Follow-Up Activities for Product-Related Injuries-Interviews

Fireworks_Questionnaire_Contractor_E
PDS
Survey Flow
Standard: Start Block (1 Question)
Authenticator: Single Sign On - Token
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Block: Introduction (5 Questions)
Block: Default Question Block (68 Questions)
Standard: submit block (1 Question)
EndSurvey: Advanced
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Start of Block: Start Block
Q91
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. CPSC conducts follow-up
investigations with a small number of people to learn more about how the injury occured. The
results of these investigations will be used to determine if similar injuries can be prevented 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: Introduction
Q4
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 complete the questionnaire.
Was the person injured 16 years old or older?

o Yes (1)
o No (2)
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Q77 According to our records from the National Electronic Injury Surveillance System (you/your
child) was injured on ${e://Field/injurydate} and received treatment in the emergency
department at ${e://Field/hospname}. Is this correct?

o Yes (1)
o No (2)
o Don't know (4)
Skip To: End of Block If Q77 = Yes

Q78 What information is incorrect from the statement above?

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injury (3)

Different Date (1)
Different Hospital (2)
(I/my child) did not receive treatment in a hospital emergency department for an

Skip To: End of Survey If Q78 = (I/my child) did not receive treatment in a hospital emergency department
for an injury
Display This Question:
If Q78 = Different Date

Q79 What is the correct date?
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Display This Question:
If Q78 = Different Hospital

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Q80 Where did (you / your child) receive treatment for (your / their) injury?
Interviewer: If necessary, indicate that the question refers to medical institution.
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End of Block: Introduction
Start of Block: Default Question Block
Q6 The person responding is:

o The victim (1)
o Parent or guardian of the injured person (2)
o Other (3)
Skip To: Q10 If Q6 = The victim
Skip To: Q8 If Q6 = Parent or guardian of the injured person

Q7 Please Specify who "Other" is:
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Q8 Did you witness the incident?

o Yes (1)
o No (2)
Skip To: Q10 If Q8 = Yes

Q9 How did you find out about the incident?
Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Display This Question:
If Q4 = Yes

Q10 Did the injury occur on the job or in connection with [your / the victim's] employment?

o Yes (1)
o No (2)
Skip To: QID67 If Q10 = Yes

Q11
The next few questions will 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 describe how the incident happened. Include what happened just
before the incident.
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Q12 Please describe [your / the victim's] injury in your own words.
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Q13 Were [you / the victim] admitted to the hospital because of this injury?

o Yes (1)
o No (2)
o Don't Know (3)
Skip To: Q16 If Q13 = No
Skip To: Q16 If Q13 = Don't Know

Q14 How long was the hospital stay (in days)?
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Q15 After discharge from the hospital, did [you/the victim] require any additional visits to the
hospital or a doctor to treat the fireworks injury?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: Q17 If Q15 = Yes
Skip To: Q19 If Q15 = No
Skip To: Q19 If Q15 = Don't know

Q16 After the emergency room visit, did [you/the victim] require any additional visits to the
hospital or a doctor to treat the fireworks injury?

o Yes (1)
o No (2)
o Don't know (3)
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Skip To: Q19 If Q16 = No
Skip To: Q19 If Q16 = Don't know

Q17 Was the purpose of the return visit(s) to: select ALL that apply.

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Change the bandage or dressing (1)
Remove stitches or a cast (2)
Surgery (3)
Some other reason (4)
Don't know (5)

Skip To: Q19 If Q17 != Some other reason

Q18 Please specify "Other Reason for Return Visit"
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Q19 Have [you/the victim] fully recovered from the injury?

o Yes (1)
o No (2)
o Don't know (3)
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Skip To: Q21 If Q19 = No
Skip To: Q22 If Q19 = Don't know

Q20 How long did it take to recover from the injury?
Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Display This Question:
If Q19 = No

Q21 How long from the injury will it take to fully recover?

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Q22 How much time will be lost from work or school as a result of this injury?
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Q23 Please describe any long-term effect of the injury, including any permanent loss of function
or activity restriction.

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Q24 Where did the incident take place?

o Yard (1)
o Porch or deck (2)
o Street (3)
o Open field (4)
o House (7)
o Other (5)
o Don't know (6)
Skip To: Q26 If Q24 != Other

Q25 Please specify "Other incident location".
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Q26 At about what time of day did the incident take place?

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Q27 Were [you/the victim] injured at a public fireworks display, for example, a fireworks show
put on by your city or town?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: Q31 If Q27 != Yes

Q28 Were [you/the victim] injured by the public display itself or by fireworks that were being
used by another spectator?

o The public display fireworks (1)
o Fireworks that you or other spectators used (2)
o Other (3)
o Don't know (4)
Skip To: Q31 If Q28 = Fireworks that you or other spectators used
Skip To: Q31 If Q28 = Don't know
Skip To: Q30 If Q28 = The public display fireworks

Q29 Please specify "Other" cause of injury.
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Display This Question:
If Q28 = The public display fireworks

Q30 Please describe the public display firework that injured you in as much detail as you can
recall.

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Skip To: Q62 If Condition: Please describe the public ... Is Equal to. Skip To: Were [you/the victim]:.

Q31 Were [you/the victim]:

o Injured by fireworks that were lit by someone else (1)
o Using or lighting the fireworks that caused the injury (2)
o Other (3)
o Don't know (4)
Skip To: Q33 If Q31 = Injured by fireworks that were lit by someone else
Skip To: Q37 If Q31 = Using or lighting the fireworks that caused the injury
Skip To: Q37 If Q31 = Don't know

Q32 Please specify "Other"
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Skip To: Q37 If Condition: Please specify "Other" Is Equal to. Skip To: Was the person who lit the firework
t....

Q33 Was the person who lit the firework that caused the injury younger than 18?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: Q35 If Q33 = No
Skip To: Q36 If Q33 = Don't know

Q34 How old was that person? (in years)

Interviewer: Age at the time of the injury. Enter respondent answer as "I don't know." if answer is
unknown.
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Display This Question:
If Q33 = No

Q35 Was the person who lit the fireworks?

o 18 to 25 years old? (1)
o 26 to 64 years old? (2)
o Age 65 or over? (3)
o Don't know (4)
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Q36 Do you think that the fireworks were thrown or aimed at or near [you/the victim] on
purpose?

o Yes (1)
o No (2)
o Don't know (3)
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Q37 Did the fireworks do what [you/the victim] expected it to do?
Interviewer: If necessary, ask how the firework was supposed to be behave when the fuse was
lit. Then ask if the firework did was was expected.

o Yes (1)
o No (2)
o Don't know (3)
Skip To: Q75 If Q37 != No

Q38 What did the firework do that was unexpected?

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Q75 The next several questions will ask about the specific type of firework involved in the
incident. If needed, I can provide you with a brief description of firework types.
Interviewer: Use the descriptions below the graphics to read to respondent if the respondent is
unclear about firework type or requests assistance. Types A, B, C, and P describe firecrackers.
The rest describe other firework device types.

Q72

Q74

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Q39 Were [you/the victim] injured by a firecracker, a device intended to produce a "bang" on the
ground, but which doesn't move?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: Q42 If Q39 = No
Skip To: Q44 If Q39 = Don't know

Q40 Was it:

o An M-80 (14)
o An M-500 (2)
o An M-1000 (3)
o A Silver Salute (4)
o A quarter stick (5)
o A half stick (6)
o A tennis ball bomb (7)
o A bird ganger or rope salute (8)
o
A large firecracker larger than 1/4 inch in diameter and 1.5 inches in length with no
warning or brand name labeling (9)

o
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 (10)
o Other (11)
o Don't know (12)

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Skip To: Q44 If Q40 != Other

Q41 Please specify "Other" firecracker type.
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Display This Question:
If Q39 = No

Q42 Were you injured by:

o
A Roman Candle (a candle shaped device that fires colored balls and makes small
explosions) (1)

o
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) (2)

o A sparkler (a stick 9-36 inches long that emits sparks after lighting (3)
o
a pest control or wildlife control device (a device like a large firecracker sold to control
birds and other wildlife) (4)
o
A multiple tube device, "cake" or multiple shot repeater (a cluster of tubes which each
shoot firework into air) (5)
o

A "re-loadable" mortar or aerial shell device (at least one mortar tube and 6 or more
shells) (6)

o A fountain type firework (cone or cylinder which emits a shower of sparks into air) (7)
o Other (8)
o Don't know (9)

Skip To: Q44 If Q42 != Other
Display This Question:
If Q42 = Other

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Q43 Please specify "Other" firework type.
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Q44 Please describe the fireworks in as much detail as you can recall.
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Q45 What brand were the fireworks?

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Q46 Did you see the label on the fireworks or package of fireworks?

o Yes (1)
o No (2)
Skip To: QID47 If Q46 = No

Q47 Did the label or package have the words:

o Consumer Display (1)
o Professional (2)
o Novelty (3)
o Other (4)
o Don't know (5)
Skip To: Q49 If Q47 != Other

Q48 Please describe "Other" package labeling.
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Q49 Were there any other markings on the label or the package? Please describe.

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Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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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.

Q50 How did [you/the person who lit the fireworks] get them? Was it from:

o A friend or relative (1)
o A stand that only sells fireworks (2)
o A store (3)
o Mail order (4)
o Internet (5)
o Somewhere else (6)
o Don't know (7)
Skip To: Q53 If Q50 = A friend or relative
Skip To: Q53 If Q50 = A stand that only sells fireworks
Skip To: Q53 If Q50 = A store
Skip To: Q53 If Q50 = Mail order
Skip To: Q52 If Q50 = Somewhere else
Skip To: Q54 If Q50 = Don't know

Q51 Please specify web site address

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Skip To: Q53 If Condition: Please specify web site add... Is Equal to. Skip To: Please specify "somewhere
else" where....

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Q52 Please specify "somewhere else" where the fireworks were purchased.
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Q53 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.
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Q54 Do you know how many were purchased?

o Yes (1)
o No (2)
Skip To: Q56 If Q54 = No

Q55 How many?
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Q56 Do [you/the person who lit the fireworks] have any more of these fireworks?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: Q58 If Q56 != Yes

Q57 How many?
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Q58 Did [you/the person who lit the fireworks] get the impression that the fireworks were legal or
illegal?

o Got the impression that they were legal (1)
o Got the impression that they were not legal (2)
o Did not get any impression (3)
Skip To: Q62 If Q58 = Did not get any impression

Q59 What information was provided about whether the fireworks were legal or illegal?

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.

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Q60 How was this information provided?

o I/the person was told at the place where the fireworks were obtained (1)
o It was in the catalog (2)
o It was on the web site (3)
o Other (4)
Skip To: Q62 If Q60 != Other

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Q61 Please specify "Other" information source (regarding the legality of the fireworks).
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Q62 Is there anything else that you think we should know about the incident or the injury?

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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Q63 Is it possible that alcohol or illegal drugs contributed to the accident?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: QID63 If Q63 != Yes

Q64 Please explain how alcohol or drugs may have contributed to the accident.

Interviewer: Enter respondent answer as "I don't know." if answer is unknown.
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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.

Q65 Are [you/the victim] Hispanic or Latino?

o Yes (1)
o No (2)
o Don't know (3)
o Prefer not to answer (4)
Q66 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)

Skip To: QID67 If Q66 != Other

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Q67 Please specify "Other" race. Please be as specific as possible.
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Thank you for your responses - we appreciate your time. The information you have given us
will be very helpful. Have a good day.
End of Block: Default Question Block
Start of Block: submit block
Q90 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.
Once you click submit, you will no longer be able edit responses.
End of Block: submit block

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