Appendix D

7DECINJURYMODULECY59FOROMB.wpd

NAME OF WORKER:____________________________

(REV. 12/7/06)

SUPPLEMENT ONLY FOR WORKERS WHO SAID “YES” TO ANY OF NL QUESTIONS (NAWS page 17)
– SECTION NL - INJURIES/ACCIDENTS 9
5
[NL3 CODES FOR “INJURY LIST”] IN THE LAST 12 MONTHS, HAVE YOU HAD ANY: ...
9a
9b
9c
9d

scrape/abrasion?
bruise/contusion?
amputation/lost of body part?
sprain/strain/torn ligament/
traumatic rupture?

9e
9f
9g
9h

broken or fracture bone/ crushed/ mangled?
dislocation?
cut/laceration/puncture/ stab/ jab?
burn/blister/scald?

9i

otro?:

9j

insect bite/ sting/ bitten by animal?

Please describe, how did you get injured? What happened when you where injured?
[INTERVIEWER: If there is more than one injury, write first the number corresponding to the incident (i.e., for the first incident
write number 1) in the “Injury Grid” (next page). Use the following grids for the other incidents and number each one of them. If
you need more grids, use “extras” from other unused supplements. In each grid, ask and write answers for questions NL3 to
NL20]
IN THE NEXT GRIDS, WRITE IN DETAIL ALL NARRATIVE RESPONSES TO PROMPT QUESTIONS FROM NL3 TO NL20. AS YOU
ASK EACH QUESTION, MARK RESPONSES; AND WHERE REQUIRED, MARK ITS CORRESPONDING BOX TO ENSURE THAT ALL
QUESTIONS ARE ASKED (i.e., What happened?; What were you doing?; Where did it happen?; What caused the injury/accident?;
What tools or machineries were you using when it happened?; etc.)
[USE A SEPARATE GRID FOR EACH INJURY/ACCIDENT]
CODES FOR NL13:
13. COMMUNITY HEALTH CENTER/
HOSPITAL/EMERGENCY ROOM
2. PRIVATE MEDICAL DOCTOR’S OFFICE/PRIVATE
CLINIC
3. HEALER/”CURANDERO”/”SOBADOR”

6.
7.
8.

MIGRANT CLINIC
CHIROPRACTOR/
NATUROPATH’S OFFICE
FIRST AID AT SCENE

9. DENTIST
10. WENT TO HOME COUNTY
11. OTHER:
12. NO MEDICAL TREATMENT

CODES FOR NL14:
1
2
3
4

PAID OUT OF MY OWN POCKET
MEDICAID/MEDICARE
NO CHARGE
EMPLOYER PROVIDED HEALTHPLAN

5 SELF OR FAMILY INSURANCE HEALTH
PLAN
8 BILLED, BUT DID NOT PAY
9 “WORKER’S COMPENSATION”
10 EMPLOYER PAID “OUT-OF-POCKET”

WORKER'S INJURY - PAGE 1 -

11 DO NOT REMEMBER WHO PAID FOR IT
6 OTHER:
7 COMBINATION OF:

INJURIES/ACCIDENTS

7DECINJURYMODULECY59FOROMB.wpd

INCIDENT #
NL3

(REV. 12/7/06)

[INTW: THIS GRID IS FOR THE FIRST INJURY/ACCIDENT MENTIONED BY THE INTERVIEWER]

The following questions are about this injury/accident incident. What part(s) of your body was (were) injured and what type(s) of injury(-ies) did you have in this
incident? [INTW: ASK FOR BODY-PARTS INJURIES, FROM THIS INCIDENT, FOR EACH BODY PART, WRITE ANSWER(S) AND CHECK ALL CODES
THAT APPLY (SEE CODES - FIRST PAGE NL3).
[BODY PARTS:
CODES FOR TYPE OF INJURY LISTED ON PREVIOUS PAGE (IN NL3). READ AND MARK ALL THAT APPLY]:

PART 1

a. 9

b. 9

c. 9

d. 9

e.

9

f.

9

g. 9

h. 9

i. 9

j. 9

PART 2

a. 9

b. 9

c. 9

d. 9

e.

9

f.

9

g. 9

h. 9

i. 9

j. 9

PART 3

a. 9

b. 9

c. 9

d. 9

e.

9

f.

9

g. 9

h. 9

i. 9

j. 9

[NARRATIVE SECTION (IF YOU NEED MORE SPACE, USE BACK PAGE). AFTER ASKING EACH PROMPT-QUESTION, MARK CORRESPONDING BOX]:
9 WHAT HAPPENED? 9 WHAT WERE YOU DOING? 9 WHERE DID IT HAPPEN? 9 WHAT CAUSED IT? 9 DETAILS? 9 NAMES OF MACHINES AND/OR TOOLS?

NL4

Where?:
NL5

When?:

9 1 “field” 9 2 “labor camp” 9 3 farm building 9 4 ranch roadway 9 5 public street
NL6
At current job?:

NL31
Doing FW or NF?:

NL8
Crop?

/
9 0 NO
9 1 YES
9 1 FW
9 2 NF
NL11
NL12
NL21
NL13
Not able to work normally # of days not able to work # of days DID NOT WORK Where treated? [ENTER ALL,
USE Codes]:
>4 hours?:
normally?:
because of
9 0 No
9 1 Yes
injury?:

WORKER'S INJURY - PAGE 2 -

9 8 other:
NL9
For FW: Task? / (for NF: Activity?):

NL14
NL20
How was it paid for? Did you receive
[Codes]:
first aid?
9 0 NO 9 1 Yes

INJURIES/ACCIDENTS
7DECINJURYMODULECY59FOROMB.wpd
INCIDENT #

NL3

(REV. 12/7/06)

[INTW: THIS GRID IS FOR THE SECOND INCIDENT (INJURY/ACCIDENT) MENTIONED BY THE INTERVIEWER. IF HE MENTIONS MORE THAN TWO INCIDENTES
(INJURIES/ACCIDENTS), USE BLANK FORMS FROM OTHER SUPPLEMENTS]

The following questions are about this injury/accident incident. What part(s) of your body was (were) injured and what type(s) of injury(-ies) did you have in this
incident? [INTW: ASK FOR BODY-PARTS INJURIES, FROM THIS INCIDENT, FOR EACH BODY PART, WRITE ANSWER(S) AND CHECK ALL CODES
THAT APPLY (SEE CODES - FIRST PAGE NL3).
[BODY PARTS:
CODES FOR TYPE OF INJURY LISTED ON PREVIOUS PAGE (IN NL1). READ AND MARK ALL THAT APPLY]:

PART 1

a. 9

b. 9

c. 9

d. 9

e.

9

f.

9

g. 9

h. 9

i. 9

j. 9

PART 2

a. 9

b. 9

c. 9

d. 9

e.

9

f.

9

g. 9

h. 9

i. 9

j. 9

PART 3

a. 9

b. 9

c. 9

d. 9

e.

9

f.

9

g. 9

h. 9

i. 9

j. 9

[NARRATIVE SECTION (IF YOU NEED MORE SPACE, USE BACK PAGE). AFTER ASKING EACH PROMPT-QUESTION, MARK CORRESPONDING BOX]:
9 WHAT HAPPENED? 9 WHAT WERE YOU DOING? 9 WHERE DID IT HAPPEN? 9 WHAT CAUSED IT? 9 DETAILS? 9 NAMES OF MACHINES AND/OR TOOLS?

NL4

Where?:
NL5

When?:
/
NL11

9 1 “field” 9 2 “labor camp” 9 3 farm building 9 4 ranch roadway 9 5 public street
NL6
At current job?:

9 0 NO
NL12

NL7
Doing FW or NF?:

9 1 YES

9 1 FW

NL8
Crop?

9 8 other:
NL9
For FW: Task? / (for NF: Activity?):

9 2 NF

NL21

NL13

NL14

NL20

Not able to work normally # of days not able to work # of days DID NOT WORK Where treated? [ENTER ALL, USE How was it paid for? Did you receive first
because of
Codes]:
>4 hours?:
[Codes]:
aid?
normally?:
injury?:
9 0 No
9 1 Yes
9 0 NO 9 1 Yes

WORKER'S INJURY - PAGE 3 -