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Survey of Residential Fire Injury Incidents
CAPI Questionnaire
Prepared for:
National Center for Injury Prevention and Control
at the
Centers for Disease Control and Prevention
Prepared by:
Centers for Public Health Research and Evaluation
July 2005
Public Reporting burden of this collection of information is estimated at 60 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is
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Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74,
Atlanta, GA 30333; Attn: PRA (0920-XXXX).
G:\Controlled Files\PD\FG487102-13\Q\Cover v4.doc
Survey of Residential Fire Injury Incidents
Page A-1
SECTION A: Behavioral Sequence Interview Technique (BSIT)
PROGRAMMER NOTE: Part A is audio recorded.
A1.
In your own words could you describe what happened during the fire incident, starting from when you first
became aware of the situation?
Cue
Action
Reason
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G:\Controlled Files\PD\FG487102-13\Q\Sect A v2.doc
Survey of Residential Fire Injury Incidents
Page B-1
NOTE: ITEMS IN ALL CAPITALS ARE NOT READ OUT LOUD. ALL QUESTIONS HAVE “DON’T KNOW” AND
“REFUSED” OPTIONS, EVEN IF NOT DISPLAYED HERE.
SECTION B: POST-BSIT FOLLOW-UP QUESTIONS
INITIAL AWARENESS (FIRE RECOGNITION)
B1.
How did you become aware of the fire? CODE ALL
THAT APPLY. PROBE: Did anything happen before
ANIMAL ALERTED PERSON ................................................ 1
that? Anything else?
FELT HEAT FROM THE FIRE............................................... 3
CO DETECTOR SOUNDED .................................................. 2
HEARD FIRE BURNING........................................................ 4
HEAT DETECTOR SOUNDED.............................................. 5
SMELLED SMOKE ................................................................ 6
PERSON WAS THERE WHEN FIRE STARTED .................. 7
SAW FLAMES ....................................................................... 8
SAW SMOKE ......................................................................... 9
SMOKE DETECTOR ALARM SOUNDED........................... 10
SOMEONE IN THE HOUSE NOTICED THE FIRE ............. 11
SPECIFY: _____________________________
B2.
How did others in the household become aware of
the fire? CODE ALL THAT APPLY.
SOMEONE OUTSIDE THE HOUSE ALERTED ................. 12
SOME OTHER WAY (SPECIFY) ......................................... 13
ANIMAL ALERTED PERSON ................................................ 1
CO DETECTOR SOUNDED .................................................. 2
FELT HEAT FROM THE FIRE............................................... 3
HEARD FIRE BURNING........................................................ 4
HEAT DETECTOR SOUNDED.............................................. 5
SMELLED SMOKE ................................................................ 6
PERSON WAS THERE WHEN FIRE STARTED .................. 7
SAW FLAMES ....................................................................... 8
SAW SMOKE ......................................................................... 9
SMOKE DETECTOR ALARM SOUNDED........................... 10
SOMEONE IN THE HOUSE NOTICED THE FIRE ............. 11
SOMEONE OUTSIDE THE HOUSE ALERTED ................. 12
B3.
SPECIFY: _____________________________
SOME OTHER WAY (SPECIFY) ......................................... 13
What were you doing when you became aware of
the fire?
SLEEPING ............................................................................. 1
COOKING .............................................................................. 2
CLEANING............................................................................. 3
WATCHING TV ...................................................................... 4
EATING.................................................................................. 5
READING............................................................................... 6
CARING FOR CHILDREN ..................................................... 7
USING THE COMPUTER ...................................................... 8
SPECIFY: _____________________________
SOMETHING ELSE (SPECIFY) ............................................ 9
ACTIONS TAKEN (BEHAVIORAL RESPONSE TO THE FIRE)
B4.
Did you try to put out or remove the fire?
YES ........................................................................................ 1
NO................................... (SKIP TO B9)................................ 2
B5.
Did you use a fire extinguisher in an attempt to put
out the fire?
YES ........................................................................................ 1
NO.......................................................................................... 2
DK ................................... (SKIP TO B9)................................ 7
RF ................................... (SKIP TO B9)................................ 8
G:\Controlled Files\PD\FG487102-13\Q\Sect B v4.doc
Survey of Residential Fire Injury Incidents
Page B-2
B6.
Other than a fire extinguisher, did you do anything
else to put out the fire?
YES ........................................................................................ 1
NO................................... (SKIP TO B9)................................ 2
DK ................................... (SKIP TO B9)................................ 7
RF ................................... (SKIP TO B9)................................ 8
B7.
What did you do to try to put out or remove the
fire? CODE ALL THAT APPLY.
BROUGHT BURNING ITEM TO THE SINK ...........................1
POURED WATER OR OTHER LIQUID ON THE
BURNING ITEM ................................................................2
CUT OFF POWER TO INVOLVED EQUIPMENT ..................3
MOVED BURNING ITEM OUTSIDE.......................................4
SEPARATED BURNING/SMOLDERING MATERIAL AND
HEAT SOURCE ................................................................5
SMOTHERED WITH POT LID, BLANKET, ETC. ...................6
USED BAKING SODA, FLOUR, SALT, OTHER
COMMON PRODUCT.......................................................7
USED HOSE ...........................................................................8
SPECIFY: _____________________________
OTHER (SPECIFY).............................................................. 10
B8.
I am going to read you a list of categories. Please
choose the best answer from the list. Did your
action (READ CATEGORIES)?
Put out the fire entirely........................................................1
Minimize the fire, but not put it out completely ...............2
Have little or no impact on the fire, or ..............................3
Make the fire worse .............................................................4
B9.
Did you yourself, make a call to the fire
department, telephone operator, or someone
else?
NO, CALLED NO ONE ...........................................................0
SPECIFY: _____________________________
YES, FIRE DEPARTMENT ............ (SKIP TO B11)................1
YES, OPERATOR (911) ................ (SKIP TO B11)................2
YES, SOMEONE ELSE .........(SPECIFY, SKIP TO B11) .......3
DK .................................................. (SKIP TO B11)................7
RF .................................................. (SKIP TO B11)................8
B10.
Why did you not make a call to them?
FIRE NOT SERIOUS ENOUGH – PUT FIRE OUT ............... 1
TELEPHONE NOT ACCESSIBLE ......................................... 2
FIRE DEPARTMENT TOO FAR AWAY ................................ 3
SOMEONE ELSE CALLED ................................................... 4
FIRE DEPARTMENT WAS ALREADY THERE..................... 5
B11.
SPECIFY: _____________________________
OTHER (SPECIFY)................................................................ 6
Who actually put out the fire? CODE ALL THAT
FIRE DEPARTMENT ............................................................. 1
APPLY.
HOUSEHOLD MEMBER, INCLUDING R .............................. 2
NEIGHBOR ............................................................................ 3
WENT OUT BY ITSELF ......................................................... 4
SPECIFY: _____________________________
B12.
Did anyone in the house try to get help from a
neighbor or someone else other than the fire
department?
OTHER PERSON (SPECIFY) ............................................... 5
YES ........................................................................................ 1
NO.......................................................................................... 2
EVACUATION
B13.
Did you try to save personal property?
YES ........................................................................................ 1
NO.......................................................................................... 2
B14.
Did you try to save any pets?
YES ........................................................................................ 1
NO.......................................................................................... 2
B15.
Did you try to help others to escape?
YES ........................................................................................ 1
NO.......................................................................................... 2
G:\Controlled Files\PD\FG487102-13\Q\Sect B v4.doc
Survey of Residential Fire Injury Incidents
B16.
Did you leave the residence?
Page B-3
YES ................................ (SKIP TO B19)............................... 1
NO.......................................................................................... 2
CODE AS YES EVEN IF R GOES TO NEIGHBORING APARTMENT OR HOME.
YES ........................................................................................ 1
NO.................................. (SKIP TO B26)............................... 2
B17.
Did you try to leave the residence but were unable
to?
B18.
What was the reason or reasons you (couldn’t/didn’t) leave the residence? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
B19.
B20.
When you left, did you leave unassisted or
assisted by someone?
UNASSISTED ................ (SKIP TO B21)............................... 1
Who assisted you?
FIRE FIGHTER ...................................................................... 1
ASSISTED ............................................................................. 2
PERSON LIVING IN THE HOUSE ........................................ 2
SPECIFY: __________________________
B21.
When you left the house, did you leave (READ
CATEGORIES)?
SPECIFY: __________________________
B22.
Is this your usual way in and out of your home?
B23.
When you were leaving your home, but still inside,
did you (READ CATEGORIES)?
B24.
NEIGHBOR ............................................................................ 3
OTHER (SPECIFY)................................................................ 4
Through the front door ....................................................... 1
Through a side or back door ............................................ 2
Through the garage............................................................ 3
Through a window ...................... (SKIP TO B23)............... 4
Basement door .................................................................... 5
Other (SPECIFY) .................................................................. 6
YES ........................................................................................ 1
NO.......................................................................................... 2
YES
NO
a.
See flames ...........................................................
1
2
b.
Pass through smoke ............................................
1
2
c.
Change your path due to smoke or flames ..........
1
2
d.
Seek a refuge room due to smoke.......................
1
2
e.
Have clear air to the exit ......................................
1
2
YES
NO
When trying to leave, did you encounter any of the
following obstructions?
a.
Bars on windows ..................................................
1
2
b.
Locked doors........................................................
1
2
c.
Closed doors ........................................................
1
2
d.
Windows permanently shut ..................................
1
2
e.
Smoke ..................................................................
1
2
f.
Flames..................................................................
1
2
g.
Any other obstruction (SPECIFY): ___________
1
2
G:\Controlled Files\PD\FG487102-13\Q\Sect B v4.doc
Survey of Residential Fire Injury Incidents
Page B-4
________________________________
PROGRAMMER NOTE: If B24b = 1 or B24c = 1, ask B25. Otherwise, skip to B26.
B25.
When you encountered the closed door, did you
(READ CATEGORIES)? CODE ALL THAT APPLY.
Just grab the handle or knob ............................................ 1
Feel the handle or knob for heat ...................................... 2
Feel the door for heat ........................................................ 3
Wrap something around the handle to open ................. 4
SPECIFY: __________________________
Other (SPECIFY) .................................................................. 5
EVACUATION TIME
B26.
How much time do you think elapsed between
when you noticed something was wrong and
when you had evacuated to outside your home or
were brought outside by someone else?
B27.
Were there any factors that prolonged the amount of time that elapsed between when you noticed
something wrong and when you had evacuated? RECORD VERBATIM.
AMOUNT TIME ELAPSED ....................................
IN MINUTES
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
RE-ENTRY
B28.
Did you reenter the building during the fire?
YES ........................................................................................ 1
NO.................................. (SKIP TO B30)............................... 2
B29.
Why did you reenter? CODE ALL THAT APPLY.
TO FIND SOMEONE ............................................................. 1
GATHER VALUABLES .......................................................... 2
CALL 911 ............................................................................... 3
FIGHT THE FIRE ................................................................... 4
SPECIFY: __________________________
B30.
FIND A PET ........................................................................... 5
OTHER (SPECIFY)................................................................ 6
In retrospect, what would you have done differently during the fire? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
G:\Controlled Files\PD\FG487102-13\Q\Sect B v4.doc
Survey of Residential Fire Injury Incidents
Page C-1
SECTION C: FIRE IGNITION CHARACTERISTICS
I would like to continue with some questions about the fire incident.
C1.
I want to confirm that the date of the fire was
(DATE FROM TRACKING). Is that correct?
A.
ENTER CORRECT DATE
CORRECT ...................... (SKIP TO C2)................................ 1
INCORRECT.......................................................................... 2
DATE: ..............................
MM
C2.
About what time of day did the fire start? IF NOON,
ENTER 12:00PM. IF MIDNIGHT, ENTER 12:00AM.
DD
TIME FIRE STARTED .. (SKIP TO C3)..
YY
:
AM
PM
DK .......................................................................................... 7
RF ................................. (SKIP TO C3).................................. 8
A.
Could you tell me if the fire happened (READ
CATEGORIES)?
C3.
At the time of the fire, was the temperature
outside below freezing, cold, mild, or hot?
In the morning, that is from 6am until before noon....... 1
In the afternoon, that is from after 12 noon until
before 5pm ....................................................................... 2
In the evening, from 5pm until before 9pm .................... 3
At night, from 9pm until before midnight ........................ 4
Overnight, from midnight until before 6am..................... 5
BELOW FREEZING ............................................................... 1
COLD ..................................................................................... 2
MILD ...................................................................................... 3
HOT........................................................................................ 4
C4.
Was it snowing, raining, excessively windy, or
clear?
SNOWING ............................................................................. 1
RAINING ................................................................................ 2
EXCESSIVELY WINDY ......................................................... 3
CLEAR ................................................................................... 4
C5.
In which room or area did the fire start?
ATTACHED GARAGE OR CARPORT .................................. 1
ATTIC..................................................................................... 2
BASEMENT ........................................................................... 3
BATHROOM .......................................................................... 4
BEDROOM ............................................................................ 5
DINING ROOM / AREA ......................................................... 6
KITCHEN ............................................................................... 7
LAUNDRY ROOM.................................................................. 8
LIVING ROOM (INCLUDING DEN, REC. ROOM, AND
FAMILY ROOM) ................................................................. 9
PORCH OR DECK............................................................... 10
ROOF................................................................................... 11
SIDING OF THE HOME....................................................... 12
CLOSET............................................................................... 13
UTILITY ROOM (INCLUDING HEATING
AREA/FURNACE ROOM)................................................ 14
WITHIN ENCLOSED WALL SPACE OR SPACE
WITHIN CEILING AND FLOOR ABOVE.......................... 15
CRAWL SPACE, INCLUDING UNDER MOBILE HOME..... 16
OTHER EXTERIOR LOCATIONS ....................................... 17
HALL, ENTRYWAY.............................................................. 18
SPECIFY: __________________________
OTHER (SPECIFY).............................................................. 19
DON’T KNOW .......................... (SKIP TO C11)................... 97
REFUSED ................................ (SKIP TO C11)................... 98
G:\Controlled Files\PD\FG487102-13\Q\Sect C v3.doc
Survey of Residential Fire Injury Incidents
C6.
C7.
Was there carpeting in the room or area where
the fire started?
YES .........................................................................................1
Was there an interior finish, such as wood
paneling or wallpaper, in the room or area where
the fire started?
YES .........................................................................................1
A.
C8.
Page C-2
NO...........................................................................................2
NO...................................(SKIP TO C8) .................................2
What type of finish was it? SPECIFY: _____________________________________________
What objects and fixtures were in the room or
area where the fire started? CODE ALL THAT
APPLY. SHOW CARD A.
APPLIANCE .......................................................................... 1
BEDDING, BLANKETS (INCLUDING SHEETS AND
PILLOWS) .......................................................................... 2
CABINETS ............................................................................. 3
CHRISTMAS TREE, OTHER HOLIDAY DECORATIONS .... 4
CLOTHING BEING WORN AT THE TIME OF THE FIRE ..... 5
CLOTHING NOT BEING WORN AT THE TIME OF THE
FIRE ................................................................................... 6
COOKING MATERIALS, FOOD, GREASE
(EXCLUDING TEXTILES, PACKAGING)........................... 7
DRAPES, CURTAINS............................................................ 8
ELECTRICAL WIRING (INCLUDING WIRING
INSULATION)..................................................................... 9
EXTERNAL STRUCTURE (ROOF, OUTSIDE OF THE
HOME, SIDING) ............................................................... 10
FABRIC AND TEXTILES; EXCEPT CLOTHING,
MATTRESSES, BEDDING/BLANKETS,
UPHOLSTERED FURNITURE, CURTAINS/DRAPES,
AND CARPETS AND RUGS ............................................ 11
FLAMMABLE LIQUID SUPPLIES (INCLUDING
GASOLINE, KEROSENE, ETC.)...................................... 12
FURNITURE, UPHOLSTERED ........................................... 13
FURNITURE, NOT UPHOLSTERED................................... 14
INTERIOR FINISH (WOOD PANELING, WALLPAPER)..... 15
LIGHTING FIXTURES OR LAMPS...................................... 16
MAGAZINE, BOOKS, NEWSPAPERS, PACKAGING......... 17
MATTRESS ......................................................................... 18
RUGS, CARPETS AND FLOOR COVERINGS ................... 19
THERMAL INSULATION ..................................................... 20
TOYS / GAMES ................................................................... 21
SPECIFY: __________________________
TRASH ................................................................................. 22
OTHER (SPECIFY).............................................................. 23
NOTHING ELSE .................................................................. 24
C9.
What was the cause of the fire? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
G:\Controlled Files\PD\FG487102-13\Q\Sect C v3.doc
Survey of Residential Fire Injury Incidents
C10.
Now please think of the items that caught on fire.
What item caught fire first?
Page C-3
APPLIANCE ...........................................................................1
BEDDING, BLANKETS (INCLUDING SHEETS AND
PILLOWS) ...........................................................................2
CABINETS ..............................................................................3
CHRISTMAS TREE, OTHER HOLIDAY DECORATIONS .....4
CLOTHING BEING WORN AT THE TIME OF THE FIRE ......5
CLOTHING NOT BEING WORN AT THE TIME OF THE
FIRE ....................................................................................6
COOKING MATERIALS, FOOD, GREASE
(EXCLUDING TEXTILES, PACKAGING)............................7
DRAPES, CURTAINS.............................................................8
ELECTRICAL WIRING (INCLUDING WIRING
INSULATION)......................................................................9
EXTERNAL STRUCTURE (ROOF, OUTSIDE OF THE
HOME, SIDING) ................................................................10
FABRIC AND TEXTILES; EXCEPT CLOTHING,
MATTRESSES, BEDDING/BLANKETS,
UPHOLSTERED FURNITURE, CURTAINS/DRAPES,
AND CARPETS AND RUGS .............................................11
FLAMMABLE LIQUID SUPPLIES (INCLUDING
GASOLINE, KEROSENE, ETC.).......................................12
FURNITURE, UPHOLSTERED ............................................13
FURNITURE, NOT UPHOLSTERED....................................14
INTERIOR FINISH (WOOD PANELING, WALLPAPER)......15
LIGHTING FIXTURES OR LAMPS.......................................16
MAGAZINE, BOOKS, NEWSPAPERS, PACKAGING..........17
MATTRESS ..........................................................................18
RUGS, CARPETS AND FLOOR COVERINGS ....................19
THERMAL INSULATION ......................................................20
TOYS / GAMES ....................................................................21
TRASH ..................................................................................22
SPECIFY: __________________________
OTHER (SPECIFY)...............................................................23
NOTHING ELSE ...................................................................24
C11.
Did any of the following liquids, gases, or vapors
ignite? Such as (READ CATEGORIES)? CODE ALL
THAT APPLY.
SPECIFY: __________________________
C12.
Where were you in relation to the fire when you
became aware of it? Were you (READ
CATEGORIES)?
G:\Controlled Files\PD\FG487102-13\Q\Sect C v3.doc
Adhesives (e.g., wallpaper paste, epoxy, or tile
cement) ........................................................................... 1
Aerosol (e.g., disinfectant spray, bug spray) ................. 2
Cleaning materials.............................................................. 3
Gasoline ............................................................................... 4
Kerosene .............................................................................. 5
Natural gas .......................................................................... 6
Propane, butane (liquid petroleum gas) ......................... 7
Diesel fuel ............................................................................ 8
Lighter fluid .......................................................................... 9
Other (SPECIFY) ................................................................ 10
At the point of ignition ........................................................ 1
In the same room as the fire, but not where it ignited.. 2
Outside of the room of fire origin ..................................... 3
Survey of Residential Fire Injury Incidents
Page D-1
SECTION D: BUILDING STRUCTURE CHARACTERISTICS
D1.
What type of home was involved in the fire we’ve
been discussing? Would you say it is a (READ
CATEGORIES)?
SPECIFY: __________________________
D2.
About how old is this structure? PROBE ONLY IF
NEEDED: Would you say (READ CATEGORIES)?
Detached single family home ........................................... 1
Mobile home or manufactured home .............................. 2
Two-family dwelling ............................................................ 3
Low-rise apartment building ............................................. 4
Townhouse or row house.................................................. 5
Other (SPECIFY) .................................................................. 6
5 YEARS OLD OR LESS................ (SKIP TO D3) ............... 1
6–15 YEARS OLD .......................... (SKIP TO D3) ............... 2
16–25 YEARS OLD ........................ (SKIP TO D3) ............... 3
26–35 YEARS OLD ........................ (SKIP TO D3) ............... 4
36–45 YEARS OLD ........................ (SKIP TO D3) ............... 5
46 YEARS OLD OR OLDER........... (SKIP TO D3) ............... 6
DK ........................................................ (ASK A) .................... 7
RF ........................................................ (ASK A) .................... 8
A.
D3.
Could you estimate in what year the structure
was build?
Do you own or rent this home?
APPROXIMATE YEAR BUILT ........................
OWN ...................................................................................... 1
RENT ..................................................................................... 2
D4.
SPECIFY: __________________________
OTHER (SPECIFY)................................................................ 3
Which of the following sources do you typically
use to heat your home? READ CATEGORIES.
Central heating .................................................................... 1
Stove ..................................................................................... 2
Electric space heater ......................................................... 3
Kerosene space heater ..................................................... 4
Fireplace .............................................................................. 5
Other (SPECIFY) .................................................................. 6
CODE ALL THAT APPLY.
SPECIFY: _____________________________
DK .......................................................................................... 7
RF .......................................................................................... 8
D5.
What type of lighting source were you using at the
time of the fire? READ CATEGORIES.
SPECIFY: _____________________________
Electric .................................................................................. 1
Oil .......................................................................................... 2
Candles ................................................................................ 3
Other (SPECIFY) .................................................................. 4
D6.
Did you have any smoke detectors in this home or
apartment at the time of the fire? Do not include
heat detectors or carbon monoxide (CO)
detectors.
YES ........................................................................................ 1
NO................................... (SKIP TO D9)................................ 2
DK ................................... (SKIP TO D9)................................ 7
D7.
Was there a smoke detector in the room where
the fire started?
YES ........................................................................................ 1
NO................................... (SKIP TO D8)................................ 2
DK ................................... (SKIP TO D8)................................ 8
A. Did the smoke detector go off?
YES ........................................................................................ 1
NO.......................................................................................... 2
Was there a smoke detector in any other room?
YES ........................................................................................ 1
NO................................... (SKIP TO D9)................................ 2
DK ................................... (SKIP TO D9)................................ 7
A. Did any of these smoke detectors go off?
YES ........................................................................................ 1
NO.......................................................................................... 2
D8.
G:\Controlled Files\PD\FG487102-13\Q\Sect D v2.doc
Survey of Residential Fire Injury Incidents
Page D-2
Now I would like to ask you some general questions about your home.
D9.
How many levels does your (home/apartment)
have? Please include an unfinished basement,
but do not include an unfinished attic. IF NEEDED
FOR PEOPLE WHO LIVE IN SHARED HOUSING
SITUATION, SAY: “I only need to know about your
unit, not the entire building.”
1 LEVEL ......................... (SKIP TO D11)............................... 1
2 LEVELS .............................................................................. 2
3 LEVELS .............................................................................. 3
4 LEVELS .............................................................................. 4
5 LEVELS .............................................................................. 5
6 LEVELS .............................................................................. 6
DK .......................................................................................... 7
D10.
On what floors are doors to the outside of your
(home/apartment) located? CODE ALL THAT
APPLY.
BASEMENT ........................................................................... 1
1
ST
FLOOR............................................................................. 2
2
ND
FLOOR ............................................................................ 3
3
RD
FLOOR ............................................................................ 4
4
TH
FLOOR............................................................................. 5
5
TH
FLOOR............................................................................. 6
ATTIC................................................................................... 10
DK .......................................................................................... 7
D11.
D12.
If needed, could you have used a window to
escape?
YES ........................................................................................ 1
At the time of the fire, was there a sprinkler
system installed in the room where the fire
started?
YES ........................................................................................ 1
NO.......................................................................................... 2
NO................................... (SKIP TO E1) ................................ 2
DK ................................... (SKIP TO E1) ................................ 7
RF ................................... (SKIP TO E1) ................................ 8
A. Did the sprinkler system spray water at the
time of the fire?
G:\Controlled Files\PD\FG487102-13\Q\Sect D v2.doc
YES ........................................................................................ 1
NO.......................................................................................... 2
Survey of Residential Fire Injury Incidents
Page E-1
SECTION E: INJURIES SUSTAINED
PROGRAMMER NOTE: If R is a “Control,” skip to F1.
Now I’d like to ask you some questions related to any illnesses or injuries associated with the fire.
E1.
Were you injured or did you become ill as a result
of the fire?
YES ........................................................................................ 1
NO................................... (SKIP TO F1) ................................ 2
DK ................................... (SKIP TO F1) ................................ 7
RF ................................... (SKIP TO F1) ................................ 8
E2.
What type of medical attention did you require?
NONE..................................................................................... 1
CODE ALL THAT APPLY.
CALL TO THE DOCTOR ....................................................... 2
VISIT TO THE DOCTOR’S OFFICE/CLINIC/HMO................ 3
TREATMENT IN THE EMERGENCY ROOM........................ 4
ADMITTED TO THE HOSPITAL............................................ 5
FIRST AID AT THE SITE ....................................................... 6
E3.
SPECIFY: __________________________
OTHER (SPECIFY)................................................................ 7
What type of fire-related injury or illness did you
have? Did you have (READ CATEGORIES)? CODE
Burns..................................................................................... 1
Smoke inhalation (e.g., trouble breathing) ..................... 2
Cuts and bruises ................................................................. 3
Broken bones/fractures ..................................................... 4
Heart trouble ........................................................................ 5
Any other illness or injury (SPECIFY) ............................... 6
ALL THAT APPLY.
SPECIFY: __________________________
E4.
Where were you when you were injured? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
E5.
How did the injury happen? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
G:\Controlled Files\PD\FG487102-13\Q\Sect E v2.doc
Survey of Residential Fire Injury Incidents
Page F-1
SECTION F: INJURIES TO OTHERS
F1.
Now let’s talk about the other people who were present during the fire. Let’s start with the youngest person. What is his or her first name?
I.
What is the first name?
II.
What is (NAME)’s
relationship to
you?
SEE CODE BOX II.
III.
What is (NAME)’s
age?
YEARS
IV.
What is
(NAME)’s
gender?
M
F
V.
At the
time, did
(NAME)
usually live
in this
residence?
VI.
Was
(NAME)
injured in
the fire?
YES
YES
NO
NO
VII.
What type
of medical
attention
was
required for
(NAME)?
VIII.
What type of
fire-related
injury or
illness did
(NAME)
sustain?
SEE CODE
BOX VII.
SEE CODE
BOX VIII.
NXT PERSON
1.
_______________________
2.
_______________________
3.
_______________________
4.
_______________________
5.
_______________________
6.
_______________________
7.
_______________________
8.
_______________________
9.
_______________________
G:\Controlled Files\PD\FG487102-13\Q\Sect F v1.doc
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
____________
_____________
____________
_____________
____________
_____________
____________
_____________
____________
_____________
____________
_____________
____________
_____________
____________
_____________
____________
_____________
Survey of Residential Fire Injury Incidents
CODE BOX II: CODE ONLY ONE.
SPOUSE ....................................................................... 1
CHILD ........................................................................... 2
PARENT........................................................................ 3
GRANDPARENT........................................................... 4
OTHER RELATIVE ....................................................... 5
SIGNIFICANT OTHER .................................................. 6
FRIEND......................................................................... 7
ROOMMATE/BOARDER .............................................. 8
OTHER (SPECIFY) ....................................................... 9
CODE BOX VII: CODE ALL THAT APPLY.
NONE.............................................................................1
CALL TO THE DOCTOR................................................2
VISIT TO THE DOCTOR’S OFFICE/CLINIC/HMO ........3
TREATMENT IN THE EMERGENCY ROOM ................4
ADMITTED TO THE HOSPITAL ....................................5
FIRST AID AT SITE .......................................................6
OTHER (SPECIFY) ........................................................7
CODE BOX VIII: CODE ALL THAT APPLY.
BURNS...........................................................................1
SMOKE INHALATION....................................................2
CUTS AND BRUISES ....................................................3
BROKEN BONES/FRACTURES....................................4
HEART TROUBLE .........................................................5
OTHER (SPECIFY) ........................................................7
G:\Controlled Files\PD\FG487102-13\Q\Sect F v1.doc
Page F-2
Survey of Residential Fire Injury Incidents
Page G-1
SECTION G: PAST FIRE TRAINING AND HOME EVACUATION PLANNING
G1.
Now let’s talk about any fire safety and response education and training that you may have had. Please
tell me if you have ever had any of the following kinds of education or training. Have you had (READ
OPTIONS)? CODE ALL THAT APPLY.
I.
How many times
have you
received this
type of fire
safety education
or training?
a.
b.
c.
d.
e.
f.
g.
YES
NO
NEXT
Fire safety awareness sessions at the local
fire station........................................................
1
2
Fire safety awareness education at a local
school or community organization ..................
1
2
Merit badge programs with the Girl or Boy
Scouts .............................................................
1
2
In-service training at your place of
employment on fire safety plan, extinguisher
use...................................................................
1
2
Training as career or volunteer fire fighter or
a military fire fighter.........................................
1
2
College-level courses on fire science, fire
protection technology, fire protection
engineering .....................................................
1
2
1
2
Any other fire safety and response education
or training (SPECIFY) .......................................
II.
When did you
last receive this
kind of
education or
training?
# OF TIMES
YEAR
SPECIFY: __________________________________________________________________
G2.
Have you learned about fire prevention, safety, or
what to do in case of fire from any of the following
sources?
YES
NO
a.
Printed materials such as brochures or flyers......
1
2
b.
Public service announcements on TV or radio ....
1
2
c.
On the internet .....................................................
1
2
d.
Any other source (SPECIFY).................................
1
2
SPECIFY: ________________________
G3.
Did you have a home evacuation plan at the time
of the fire incident?
YES ........................................................................................ 1
NO................................... (SKIP TO H1) ............................... 2
DK ................................... (SKIP TO H1) ............................... 7
RF ................................... (SKIP TO H1) ............................... 8
G:\Controlled Files\PD\FG487102-13\Q\Sect G v2.doc
Survey of Residential Fire Injury Incidents
G4.
Page G-2
What was your home evacuation plan at the time of the fire incident? RECORD VERBATIM.
RECORD VERBATIM: __________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
G5.
Did your household practice the evacuation plan?
YES ........................................................................................ 1
NO................................... (SKIP TO G7) ............................... 2
DK ................................... (SKIP TO G7) ............................... 7
RF ................................... (SKIP TO G7) ............................... 8
G6.
How many times was it practiced? Would you say
(READ CATEGORIES)?
Once or twice ...................................................................... 1
Three to 5 times .................................................................. 2
More than 5 times ............................................................... 3
G7.
On the day of the fire incident, did you follow your
home evacuation plan?
YES ........................................................................................ 1
NO.......................................................................................... 2
G:\Controlled Files\PD\FG487102-13\Q\Sect G v2.doc
Survey of Residential Fire Injury Incidents
Page H-1
SECTION H: PAST FIRE EXPERIENCE
Now let’s talk about other times when you may have been in a fire, including fires in your place of work,
cars, or elsewhere.
H1.
Have you ever been in a fire before this one?
YES.........................................................................................1
NO ....................................(SKIP TO J1) ................................2
DK .....................................(SKIP TO J1) ................................7
RF .....................................(SKIP TO J1) ................................8
H2.
How many fires had you been in before this one?
# OF FIRES .................................................................
PROGRAMMER NOTE: Repeat H3-H4 for the number of times in H2. H3_1 to H4_1, H3_2 to H4_2, etc.
H3.
What year did the (first fire/next fire) occur?
YEAR ...............................................................
H4.
Where did the (first fire/next fire) occur?
AT HOME ...............................................................................1
AT A JOB ................................................................................2
SCHOOL.................................................................................3
STORE ...................................................................................4
CAR OR VEHICLE .................................................................5
SPECIFY: __________________________
G:\Controlled Files\PD\FG487102-13\Q\Sect H v2.doc
OTHER (SPECIFY) ................................................................6
Survey of Residential Fire Injury Incidents
Page J-1
SECTION J: MENTAL AND PHYSICAL HEALTH
The next set of questions relate to your mental and physical health. These questions are meant to help
us understand factors related to residential fires.
J1.
During the two weeks before the fire incident,
on how many occasions did you use (READ
ITEM)? Would you say (READ CATEGORIES)?
SHOW CARD B.
Never
1-2
times
3-5
times
6-9
times
10-19
times
20 or
more
times
a. Tobacco .................................................................
1
2
3
4
5
6
b. Alcohol (beer, wine, liquor) ....................................
1
2
3
4
5
6
c. Marijuana (Hash, pot, hash oil)..............................
1
2
3
4
5
6
d. Other illegal drugs..................................................
1
2
3
4
5
6
PROGRAMMER NOTE: IF J1a = 1, SKIP TO J3.
J2.
Were you smoking tobacco within one hour of
the fire incident?
YES ........................................................................................ 1
NO.......................................................................................... 2
PROGRAMMER NOTE: IF J1b = 1, SKIP TO J6.
J3.
Did you consume alcohol within five hours of the
fire incident?
YES ........................................................................................ 1
NO................................. (SKIP TO J6) .................................. 2
DK ................................. (SKIP TO J6) .................................. 7
RF ................................. (SKIP TO J6) .................................. 8
J4.
On the day of the fire incident, how many hours
did you spend drinking alcohol? Please give your
best estimate.
# HOURS DRINKING ALCOHOL ................................
J5.
How many alcoholic drinks did you consume over
that time period? Please give you best estimate.
# OF ALCOHOLIC DRINKS.........................................
J6.
During the two weeks before the fire incident,
were you taking prescriptions or medications?
YES ........................................................................................ 1
NO................................. (SKIP TO J8) .................................. 2
DK ................................. (SKIP TO J8) .................................. 7
RF ................................. (SKIP TO J8) .................................. 8
A.
Please tell me what types of prescriptions and medications you were taking.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
J7.
On the day of the fire incident, were you taking
prescriptions or medications?
A.
YES ........................................................................................ 1
NO.......................................................................................... 2
Please tell me what types of prescriptions and medications you were taking.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
G:\Controlled Files\PD\FG487102-13\Q\Sect J v2.doc
Survey of Residential Fire Injury Incidents
J8.
Page J-2
Do you have any problems with (READ OPTION)?
YES
NO
a.
your eyesight ........................................................
1
2
b.
your hearing..........................................................
1
2
c.
your sense of smell ..............................................
1
2
PROGRAMMER NOTE: For each “Yes” to J8, ask J9 and J10. (J9_1, J10_1, J9_2, J10_2, etc.)
YES ........................................................................................ 1
NO...................................(SKIP TO J11) ............................... 2
DK ...................................(SKIP TO J11) ............................... 7
RF ...................................(SKIP TO J11) ............................... 8
J9.
Do you think the problem with your
(eyesight/hearing/smell) affected your ability to
recognize and respond to the fire?
J10.
How do you think this problem affected you? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
J11.
Do you have any of the following conditions?
READ CATEGORIES. CODE ALL THAT APPLY.
A.
Breathing difficulties ...................(ASK A) .......................... 1
Dizziness .................................(SKIP TO J12) ..................... 2
Pregnancy ...............................(SKIP TO J12) ..................... 3
Migraines.................................(SKIP TO J12) ..................... 4
Fainting ....................................(SKIP TO J12) ..................... 5
Vertigo .....................................(SKIP TO J12) ..................... 6
Balance problems ..................(SKIP TO J12) ..................... 7
None of the above .............................................................. 8
What kinds of breathing difficulties do you have? RECORD VERBATIM.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
J12.
Around the time of the fire incident, did you have
any health problem that required you to use
special equipment, such as a cane, a wheelchair,
oxygen tank, a special bed, or a special phone?
YES ........................................................................................ 1
NO...................................(SKIP TO J15) ............................... 2
DK ...................................(SKIP TO J15) ............................... 7
RF ...................................(SKIP TO J15) ............................... 8
J13.
Is this condition permanent or temporary?
PERMANENT ........................................................................ 1
TEMPORARY ........................................................................ 2
J14.
Around the time of the fire incident, what type of
mobility aid were you using? CODE ALL THAT
APPLY.
WHEELCHAIR ....................................................................... 1
CRUTCHES ........................................................................... 2
CANE ..................................................................................... 3
WALKER ................................................................................ 4
OTHER (SPECIFY)................................................................ 5
NONE..................................................................................... 6
SPECIFY: __________________________
J15.
Now I’d like you to think about your mental health,
which includes dealing with stress, feelings, and
emotions. On the day of the fire incident, before
the fire, would you say that your mental health
was (READ CATEGORIES)?
Excellent ............................................................................... 1
Very good ............................................................................. 2
Fair ........................................................................................ 3
Poor....................................................................................... 4
J16.
During the past two weeks before the fire incident,
about how many days did poor physical or mental
health keep you from doing your usual activities,
such as self-care, work, or recreation?
# OF DAYS ........................................................
NONE........................................................................00
G:\Controlled Files\PD\FG487102-13\Q\Sect J v2.doc
Survey of Residential Fire Injury Incidents
Page K-1
SECTION K: BACKGROUND INFORMATION
The last few questions are used for statistical purposes.
K1.
Which of the following best describes your work
status at the time of the fire? READ CATEGORIES.
SPECIFY: _____________________________
K2.
What is the highest level of education that you
have completed? ONLY READ LIST IF NEEDED.
Employed full time outside the home .............................. 1
Employed part time outside the home ............................ 2
Self-employed ..................................................................... 3
Keeping house .................................................................... 4
Retired .................................................................................. 5
Student ................................................................................. 6
Unemployed, looking for work .......................................... 7
Other (SPECIFY) .................................................................. 8
LESS THAN HIGH SCHOOL ................................................. 1
SOME HIGH SCHOOL .......................................................... 2
HIGH SCHOOL GRADUATE ................................................. 3
TECHNICAL/VOCATIONAL SCHOOL TRAINING ................ 4
SOME COLLEGE .................................................................. 5
COLLEGE GRADUATE ......................................................... 6
POSTGRADUATE WORK ..................................................... 7
Less than $15,000 .............................................................. 1
$15,000 to less than $35,000 ........................................... 2
$35,000 to less than $75,000 ........................................... 3
$75,000 or more ................................................................. 4
K3.
Please tell me which of the following categories
best describes your household income for 2005?
SHOW CARD C.
K4.
In what year were you born?
YEAR OF BIRTH ............................................
K5.
Are you of Hispanic or Latino descent?
YES ........................................................................................ 1
NO.......................................................................................... 2
K6.
What do you consider your race to be? Are you
(READ CATEGORIES)? SELECT ONE OR MORE.
SHOW CARD D.
K7.
What is your primary language; that is the
language you are most comfortable speaking?
White ..................................................................................... 1
Black or African-American ................................................ 2
Asian ..................................................................................... 3
Native Hawaiian or Other Pacific Islander ..................... 4
American Indian or Alaska Native ................................... 5
ENGLISH ............................................................................... 1
SPANISH ............................................................................... 2
OTHER (SPECIFY)................................................................ 3
SPECIFY: __________________________
K8.
Please indicate your opinion about the following
statement: “These questions made me feel upset
because they reminded me of my experiences in
a fire.” Do you (READ CATEGORIES)?
Strongly Agree .................................................................... 1
Agree .................................................................................... 2
Neither Agree nor Disagree .............................................. 3
Disagree ............................................................................... 4
Strongly Disagree ............................................................... 5
K9.
INDICATE SEX OF RESPONDENT WITHOUT
ASKING.
MALE ..................................................................................... 1
FEMALE................................................................................. 2
I’d like to thank you for taking the time to help us answer these important questions. The information you
have given us will be very helpful. Thank you for your cooperation.
G:\Controlled Files\PD\FG487102-13\Q\Sect K v4.doc
Survey of Residential Fire Injury Incidents
Page L-1
SECTION L: INTERVIEWER OBSERVATIONS
DO NOT READ TO RESPONDENT.
L1.
Interview took place:
IN THE HOME WHERE FIRE OCCURRED .......................... 1
IN A TEMPORARY HOME .................................................... 2
IN A SHELTER ...................................................................... 3
SPECIFY: __________________________
L2.
IN A HOSPITAL ..................................................................... 4
OTHER PLACE (SPECIFY) ................................................... 5
Please indicate if any of the following occurred:
R BECAME UPSET DURING INTERVIEW ........................... 1
CODE ALL THAT APPLY.
R WAS DISORIENTED OR NOT ALERT .............................. 2
MANY DISTRACTIONS DURING THE INTERVIEW ............ 3
SIGNIFICANT INCONSISTENCIES IN R’S RESPONSES ... 4
SPECIFY: __________________________
G:\Controlled Files\PD\FG487102-13\Q\Sect L v2.doc
ANYTHING ELSE ABOUT THE INTERVIEW (SPECIFY)..... 5
| File Type | application/pdf |
| File Modified | 2006-07-19 |
| File Created | 2006-01-25 |