Follow-Up Activities for Product-Related Injuries-Interviews

Bicycle Study Survey - Contractors
Survey Flow
Standard: Start Block (1 Question)
Authenticator: Single Sign On - Token
EmbeddedData
hospnameValue will be set from Panel or URL.
injurydateValue will be set from Panel or URL.
tknoValue will be set from Panel or URL.
Standard: Introductory Block (5 Questions)
Standard: Item Verification Block (9 Questions)
Branch: New Branch
If
If Was the bicycle unpowered?Interviewer instruction: Powered bicycles have a power
source like electri Yes Is Selected
And Did the bicycle have pedals? Yes Is Selected
ElseIf
If Was the bicycle an electric powered bicycle? Yes Is Selected
And Did the bicycle have pedals? Yes Is Selected
ElseIf
If Was the bicycle a moped or motorcycle that is gas powered? Yes Is Selected
And Did the bicycle have pedals? Yes Is Selected
Standard: Incident Description Block (2 Questions)
Standard: Incident Block (13 Questions)
Standard: Bicycle Characteristics Block (14 Questions)
Branch: New Branch
If
If You/the victim were/was: Pedestrian struck by bicycle Is Selected
Standard: Pedestrian Block (3 Questions)
Block: Closing block (9 Questions)
Standard: Submit Message Block (1 Question)
Block: Closing block (9 Questions)
Standard: Submit Message Block (1 Question)
Block: Closing block (9 Questions)
Standard: Submit Message Block (1 Question)
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Start of Block: Start Block
Q1
Interviewer instructions: In this questionnaire, please read the response categories unless indicated
otherwise, or unless necessary for prompting the respondent to answer the question. Italicized words are
meant to serve as a guide to emphasis.
Hello, I'm_______________[interviewer's name] from ______________________ [interviewer's company].
We are working with the U.S. Consumer Product Safety Commission (CPSC). CPSC collects data through the
National Electronic Injury Surveillance System (NEISS) on injuries treated in hospital emergency
departments. In cooperation with the NEISS hospitals, CPSC conducts a follow-up investigation on a small
number of records to learn more about the circumstances of how the injury occurred. Results of the
investigations will be analyzed to determine if CPSC can reduce similar injuries from occurring in the future.
Your participation in this survey is completely voluntary and your identity and answers will be strictly
confidential. This survey will take between 10-15 minutes and data are used for statistical purposes only.
The following information is needed to continue:
1. Investigation Task Number
2. Randomly generated password
To continue, you will have to enter the task number correctly on the next page:

End of Block: Start Block
Start of Block: Introductory Block
I1
CPSC would prefer that the person who answers this questionnaire is the actual person injured and treated in
the hospital emergency department. If the injured person is under the age of 16, CPSC would prefer that a
parent or guardian completes the questionnaire.
Was the injured person 16 years old or older?
Interviewer instruction: If the respondent answers that they are the injured person and they are under 16,
please ask to speak to a parent or guardian. If no one is available, it is okay to interview the under 16 year old.

o Yes (1)
o No (2)

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I2 According to our records from the National Electronic Injury Surveillance System the injured person was
seen on ${e://Field/injurydate} in the emergency department at ${e://Field/hospname} for an injury that involved
a bicycle. Is that correct?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: End of Block If I2 = Don't know
Skip To: End of Block If I2 = Yes

I3 What information is incorrect from the statement above?

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(3)

Different date (1)
Different hospital (2)
(I/the victim) did not receive treatment in a hospital emergency department for a bicycle injury

Skip To: End of Survey If I3 = (I/the victim) did not receive treatment in a hospital emergency department for a bicycle
injury

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Display This Question:
If I3 = Different date

I4 What is the correct date?
________________________________________________________________

Display This Question:
If I3 = Different hospital

I5 Where did (you / the victim) receive treatment for (your / their) injury?
________________________________________________________________
End of Block: Introductory Block
Start of Block: Item Verification Block
V1 Respondent is:

o Injured person (1)
o Parent or guardian of injured person (2)
o Other (specify in the next window) (3)
Display This Question:
If V1 = Other (specify in the next window)

V2 Specify relationship:
________________________________________________________________

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Display This Question:
If V1 = Injured person
Or V1 = Parent or guardian of injured person
Or Or Specify relationship: Text Response Is Not Empty

V3 Was the bicycle unpowered?
Interviewer instruction: Powered bicycles have a power source like electric or gas

o Yes (1)
o No (2)
o Don't know (3)
Display This Question:
If V3 = No
Or V3 = Don't know

V4 Was the bicycle an electric powered bicycle?

o Yes (1)
o No (2)
Display This Question:
If V4 = Yes

V5 What was the wattage for the electric bicycle (electric bicycles usually range from 300 to 1000 watts)?
Enter a number or "don't know."
________________________________________________________________

Display This Question:
If V4 = No

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V6 Was the bicycle a moped or motorcycle that is gas powered?

o Yes (1)
o No (2)
Skip To: End of Block If V6 = Yes

Page Break

V7 Did the bicycle have pedals?

o Yes (1)
o No (2)
Page Break

V9 You/the victim were/was:

o Riding the bicycle (1)
o Pedestrian struck by bicycle (2)
o Other (specify) (3)
Display This Question:
If V9 = Other (specify)

Q21 Specify:
________________________________________________________________
Skip To: End of Block If Condition: Specify: Is Not Empty. Skip To: End of Block.

End of Block: Item Verification Block
Start of Block: Incident Description Block

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A1 Please describe how the accident happened. That is, what were you/the victim doing just before, during,
and just after the injury occurred? Please specify the location of the accident and any environmental factors;
such as weather, temperature, and anything else that may have contributed to the accident.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

A2 Next, I am going to ask some specific questions about the incident that you may have already described.
Please bear with us as we collect this information from you.
End of Block: Incident Description Block
Start of Block: Incident Block
A3 What was the surface?

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Paved Road (1)
Paved Sidewalk (2)
Gravel (3)
Grass (4)
Driveway (5)
Other (specify in next window) (6)

Display This Question:
If A3 = Other (specify in next window)

A3a Specify:
________________________________________________________________

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Page Break
Display This Question:
If A3 = Paved Road
Or A3 = Gravel
Or A3 = Driveway
Or A3 = Other (specify in next window)

A4a Were you/was the victim riding on a road?

o Yes (1)
o No (2)
Display This Question:
If A4a = Yes

A4b Were you on the shoulder of the road, in a bike lane, or in a lane that cars use?

o Shoulder (1)
o Bike Lane (2)
o Car Lane (3)
o Other (4)
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Display This Question:
If A3 = Paved Road
Or A3 = Gravel
Or A3 = Driveway
Or A3 = Other (specify in next window)

A4c Did the accident involve a motor vehicle?

o Yes (1)
o No (2)
Display This Question:
If A4c = Yes

A4d Did the accident happen at an intersection?

o Yes (1)
o No (2)
Display This Question:
If A4c = Yes

A4e Did the motor vehicle run you/the victim over?

o Yes (1)
o No (2)
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A5 Was it dark or difficult to see?

o Yes (1)
o No (2)
Page Break
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A6 Was the bicycle travelling uphill, downhill, or was it on a fairly level surface?

o Uphill (1)
o Downhill (2)
o Fairly level (3)
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A7 Was there anything else occuring at the time of the accident such as cell phone interference or loud music?

o Yes (1)
o No (2)
o Don't know (3)
Display This Question:
If A7 = Yes

A7a Please specify the additional factors.
________________________________________________________________

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A8 Were you/the victim carrying or holding something such as a bag, purse, or backpack?

o Yes (1)
o No (2)
o Don't know (3)
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Display This Question:
If A8 = Yes

A9 What were you carrying?
________________________________________________________________
End of Block: Incident Block
Start of Block: Bicycle Characteristics Block
Display This Question:
If A2 Displayed

S1 Which of the following best describes the bicycle?

o Rental (1)
o Owned by victim (2)
o Borrowed (3)
o Other (specify in next window) (4)
o Don't know (5)
Display This Question:
If S1 = Other (specify in next window)

S2 Specify:
________________________________________________________________

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Display This Question:
If S1 = Rental

S3 Who was the bicycle rented from?
________________________________________________________________

Page Break
Display This Question:
If S1 = Borrowed
Or S1 = Owned by victim
Or S1 = Don't know
Or Or Specify: Text Response Is Not Empty
Or Or Who was the bicycle rented from? Text Response Is Not Empty

S4 Do you know the brand and model names of the bicycle involved in the injury?

o Yes (1)
o No (2)
Skip To: S7 If S4 = No
Display This Question:
If S4 = Yes

S5 Specify brand:
________________________________________________________________

Display This Question:
If S4 = Yes

S6 Specify model (if brand is known but model is not, enter unknown below)
________________________________________________________________

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S7 It is very important for us to know what brands are involved in these injuries. If I hold on, would you be
willing/able to go look at the bicycle and tell me what the brand and model names are?

o Yes (1)
o No (2)
Skip To: S10 If S7 = No
Display This Question:
If S7 = Yes

S8 Specify brand
________________________________________________________________

Display This Question:
If S7 = Yes

S9 Specify model (if brand is known but model is not, enter unknown below)
________________________________________________________________

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Display This Question:
If If Specify model (if brand is known but model is not, enter unknown below) Text Response Is Not Empty
Or S4 = Yes
Or S7 = No

S10 I'm going to read a list of safety equipment that riders might wear. Please tell me if the rider was wearing
any of these at the time of the incident.

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Helmet (1)
Padding (such as knee pads, elbow pads, or wrist pads) (2)
Reflective vest (3)
Blinking lights/Head lamp (4)
Other (specify in next window) (5)
None of the above (6)

Display This Question:
If S10 = Other (specify in next window)

S11 Specify:
________________________________________________________________

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Display This Question:
If A2 Displayed

S12 Please estimate the speed at which the bicycle was travelling when the accident occurred in miles per
hour, your best guess is OK.
________________________________________________________________

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Display This Question:
If A2 Displayed

S13 How tall are you/ was the victim when the accident occurred (in feet and inches)? If you don’t know, just
provide your best estimate.
________________________________________________________________

Display This Question:
If A2 Displayed

S14 What did you/did the victim weigh when the accident occurred (in pounds)? If you don’t know, just provide
your best estimate.
________________________________________________________________
End of Block: Bicycle Characteristics Block
Start of Block: Pedestrian Block
A10 Which of the following best describes how you were injured?

o Hit from the front (1)
o Hit from the side (2)
o Hit from behind (3)
o Other (specify in next window) (4)
o Don't know (5)
Display This Question:
If A10 = Other (specify in next window)

A11 Specify:
________________________________________________________________

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A12 Was there any warning before you/the victim were/was hit? (ex. bell, shouting, or other noise)

o Yes (1)
o No (2)
o Don't know (3)
End of Block: Pedestrian Block
Start of Block: Closing block
C1 Is there anything else about this accident or the bicycle involved that you would like me to know?

o Yes (1)
o No (2)
Page Break
Display This Question:
If C1 = Yes

C2 Explain.
________________________________________________________________

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C3 The following race and ethnicity questions will help the U.S. Consumer Product Safety Commission better
focus outreach and education efforts related to bicycle safety.

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C4 Are [you/the victim] Hispanic or Latino?

o Yes (1)
o No (2)
o Don't know (3)
o Prefer not to answer (4)
C5 What race(s) do you consider yourself to be? Please check all that apply.

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White (1)
Black or African American (2)
American Indian or Alaska Native (3)
Asian (4)
Native Hawaiian or Pacific Islander (5)
Other (6)
Don't Know (7)
Prefer not to answer (8)

Display This Question:
If C5 = Other

C6 Please specify "Other" race. Please be as specific as possible.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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________________________________________________________________

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C7 We may be interested in sending a CPSC investigator to your home to gather more information about how
the accident occurred and take pictures of the bicycle. This investigation would be set up at your convenience.
May we have an investigator contact you by phone to setup a visit?

o Yes (1)
o No (2)
Skip To: End of Survey If C7 = No
Display This Question:
If C7 = Yes

C8 Please provide your phone number.
________________________________________________________________

Display This Question:
If C7 = Yes

C9 When is a good time to call? (Check all that apply.)

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Morning (1)
Afternoon (2)
Evening (3)

End of Block: Closing block
Start of Block: Submit Message Block
Q18 Interviewer Instructions: You have reached the end of the survey.
If you wish to come back and edit later, exit the survey by closing the browser window.
Click 'Submit' to complete the survey.
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Once you click submit, you will no longer be able edit responses.
End of Block: Submit Message Block

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