.) Otherwise, simply state 'biracial' or 'multiracial'.
_____________________________________________________________________________

(10006-10105)

Q.87 On behalf of the Consumer Product Safety Commission, I would like to thank you for your
cooperation during this interview. If we need to follow-up on this interview, would it be alright for us to
get back in touch with you?
[REQUIRE ANSWER]
(10106)

 1 Yes
 2 No
 3 Refused

Q.88 Thank you for your time.
Interviewer: End Interview

Q.89 Interviewer: What is the date this interview was completed (MMDDYY)?
MMDDYY ..........

____________ (10107-10112)