[p. 31]
Section III -- INJURIES
In this next set of questions, I will ask about INJURIES AND POISONINGS that happened in the PAST THREE MONTHS that REQUIRED MEDICAL ADVICE OR TREATMENT, including calls to a poison control center.
FIJ.010
DURING THE PAST THREE MONTHS, that is since {91 days before today date}, {were/was} {you/anyone in the family} injured or poisoned seriously enough that {you/they} got medical advice or treatment?
FINJ3M
(1) Yes (FIJ.020)
(2) No (FAU.010)
(7) Refused (FAU.010)
(9) Don't know (FAU.010)
(2) No (FAU.010)
(7) Refused (FAU.010)
(9) Don't know (FAU.010)
FIJ.020
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who was this? (Anyone else?)
Who was this? (Anyone else?)
PINJ3M
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
FIJ.030
How many different times in the PAST THREE MONTHS {were/was} {you/subject name} injured or poisoned seriously enough to seek medical advice or treatment?
IJNO3M_T
Times Injured (01-94):
[If IJNO3M_T gt 5]
FR: DO NOT READ.
{IJNO3M_T} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
[If IJNO3M_T gt 5]
FR: DO NOT READ.
{IJNO3M_T} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
IJNO3M_M
(1) Make correction
(2) Proceed
(2) Proceed
FIJ.040
[If IJNO3M_T = 1]
Now I'm going to ask a few questions about {your/subject name}'s most recent injury/poisoning.
When did it happen?
FR: SHOW CALENDAR CARD - PROBE FOR SPECIFIC DATE
Now I'm going to ask a few questions about {your/subject name}'s most recent injury/poisoning.
When did it happen?
FR: SHOW CALENDAR CARD - PROBE FOR SPECIFIC DATE
IJDATE_M MONTH:
IJDATE_D DAY:
IJDATE_Y YEAR:
[p. 32]
[If IJNO3M_T gt 1 and the other injuries are asked]
We just talked about {your/subject name}'s injury/poisoning on {recent injury date}. When did {your/subject name}'s injury BEFORE THAT happen?
FR: SHOW CALENDAR CARD - PROBE FOR SPECIFIC DATE
We just talked about {your/subject name}'s injury/poisoning on {recent injury date}. When did {your/subject name}'s injury BEFORE THAT happen?
FR: SHOW CALENDAR CARD - PROBE FOR SPECIFIC DATE
IJDATE_M MONTH:
IJDATE_D DAY:
IJDATE_Y YEAR:
FIJ.045
Where did {you/subject name} receive MEDICAL ADVICE OR TREATMENT for this injury/poisoning? Anywhere else?
FR: SHOW FLASHCARD F3. MARK ALL THAT APPLY. ENTER (N) FOR NO MORE.
(1) Yes
(2) No
(7) Refused
(9) Don't know
Card F3FR: SHOW FLASHCARD F3. MARK ALL THAT APPLY. ENTER (N) FOR NO MORE.
(1) Yes
(2) No
(7) Refused
(9) Don't know
You may choose more than one.
1. Did not receive medical treatment or advice
2. Phone call to doctor or health care professional
3. Phone call to Poison Control Center
4. Visit to Doctor's Office
5. Visit to Clinic or Outpatient department
6. Visit to Emergency department
7. Hospitalized for at least one night
1. Did not receive medical treatment or advice
2. Phone call to doctor or health care professional
3. Phone call to Poison Control Center
4. Visit to Doctor's Office
5. Visit to Clinic or Outpatient department
6. Visit to Emergency department
7. Hospitalized for at least one night
IJMED_2 (2) Phone call to doctor or health care professional
IJMED_3 (3) Phone call to Poison Control Center
IJMED_4 (4) Visit to Doctor's Office
IJMED_5 (5) Visit to Clinic or Outpatient department
IJMED_6 (6) Visit to Emergency department
IJMED_7 (7) Visit to Hospital (stayed at least one night) (FIJ.047)
[If IJMED_2 to IJMED_7 equal 2, skip to FIJ.046]
FIJ.046
FR: PLEASE VERIFY:
{You/subject name} DID NOT receive any medical treatment or advice for this injury/poisoning - even a phone call to a doctor's office for advice. Is that correct?
{You/subject name} DID NOT receive any medical treatment or advice for this injury/poisoning - even a phone call to a doctor's office for advice. Is that correct?
IJMED_M
(1) Make correction
(2) Proceed
[p. 33]
(2) Proceed
FIJ.047
How many nights {were/was} {you/subject name} in the hospital?
FR: IF "STILL IN HOSPITAL," ASK HOW MANY NIGHTS UP TO TODAY.
FR: IF "STILL IN HOSPITAL," ASK HOW MANY NIGHTS UP TO TODAY.
IHNO
(01-94) 01-94 nights
(95) 95+ nights
(97) Refused
(99) Don't Know
[If IHNO gt 60]
FR: DO NOT READ.
{IHNO} is an unusually large number. Verify entry. DO NOT PROBE. MAKE CORRECTIONS IF NECESSARY.
(95) 95+ nights
(97) Refused
(99) Don't Know
[If IHNO gt 60]
FR: DO NOT READ.
{IHNO} is an unusually large number. Verify entry. DO NOT PROBE. MAKE CORRECTIONS IF NECESSARY.
IHNO_M
(1) Make correction
(2) Proceed
[FIJ.050 to FIJ.295 are asked for each injury/poisoning episode as appropriate]
[p. 34]
(2) Proceed
[FIJ.050 to FIJ.295 are asked for each injury/poisoning episode as appropriate]
FIJ.050
At the time, what part(s) of {your/subject name}'s body was/were hurt? What kind of injury/poisoning was it? Anything else?
FR: RECORD THE BODY PART, THEN THE KIND OF INJURY. RECORD UP TO FOUR PART/KIND COMBINATIONS. FOR POISONINGS AFFECTING THE WHOLE BODY, INDICATE "WHOLE BODY" UNDER BODY PART AND SUBSTANCE CAUSING THE POISONING UNDER KIND OF POISONING.
ENTER (N) WHEN ALL ENTRIES HAVE BEEN MADE.
BODY PART
FR: RECORD THE BODY PART, THEN THE KIND OF INJURY. RECORD UP TO FOUR PART/KIND COMBINATIONS. FOR POISONINGS AFFECTING THE WHOLE BODY, INDICATE "WHOLE BODY" UNDER BODY PART AND SUBSTANCE CAUSING THE POISONING UNDER KIND OF POISONING.
ENTER (N) WHEN ALL ENTRIES HAVE BEEN MADE.
BODY PART
IJBODY1 __________________________
IJBODY2 __________________________
IJBODY3 __________________________
IJBODY4 __________________________
KIND OF INJURY OR POISONING
IJKIND1 ___________________________
IJKIND2 ___________________________
IJKIND3 ___________________________
IJKIND4 ___________________________
FIJ.070
FR: VERIFY OR ASK:
How did {your/subject name}'s injury/poisoning happen? Please describe fully the circumstances or events leading to the injury/poisoning, and any object, substance, or other person involved.
FR: ENTER THE VERBATIM RESPONSE, PROBING FOR AS MUCH DETAIL AS POSSIBLE, INCLUDING SPECIFICALLY WHAT THE PERSON WAS DOING AT THE TIME AND ALL CIRCUMSTANCES SURROUNDING THE EVENT. RECORD ALL VOLUNTEERED INFORMATION. ENTER (N) FOR NO MORE.
How did {your/subject name}'s injury/poisoning happen? Please describe fully the circumstances or events leading to the injury/poisoning, and any object, substance, or other person involved.
FR: ENTER THE VERBATIM RESPONSE, PROBING FOR AS MUCH DETAIL AS POSSIBLE, INCLUDING SPECIFICALLY WHAT THE PERSON WAS DOING AT THE TIME AND ALL CIRCUMSTANCES SURROUNDING THE EVENT. RECORD ALL VOLUNTEERED INFORMATION. ENTER (N) FOR NO MORE.
IJHOW1 ________________________________
IJHOW2 ________________________________
IJHOW3 ________________________________
IJHOW4 ________________________________
FIJ.080
FR: ENTER THE FIRST APPROPRIATE BOX WHICH DESCRIBES THE CAUSE OF THE PERSON'S INJURY/POISONING FROM THE LIST BELOW.
CAUSNEW
(01) Transportation, including motor vehicle/bicycle/motorcycle/pedestrian/train/boat/airplane (FIJ.090)
(02) Fire/burn/scald related (FIJ.150)
(03) Fall (FIJ.171)
(04) Poisoning (FIJ.195)
(05) Overexertion/strenuous movements (FIJ.200)
(06) Struck by object or person (FIJ.200)
(07) Animal or insect bite (FIJ.191)
(08) Cut/pierce (FIJ.200)
(09) Machinery (FIJ.200)
(10) Other (FIJ.200)
(97) Refused (FIJ.200)
(99) Don't know (FIJ.200)
[p. 35](02) Fire/burn/scald related (FIJ.150)
(03) Fall (FIJ.171)
(04) Poisoning (FIJ.195)
(05) Overexertion/strenuous movements (FIJ.200)
(06) Struck by object or person (FIJ.200)
(07) Animal or insect bite (FIJ.191)
(08) Cut/pierce (FIJ.200)
(09) Machinery (FIJ.200)
(10) Other (FIJ.200)
(97) Refused (FIJ.200)
(99) Don't know (FIJ.200)
FR: THE NEXT SET OF QUESTIONS ARE ASKED TO VERIFY DETAILS OF THE CIRCUMSTANCES SURROUNDING THE INJURY(S). IF YOU ALREADY KNOW THE ANSWER BECAUSE OF THE VERBATIM RESPONSE FOR HOW THE INJURY(S) OCCURRED, VERIFY THE ANSWER WITH THE RESPONDENT. OTHERWISE, ASK THE QUESTION.
FIJ.090
{Were/Was} {you/subject name} injured as the driver of a vehicle, a passenger in a vehicle, a bicycle rider, or as a pedestrian?
MVWHO
(1) Driver of a vehicle (FIJ.100)
(2) Passenger of a vehicle (FIJ.100)
(3) Bicycle rider (FIJ.130)
(4) Pedestrian (FIJ.140)
(7) Refused (FIJ.200)
(9) Don't know (FIJ.200)
(2) Passenger of a vehicle (FIJ.100)
(3) Bicycle rider (FIJ.130)
(4) Pedestrian (FIJ.140)
(7) Refused (FIJ.200)
(9) Don't know (FIJ.200)
FIJ.100
What type of vehicle {were/was} {you/subject name} in?
MVTYP
(01) Passenger car (FIJ.120)
(02) Light truck (including pickups, vans, and utility vehicle/SUVs) (FIJ.120)
(03) Bus (FIJ.200)
(04) Large truck (FIJ.120)
(05) Motorcycle (including mopeds, minibikes) (FIJ.130)
(06) All terrain vehicle or ski/snow mobile (FIJ.130)
(07) Farm equipment (tractor) (FIJ.200)
(08) Airplane (FIJ.200)
(09) Boat (FIJ.200)
(10) Train (FIJ.200)
(11) Other (FIJ.200)
(97) Refused (FIJ.200)
(99) Don't know (FIJ.200)
(02) Light truck (including pickups, vans, and utility vehicle/SUVs) (FIJ.120)
(03) Bus (FIJ.200)
(04) Large truck (FIJ.120)
(05) Motorcycle (including mopeds, minibikes) (FIJ.130)
(06) All terrain vehicle or ski/snow mobile (FIJ.130)
(07) Farm equipment (tractor) (FIJ.200)
(08) Airplane (FIJ.200)
(09) Boat (FIJ.200)
(10) Train (FIJ.200)
(11) Other (FIJ.200)
(97) Refused (FIJ.200)
(99) Don't know (FIJ.200)
FIJ.120
FR: VERIFY OR ASK
[If AGE is ge 5]
{Were/Was} {you/subject name} wearing a safety belt at the time of the accident?
[Else]
{Were/Was} {you/subject name} buckled in a car safety seat at the time of the accident?
[If AGE is ge 5]
{Were/Was} {you/subject name} wearing a safety belt at the time of the accident?
[Else]
{Were/Was} {you/subject name} buckled in a car safety seat at the time of the accident?
SBELT
(1) Yes
(2) No
(7) Refused
(9) Don't know
(Go to FIJ.200)
(2) No
(7) Refused
(9) Don't know
(Go to FIJ.200)
FIJ.130
FR: VERIFY OR ASK:
{Were/Was} {you/subject name} wearing a helmet at the time of the accident?
{Were/Was} {you/subject name} wearing a helmet at the time of the accident?
HELMT
(1) Yes
(2) No
(7) Refused
(9) Don't know
(Go to FIJ.200)
[p. 36]
(2) No
(7) Refused
(9) Don't know
(Go to FIJ.200)
FIJ.140
What type of vehicle {were/was} {you/subject name} struck by?
MVHIT
(01) Passenger car
(02) Light truck (including pickups, vans, and utility vehicles)
(03) Bus
(04) Large truck
(05) Motorcycle (including mopeds and minibikes)
(06) All terrain vehicle or ski or snow-mobile
(07) Farm equipment (tractor)
(08) Bicycle
(09) Train
(10) Boat (includes all on water vehicles)
(11) Other
(97) Refused
(99) Don't know
(Go to FIJ.200)
(02) Light truck (including pickups, vans, and utility vehicles)
(03) Bus
(04) Large truck
(05) Motorcycle (including mopeds and minibikes)
(06) All terrain vehicle or ski or snow-mobile
(07) Farm equipment (tractor)
(08) Bicycle
(09) Train
(10) Boat (includes all on water vehicles)
(11) Other
(97) Refused
(99) Don't know
(Go to FIJ.200)
FIJ.150
What was it that burned/scalded {you/subject name}?
FR: IF RESPONSE IS FIRE OR SMOKE ASK:
What caused the fire/smoke?
FR: IF RESPONSE IS FIRE OR SMOKE ASK:
What caused the fire/smoke?
BURN
(01) Cigarette, cigar, pipe
(02) Cooking unit
(03) Heater
(04) Wiring
(05) Motor vehicle battery caps, radiator caps
(06) Fireworks
(07) Other explosive
(08) Water or steam
(09) Food
(10) Chemicals
(11) Other
(97) Refused
(99) Don't know
(Go to FIJ.200)
[p. 37]
(02) Cooking unit
(03) Heater
(04) Wiring
(05) Motor vehicle battery caps, radiator caps
(06) Fireworks
(07) Other explosive
(08) Water or steam
(09) Food
(10) Chemicals
(11) Other
(97) Refused
(99) Don't know
(Go to FIJ.200)
FIJ.171
FR: VERIFY OR ASK. SHOW FLASHCARD F4. RECORD UP TO 2 RESPONSES: ENTER (N) FOR NO MORE.
How did {you/subject name} fall? Anything else?
On or down, from or into:
Card F4
How did {you/subject name} fall? Anything else?
On or down, from or into:
On or down from or into:
1. Stairs, steps or Escalator
2. Floor/Level ground
3. Curb, including sidewalk
4. Ladder or scaffolding
5. Playground equipment
6. Building or other structure
7. Chair, bed, sofa, or other furniture
8. Bathtub, shower, toilet or commode
9. Hole or other opening
10. Other
2. Floor/Level ground
3. Curb, including sidewalk
4. Ladder or scaffolding
5. Playground equipment
6. Building or other structure
7. Chair, bed, sofa, or other furniture
8. Bathtub, shower, toilet or commode
9. Hole or other opening
10. Other
FALLNEW1
FALLNEW2
(01) Stairs, steps, or escalator
(02) Floor/level ground
(03) Curb, including sidewalk
(04) Ladder or scaffolding
(05) Playground equipment
(06) Building or other structure
(07) Chair, bed, sofa or other furniture
(08) Bathtub, shower, toilet, or commode
(09) Hole or other opening
(10) Other
(97) Refused
(99) Don't know
[ ]
[ ]
(02) Floor/level ground
(03) Curb, including sidewalk
(04) Ladder or scaffolding
(05) Playground equipment
(06) Building or other structure
(07) Chair, bed, sofa or other furniture
(08) Bathtub, shower, toilet, or commode
(09) Hole or other opening
(10) Other
(97) Refused
(99) Don't know
[ ]
[ ]
FIJ.180
What caused {you/subject name} to fall? Was it due to:
FWHY
(1) Slipping, tripping or stumbling
(2) Jumping or diving
(3) Collision with/pushing, shoving by another person
(4) Loss of balance/dizziness/becoming faint/seizure
(5) Or something else
(7) Refused
(9) Don't know
(Go to FIJ.200)
(2) Jumping or diving
(3) Collision with/pushing, shoving by another person
(4) Loss of balance/dizziness/becoming faint/seizure
(5) Or something else
(7) Refused
(9) Don't know
(Go to FIJ.200)
FIJ.191
What type of animal or insect bit {you/subject name}?
ANIMAL
(01) Dog
(02) Cat
(03) Poisonous snake/reptile
(04) Nonpoisonous snake/reptile
(05) Unknown snake/reptile
(06) Poisonous insect
(07) Nonpoisonous insect
(08) Unknown insect
(09) Rodent
(10) Other
(97) Refused
(99) Don't know
(Go to FIJ.200)
[p. 38]
(02) Cat
(03) Poisonous snake/reptile
(04) Nonpoisonous snake/reptile
(05) Unknown snake/reptile
(06) Poisonous insect
(07) Nonpoisonous insect
(08) Unknown insect
(09) Rodent
(10) Other
(97) Refused
(99) Don't know
(Go to FIJ.200)
FIJ.195
FR: SHOW FLASHCARD F5.
Did {your/subject name} poisoning result from:
Card F5Did {your/subject name} poisoning result from:
1. A drug or medical substance used mistakenly or in overdose
2. A harmful or toxic solid or liquid substance
3. Inhaling gases or vapors
4. Eating a poisonous plant or other substance mistaken for food
5. A venomous animal or plant
6. Food poisoning
7. Allergic Reaction
8. Something else
2. A harmful or toxic solid or liquid substance
3. Inhaling gases or vapors
4. Eating a poisonous plant or other substance mistaken for food
5. A venomous animal or plant
6. Food poisoning
7. Allergic Reaction
8. Something else
POITP
(01) A drug or medical substance used mistakenly or in overdose
(02) A harmful or toxic solid or liquid substance
(03) Inhaling gases or vapors
(04) Eating a poisonous plant or other substance mistaken for food
(05) A venomous animal or plant
(06) Food poisoning
(07) Allergic Reaction
(08) Something else
(97) Refused
(99) Don't know
(02) A harmful or toxic solid or liquid substance
(03) Inhaling gases or vapors
(04) Eating a poisonous plant or other substance mistaken for food
(05) A venomous animal or plant
(06) Food poisoning
(07) Allergic Reaction
(08) Something else
(97) Refused
(99) Don't know
FIJ.200
FR: VERIFY OR ASK. SHOW FLASHCARD F6. RECORD UP TO 2 RESPONSES: ENTER (N) FOR NO MORE.
What {were/was} {you/subject name} doing when the injury/poisoning happened?
Card F6What {were/was} {you/subject name} doing when the injury/poisoning happened?
1. Driving or riding in a motor vehicle
2. Working at paid job
3. Working around the house or yard
4. Attending school
5. Unpaid work (including housework, shopping, volunteer work)
6. Sports (organized team or individual sport such as running, biking, skating)
7. Leisure activity (excluding sports)
8. Sleeping, resting, eating, drinking
9. Cooking
10. Being cared for (hands on care from other person)
11. Other
2. Working at paid job
3. Working around the house or yard
4. Attending school
5. Unpaid work (including housework, shopping, volunteer work)
6. Sports (organized team or individual sport such as running, biking, skating)
7. Leisure activity (excluding sports)
8. Sleeping, resting, eating, drinking
9. Cooking
10. Being cared for (hands on care from other person)
11. Other
WHAT_1
WHAT_2
(01) Driving or riding in a motor vehicle
(02) Working at a paid job
(03) Working around the house or yard
(04) Attending school
(05) Unpaid work (including housework, shopping, volunteer work)
(06) Sports (organized team or individual sport such as running, biking, skating)
(07) Leisure activity (excluding sports)
(08) Sleeping, resting, eating, drinking
(09) Cooking
(10) Being cared for (hands on care from other person)
(11) Other
(97) Refused
(99) Don't know
[ ]
[ ]
[p. 39]
(02) Working at a paid job
(03) Working around the house or yard
(04) Attending school
(05) Unpaid work (including housework, shopping, volunteer work)
(06) Sports (organized team or individual sport such as running, biking, skating)
(07) Leisure activity (excluding sports)
(08) Sleeping, resting, eating, drinking
(09) Cooking
(10) Being cared for (hands on care from other person)
(11) Other
(97) Refused
(99) Don't know
[ ]
[ ]
FIJ.221
FR: VERIFY OR ASK. SHOW FLASHCARD F7. RECORD UP TO 2 RESPONSES. ENTER (N) FOR NO MORE.
Where (were/was} {you/subject name} when the injury/poisoning happened?
Card F7Where (were/was} {you/subject name} when the injury/poisoning happened?
1. Home (inside)
2. Home (outside)
3. School (not residential)
4. Child care center or Preschool
5. Residential institution (excluding hospital)
6. Health care facility (including hospital)
7. Street/highway
8. Parking lot
9. Sport facility, athletic field or playground
10. Trade and service areas (shopping center, restaurant, store, bank, gas station)
11. Farm
12. Park/recreation area (fields, bike or jog path)
13. River/lake/stream/ocean
14. Industrial or construction area
15. Other public building
16. Other
2. Home (outside)
3. School (not residential)
4. Child care center or Preschool
5. Residential institution (excluding hospital)
6. Health care facility (including hospital)
7. Street/highway
8. Parking lot
9. Sport facility, athletic field or playground
10. Trade and service areas (shopping center, restaurant, store, bank, gas station)
11. Farm
12. Park/recreation area (fields, bike or jog path)
13. River/lake/stream/ocean
14. Industrial or construction area
15. Other public building
16. Other
WHERNEW1
WHERNEW2
(01) Home (inside)
(02) Home (outside)
(03) School (not residential)
(04) Child care center or Preschool
(05) Residential institution (excluding hospital)
(06) Health care facility (including hospital)
(07) Street/highway
(08) Parking lot
(09) Sport facility, athletic field, or playground
(10) Trade and service areas (shopping center, restaurant, store, bank, gas station)
(11) Farm
(12) Park/recreation area (fields, bike or jog path)
(13) River/lake/stream/ocean
(14) Industrial or construction area
(15) Other public building
(16) Other
(97) Refused
(99) Don't know
[ ]
[ ]
(02) Home (outside)
(03) School (not residential)
(04) Child care center or Preschool
(05) Residential institution (excluding hospital)
(06) Health care facility (including hospital)
(07) Street/highway
(08) Parking lot
(09) Sport facility, athletic field, or playground
(10) Trade and service areas (shopping center, restaurant, store, bank, gas station)
(11) Farm
(12) Park/recreation area (fields, bike or jog path)
(13) River/lake/stream/ocean
(14) Industrial or construction area
(15) Other public building
(16) Other
(97) Refused
(99) Don't know
[ ]
[ ]
Check item FIJCCI1: If AGE is greater than 13, then go to FIJ.260; Else
If AGE is greater than 4 and less than 14 then go to FIJ.270; Else
If AGE is less than 5 then return to FIJ.040 for next injury/poisoning event or next person. If there are no more persons and no more injury/poisoning events, go to FAU.010.
If AGE is greater than 4 and less than 14 then go to FIJ.270; Else
If AGE is less than 5 then return to FIJ.040 for next injury/poisoning event or next person. If there are no more persons and no more injury/poisoning events, go to FAU.010.
FIJ.260
FR: SHOW FLASHCARD F8.
As a result of this injury/poisoning, how much work did {you/subject name} miss?
Card F8As a result of this injury/poisoning, how much work did {you/subject name} miss?
Not employed at the time of the injury/poisoning
None
Less than 1 day
One to five days
Six or more days
None
Less than 1 day
One to five days
Six or more days
WKLS
(1) Not employed at the time of the injury/poisoning
(2) None
(3) Less than 1 day
(4) One to five days
(5) Six or more days
(7) Refused
(9) Don't know
[p. 40]
(2) None
(3) Less than 1 day
(4) One to five days
(5) Six or more days
(7) Refused
(9) Don't know
FIJ.270
FR: SHOW FLASHCARD F9.
As a result of this injury/poisoning, how much school did {you/subject name} miss?
Card F9As a result of this injury/poisoning, how much school did {you/subject name} miss?
Not in school at the time of the injury/poisoning
None
Less than 1 day
One to five days
Six or more days
None
Less than 1 day
One to five days
Six or more days
SCLS
(1) Not in school at the time of the injury/poisoning
(2) None
(3) Less than 1 day
(4) One to five days
(5) Six or more days
(7) Refused
(9) Don't know
(2) None
(3) Less than 1 day
(4) One to five days
(5) Six or more days
(7) Refused
(9) Don't know
FIJ.280
As a result of this injury/poisoning {do/does}{you/subject name} now need the help of other persons with {your/his/her} personal care needs, such as eating, bathing, dressing, or getting around this home?
IJADL
(1) Yes (FIJ.285)
(2) No (FIJ.290)
(9) Don't know (FIJ.290)
(7) Refused (FIJ.290)
(2) No (FIJ.290)
(9) Don't know (FIJ.290)
(7) Refused (FIJ.290)
FIJ.285
Do you expect {you/subject name} will need this help for a total of 6 months or longer?
LIMTM
(1) Yes
(2) No
(7) Refused
(9) Don't know
(2) No
(7) Refused
(9) Don't know
FIJ.290
As a result of this injury/poisoning {do/does} {you/subject name} now need the help of other persons in handling routine needs such as everyday household chores, doing necessary business, shopping or getting around for other purposes?
IJIAD
(1) Yes (FIJ.295)
(2) No (Check Item FIJCCI1A)
(7) Refused (Check Item FIJCCI1A)
(9) Don't know (Check Item FIJCCI1A)
(2) No (Check Item FIJCCI1A)
(7) Refused (Check Item FIJCCI1A)
(9) Don't know (Check Item FIJCCI1A)
FIJ.295
Do you expect {you/subject name} will need this help for a total of 6 months or longer?
HLIMT
(1) Yes
(2) No
(7) Refused
(9) Don't know
(2) No
(7) Refused
(9) Don't know
Check item FIJCCI1A: Return to FIJ.040 for next injury/poisoning episode or next person. If there are no more persons and no more injury episodes, go to FAU.010.
(Go to next section--Health Care Access and Utilization.)
[p. 41]
Section IV -- HEALTH CARE ACCESS AND UTILIZATION
Part A -- Access to Care
The following questions are about the use of health care. Do not include dental care.
DURING THE PAST 12 MONTHS, has medical care been delayed for {you/anyone in the family} because of worry about the cost?
DURING THE PAST 12 MONTHS, has medical care been delayed for {you/anyone in the family} because of worry about the cost?
FDMED12M
(1) Yes (FAU.020)
(2) No (FAU.030)
(7) Refused (FAU.030)
(9) Don't know (FAU.030)
(2) No (FAU.030)
(7) Refused (FAU.030)
(9) Don't know (FAU.030)
FAU.020
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
For which family member was medical care delayed? (Anyone else?)
For which family member was medical care delayed? (Anyone else?)
PDMED12M
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DURING THE PAST 12 MONTHS, was there any time when {you/someone in the family} needed medical care, but did not get it because {you/the family} couldn't afford it?
FNMED12M
(1) Yes) (FAU.040)
(2) No (FAU.050)
(7) Refused (FAU.050)
(9) Don't know (FAU.050)
(2) No (FAU.050)
(7) Refused (FAU.050)
(9) Don't know (FAU.050)
FAU.040
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who didn't get needed care? (Anyone else?)
Who didn't get needed care? (Anyone else?)
PNMED12M
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[p. 42]
Part B -- Hospital Utilization
DURING THE PAST 12 MONTHS, {were/was} {you/anyone in the family} a patient in a hospital OVERNIGHT? (Do not include an overnight stay in the emergency room.)
[If there is a child lt 1 year old in the family add]
Remember to include any new mothers and/or babies who were hospitalized for the baby's birth.
[If there is a child lt 1 year old in the family add]
Remember to include any new mothers and/or babies who were hospitalized for the baby's birth.
FHOSPYR
(1) Yes (FAU.060)
(2) No (FAU.120)
(7) Refused (FAU.120)
(9) Don't know (FAU.120)
(2) No (FAU.120)
(7) Refused (FAU.120)
(9) Don't know (FAU.120)
FAU.060
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who was in a hospital overnight? (Anyone else?)
Who was in a hospital overnight? (Anyone else?)
PHOSPYR
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How many different times did {you/subject's name} stay in any hospital overnight or longer DURING THE PAST 12 MONTHS?
HOSPNO
(001-365) 1-365 Times
(997) Refused
(999) Don't Know
[If HOSPNO gt 10]
FR: DO NOT READ.
{HOSPNO} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
(997) Refused
(999) Don't Know
[If HOSPNO gt 10]
FR: DO NOT READ.
{HOSPNO} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
HOSPNO_M
(1) Make correction
(2) Proceed
(2) Proceed
[p. 43]
Altogether how many nights {were/was} {you/subject's name} in the hospital DURING THE PAST 12 MONTHS?
HPNITE
(001-365) 1-365 Nights
(997) Refused
(999) Don't know
[If HPNITE gt 50]
FR: DO NOT READ.
{HPNITE} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
(997) Refused
(999) Don't know
[If HPNITE gt 50]
FR: DO NOT READ.
{HPNITE} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
HPNITE_M
(1) Make correction
(2) Proceed
(2) Proceed
FAU.115
FR: DO NOT READ:
[fill HPNITE_N} is less than the total number of times just reported that [fill F_DTEMPNAME] was in the hospital overnight. PROBE TO CORRECT.
[fill HPNITE_N} is less than the total number of times just reported that [fill F_DTEMPNAME] was in the hospital overnight. PROBE TO CORRECT.
HPVER
(1) Increase total number of nights in hospital (FAU.110)
(2) Decrease total number of times [fill F_TEMPNAME] stayed in hospital (FAU.070)
(3) Proceed without correcting (Check item NEXT_HOSP)
(2) Decrease total number of times [fill F_TEMPNAME] stayed in hospital (FAU.070)
(3) Proceed without correcting (Check item NEXT_HOSP)
Check item: NEXT_HOSP:Go back to HOSPNO/FAU.070 for next person listed in FAU.060. When no more people, go to FAU.120.
[p. 44]
Part C -- Health Care Contacts
FR: HAND CALENDER CARD
These next questions are about health care received during the 2 WEEKS outlined on that calendar. Include care from ALL types of medical doctors, such as dermatologists, psychiatrists, ophthalmologists, and general practitioners. Also include care from OTHER health professionals such as nurses, physical therapists, and chiropractors. Do not include dental care.
During those 2 WEEKS, did {you/anyone in the family} receive care AT HOME from a nurse or other health care professional?
These next questions are about health care received during the 2 WEEKS outlined on that calendar. Include care from ALL types of medical doctors, such as dermatologists, psychiatrists, ophthalmologists, and general practitioners. Also include care from OTHER health professionals such as nurses, physical therapists, and chiropractors. Do not include dental care.
During those 2 WEEKS, did {you/anyone in the family} receive care AT HOME from a nurse or other health care professional?
FHCHM2W
(1) Yes (FAU.130)
(2) No (FAU.150)
(7) Refused (FAU.150)
(9) Don't know (FAU.150)
(2) No (FAU.150)
(7) Refused (FAU.150)
(9) Don't know (FAU.150)
FAU.130
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who received care at home? (Anyone else?)
Who received care at home? (Anyone else?)
PHCHM2W
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How many home visits did {you/subject's name} receive during those 2 WEEKS?
PHCHMN2W
(01-49) 1-49 visits
(50) 50+ visits
(97) Refused
(99) Don't know
[If PHCHMN2W gt 14]
FR: DO NOT READ.
{PHCHMN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
(50) 50+ visits
(97) Refused
(99) Don't know
[If PHCHMN2W gt 14]
FR: DO NOT READ.
{PHCHMN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
PHCHMN2W_M
(1) Make correction
(2) Proceed
(2) Proceed
During those 2 WEEKS, did {you/anyone in the family} get any medical advice or test results over the PHONE from a doctor, nurse, or other health care professional?
Do not include phone calls to make appointments, for billing questions or for prescription refills.
Do not include phone calls to make appointments, for billing questions or for prescription refills.
FHCPH2W
(1) Yes (FAU.160)
(2) No (FAU.180)
(7) Refused (FAU.180)
(9) Don't know (FAU.180)
(2) No (FAU.180)
(7) Refused (FAU.180)
(9) Don't know (FAU.180)
[p. 45]
FAU.160
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who was the phone call about? (Anyone else?)
Who was the phone call about? (Anyone else?)
PHCPH2WR
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During those 2 WEEKS, how many telephone calls
[If single person family] did you make?
[else]
were made about {subject's name}?
[If single person family] did you make?
[else]
were made about {subject's name}?
PHCHMN2W
(01-49) 1-49 calls
(50) 50+ calls
(97) Refused
(99) Don't know
[If PHCPHN2W gt 14]
FR: DO NOT READ.
{PHCPHN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
(50) 50+ calls
(97) Refused
(99) Don't know
[If PHCPHN2W gt 14]
FR: DO NOT READ.
{PHCPHN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
PHCPHN2W_M
(1) Make correction
(2) Proceed
(2) Proceed
During those 2 WEEKS, did {you/anyone in the family} see a doctor or other health care professional at a doctor's OFFICE, a clinic, an emergency room, or some other place? (Do not include times during an overnight hospital stay.)
FHCDV2W
(1) Yes (FAU.190)
(2) No (FAU.210)
(7) Refused (FAU.210)
(9) Don't know (FAU.210)
(2) No (FAU.210)
(7) Refused (FAU.210)
(9) Don't know (FAU.210)
FAU.190
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who received care? (Anyone else?)
Who received care? (Anyone else?)
PHCDV2W
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[p. 46]
How many times did {you/subject's name} visit a doctor or other health care professional during those 2 WEEKS?
PHCDVN2W
(01-49) 1-49 times
(50) 50+ times
(97) Refused
(99) Don't know
[If PHCDVN2W gt 14]
FR: DO NOT READ.
{PHCDVN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
(50) 50+ times
(97) Refused
(99) Don't know
[If PHCDVN2W gt 14]
FR: DO NOT READ.
{PHCDVN2W} is an unusually large number. Verify entry. DO NOT PROBE. Make corrections if necessary.
PHCDVN2W_M
(1) Make correction
(2) Proceed
(2) Proceed
During the past 12 MONTHS did {you/any member of the family} receive care from doctors or other health care professionals 10 or more times?
F10DVYR
(1) Yes (FAU.220)
(2) No (FHI.010)
(7) Refused (FHI.010)
(9) Don't know (FHI.010)
(2) No (FHI.010)
(7) Refused (FHI.010)
(9) Don't know (FHI.010)
FAU.220
FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S). ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.
Who received care 10 or more times (exclude telephone calls)? (Anyone else?)
Who received care 10 or more times (exclude telephone calls)? (Anyone else?)
P10DVYR
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(Go to next section--Health Insurance)