Form QID All - Terrain Vehicle Prevlance and Injury Questionnaire

Project 915				OMB No. 0535-0235 Approval Expires 12/31/2011
	NATIONAL AGRICULTURAL STATISTICS SERVICE	All-TerraIn Vehicle prevlance and INJURY QUESTIONNAIRE
U.S. Department of Agriculture, Rm 5030, South Building 1400 Independence Ave., S.W. Washington, DC 20250-2000 Phone: 1-800-727-9540 Fax: 202-690-2090 Email: nass@nass.usda.gov		(Phone Script – This survey is conducted totally by Phone Enumerators. Pre-survey letters are sent to the respondents notifying them of our upcoming calls.)					Form Approval
						National
Please make corrections to name, address and Zip Code, if necessary.

Intro 1	Hello, my name is _________________________. I am working with the National Agricultural Statistics Service on behalf of the Center for Disease Control and Prevention. We are interested in learning more about all-terrain-vehicle (ATV) use on farms. We are asking farmers/ranchers for information about their operations, as well as information on ATVs and any associated injuries that occurred on the farm/ranch in 2011. This will take about 10 minutes.
	The information you provide will be held strictly CONFIDENTIAL. Your cooperation is VOLUNTARY, and you may refuse to answer any question. This information will be combined with other’s to help identify the prevalence of ATVs on farms and to develop injury prevention and health promotion programs nationwide. Would you help us by answering these questions?
	- YES [Continue on Intro 2]
	- NO
		I assure you that everything you tell us will be kept CONFIDENTIAL. Your answers are very important to us even if you did not have an ATV on your farm, or did not have an ATV-related injury on your farm in 2011. The information will help identify programs for preventing these injuries in the future. Your cooperation will benefit all farm/ranch families. Would you please consider helping us?
		YES - [Continue on Intro 2]
		NO – I’m sorry to have bothered you. Thank you for your time.
		Says not a farm - [Continue with Intro 1a]
		Does not speak English

Intro 1a

Please answer the following question(s) for the total acres you (name on label) operate.

a. Did you grow any crops or cut hay in 2011?

Yes – [Go to Intro 2]

No – [Continue]

b. Is any of the land in this operation cropland? (Including idle cropland and cropland in government programs such as CRP, etc.)

Yes – [Go to Intro 2]

No – [Continue]

c. In 2011 did you have any whole grains, oilseeds, or hay stored on this operation?

Yes – [Go to Intro 2]

No – [Continue]

d. Do you have facilities for storing whole grains or oilseeds?

Yes – [Go to Intro 2]

No – [Continue]

e. Do you own or raise any livestock or poultry?

Yes – [Go to Intro 2]

No – [Go to Conclusion]

Intro 2

May I please speak to the farm operator?

01 Yes

02 Not available

When would be a good time to call back? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

03 Spouse will give information

04 Non-farm residence/business address

2.

Please verify name and mailing address of this operation. Make corrections (including the correct operation name) on the label and continue.

[Check box if name and address are verified].

3.

How many people live in your household (INCLUDING yourself, and EXCLUDING temporary visitors)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.

How many of these household members are under the age of 20?

RESPONDENT SUMMARY

1.

Respondent’s Gender?

01 Male

02 Female

2.

What was your age on your last birthday? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.

What is the highest education level you have achieved? (Check ONLY ONE)

01 Less than high school

07 Doctorate

02 High school diploma/GED

08 Professional – MD, JD, DDS, etc.

03 Associates, two-year Junior College degree

09 Other (Specify __________________)

04 Vocational/Technical school

77 Don’t know

05 Bachelor’s degree

99 Refused

06 Master’s degree

4.

What is your marital status? (Please √ only one)

01 Married

05 Married, but apart

99 Refused

02 Widowed

06 Single

03 Divorced

07 Single, living with a partner

04 Separated

77 Don’t know

5.

At anytime during 2011, did you operate or ride as a passenger on an all-terrain vehicle (ATV), either for work or recreation, on the farm or ranch?

01 Yes

03 No (Go to HH summary)

6.	Have you ever completed a formal ATV safety training course?
	01 Yes	03 No
7.	On average, how often would you say you operated or rode on an ATV in 2011?
	01 10 or more times a month	04 Less than once a month
	02 5 to 9 times a month	77 Don’t know
	03 1 to 4 times a month	99 Refused
8.	Would you say that you always, sometimes, or never wear a helmet?
	01 Always (Go to HH Summary)	77 Don’t know
	02 Sometimes	99 Refused
	03 Never (Go to HH summary)
9.	What factors influence your decision to wear a helmet? (√ all that apply)
	01 Required by law	06 Weather conditions
	02 Riding terrain conditions	07 Public road
	03 Recreational use	08 Other (Specify ____________________)
	04 Presence of youth	77 Don’t know
	05 Type of work task	99 Refused
HOUSEHOLD SUMMARY
Enumerator note: If Married (01) or Single, living with a partner (07) are marked in question 4, complete questions 1 through 7. Otherwise go to question 8 if Intro 2, question 3 indicates others in the household.
1.	Gender of spouse/partner?
	01 Male	02 Female
2.	What was his/her age on his/her last birthday? . . . . . . . . . . . . . . . . . . . . . . . .
3.	What is the highest education level he/she has achieved? (Check ONLY ONE)
	01 Less than high school	07 Doctorate
	02 High school diploma/GED	08 Professional – MD, JD, DDS, etc.
	03 Associates, two-year Junior College degree	09 Other (Specify __________________)
	04 Vocational/Technical school	77 Don’t know
	05 Bachelor’s degree	99 Refused
	06 Master’s degree
4.	Did he/she operate or ride as a passenger on an ATV, either for work or recreation, on the farm or ranch anytime in 2011?
	01 Yes	03 No (Go to Question 8 if question 3 >2)

5.	Has he/she ever completed a formal ATV safety training course?
	01 Yes	03 No
6.	On average, how often would you say he/she operated or rode on an ATV in 2011?
	01 10 or more times a month	04 Less than once a month
	02 5 to 9 times a month	77 Don’t know
	03 1 to 4 times a month	99 Refused
7.	Would you say that he/she always, sometimes, or never wears a helmet?
	01 Always	77 Don’t know
	02 Sometimes	99 Refused
	03 Never
Enumerator note: Ask the following questions for each person living within the household. Report information for up to 10 household members.
Now I would like to ask you some questions about each of the remaining people living in your household, starting with the oldest.
8.	Gender?
	01 Male	02 Female
9.	What was his/her age on their last birthday? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.	How many years of schooling has he/she completed? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.	Did he/she operate or ride as a passenger on an ATV, either for work or recreation, on the farm or ranch anytime in 2011?
	01 Yes	03 No (Go to ATV Summary Question 1)
12.	Has he/she ever completed a formal ATV safety training course?
	01 Yes	03 No
13.	On average, how often would you say he/she operated or rode on an ATV in 2011?
	01 10 or more times a month	04 Less than once a month
	02 5 to 9 times a month	77 Don’t know
	03 1 to 4 times a month	99 Refused

14.	Would you say that he/she always, sometimes, or never wears a helmet?
	01 Always	77 Don’t know
	02 Sometimes	99 Refused
	03 Never

Enumerator note: Ask the next question only if the household member is less than 16 years of age.
15.	Do they ever ride an ATV with an engine size greater than 400 cc?
	01 Yes	03 No
ATV SUMMARY
As you may know, ATVs are becoming more common on farms. In order to accurately access the prevalence of ATVs on farms, we need to ask you some information about any ATVs used on your farm/ranch.
1.	How many ATVs or utility vehicles such as a Gator® or Mule® (do you/does the farm operator) have on your farm?
	Number __________________________	(If 0, go to question 9)
	77 Don’t know
	99 Refused
2.	How many of these are the utility type with a bench seat, such as a Gator® or Mule®?
	Number __________________________
	77 Don’t know
	99 Refused
3.	How many of the ATVs were used for work purposes? (If 0, go to question 7)
	Number __________________________
	77 Don’t know
	99 Refused
4.	How many of the ATVs used for work have a PTO?
	Number __________________________
	77 Don’t know
	99 Refused

5.	(Have you/has the farm operator) used an ATV for any of the following tasks at any time during 2011 (√ all that apply). ENUM NOTE: Please read categories.
	01 Using a wench	07 Spraying/chemical application
	02 Moving livestock	08 General Farm Transportation (incl. supervision of workers, inspection of crops/livestock, etc.)
	03 Transporting materials (towing or hauling)	09 Seeding
	04 Using a blade to move snow/dirt/other	77 Don’t know
	05 Mowing/brush-hog	99 Refused
	06 Plowing/soil preparation

Enumerator note: Ask question 6 for each task identified in Question 5.
6.	How was this task completed prior to using an ATV?
	01 Tractor	05 Task not performed prior to ATV
	02 Truck	06 Other (Specify _________________)
	03 Horse	77 Don’t know
	04 Skid-steer loader	99 Refused
Beginning with the newest ATV and working back to the oldest ATV:
Enumerator note: Repeat questions 7 and 8 for up to 5 ATVs.
7.	What make is the ATV?
	01 Argo	08 Recreative Industries
	02 Arctic Cat	09 Suzuki
	03 Bombardier	10 Yamaha
	04 Honda	11 Other (Specify _________________)
	05 John Deere	77 Don’t know
	06 Kawasaki	99 Refused
	07 Polaris
8.	What is the size of the ATV?
	01 200 cc and smaller	03 501 cc and larger
	02 201-300 cc	77 Don’t know
	03 301-400 cc	99 Refused
	04 401-500 cc

Now I’d like to ask you a few questions about anyone you may hire to work on your farm or ranch.
9.			During 2011, approximately how many people were hired to work on the farm or ranch (excluding household members and contract labor)? (If 0, go to Injury Summary, question 1)
			Enumerator note: use 7777 for unknown and 9999 for refusal
10.		For each worker, please tell me their age, gender, and whether or not they operated an ATV. ENUMERATOR NOTE: Repeat for up to 20 workers.
Worker				Age	Gender		Operated ATV
a.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
b.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
c.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
d.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
e.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
f.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
g.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
h.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
i.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
j.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
k.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
l.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
m.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
n.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
o.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
p.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
q.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
r.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
s.					Male	Female	Yes	No (Go to Inj. Summary if last worker)
t.					Male	Female	Yes	No (Go to Inj. Summary if last worker)

11.	Do you require your hired workers to wear a helmet when operating an ATV?
	01 Yes	03 No
12.	Do you require your hired workers to complete an ATV safety course?
	01 Yes	03 No

INJURY SUMMARY
Next, I’m going to ask you some questions about any ATV-related injuries that occurred on your farm or ranch.
1.	During 2011, did anyone on the farm/ranch experience an ATV-related injury which required at least 4 hours of restricted activity or required professional medical attention? These injuries would include those resulting from both work and recreation.
	01 Yes	03 No (Go to question 34)
2.	How many injuries of this type occurred on the farm or ranch during 2011? . . . . . . . . . . .
Now, we would like to ask you some questions about each of these injuries.
ENUMERATOR NOTE: Ask questions 3 to 33 for up to 2 injuries, if respondent does not want to provide the first name of the injured person, please use a unique identifier (such as Person A) which should also be used when completing the narrative.
3.	Starting with the most recent injury, what is the first name of the injured person?
4.	Are they male or female?
	01 Male	02 Female
5.	How old was he/she at the time of the injury? . . . . . . . . . . . . . . . . . . . . . . . .
6.	What is his/her relationship to the farm or ranch?
	01 Self	06 Boarder
	02 Child/step-child	07 Other (Specify _________________) (e.g., visitor, friend)
	03 Spouse	77 Don’t know
	04 Other relative	99 Refused
	05 Worker
7.	Is he/she Hispanic, or Latino, such as Mexican, Cuban, or Puerto Rican, regardless of race?
	01 Yes	03 No
8.	What is his/her race? (√ all that apply)
	01 American Indian or Alaska Native	04 Native Hawaiian or other Pacific Islander
	Specify tribe: _________________	05 White
	02 Asian	77 Don’t know
	03 Black or African American	99 Refused

9.	In what month did the injury occur?
	01 January	08 August
	02 February	09 September
	03 March	10 October
	04 April	11 November
	05 May	12 December
	06 June	77 Don’t know
	07 July	99 Refused
10.	Did he/she live on the farm or ranch?
	01 Yes (Go to question 13)	03 No
11.	Was he/she visiting the farm at the time of the injury?
	01 Yes	03 No
12.	Had he/she completed a training class for operating an ATV?
	01 Yes	03 No
13.	Was he/she wearing a helmet at the time of the injury?
	01 Yes	03 No
14.	Was he/she operating the ATV at the time of the injury?
	01 Yes	03 No
15.	Did the injury occur on a 3-wheel, 4-wheel, or more than 4-wheel ATV?
	01 3-wheel	77 Don’t Know
	02 4-wheel	99 Refused
	03 More than 4-wheel
16.	What was the engine size of the ATV involved in the injury?
	01 200 cc and smaller	03 501 cc and larger
	02 201-300 cc	77 Don’t know
	03 301-400 cc	99 Refused
	04 401-500 cc
17.	Was he/she towing or hauling anything when the injury occurred?
	01 Yes	03 No

18.	At the time of the injury, how many hours per week did he/she typically operate an ATV on the farm/ranch?
	01 0-10 hours	05 More than 40 hours
	02 11-20 hours	77 Don’t know
	03 21-30 hours	99 Refused
	04 31-40 hours
19.	When the injury occurred, was he/she using the ATV for recreation, using the ATV for general transportation not related to farm work, or using the ATV for farm work or chores?
	01 Recreation (Go to question 22)
	02 General transportation not related to farm work (Go to question 22)
	03 Farm work or chores
	77 Don’t Know
	99 Refused
20.	Which of the following best describes what he/she was doing at the time of the injury?
	01 Using a wench	07 Spraying/chemical application
	02 Moving livestock	08 General Farm Transportation (incl. supervision of workers, inspection of crops/livestock, etc.)
	03 Transporting materials (towing or hauling)	09 Seeding
	04 Using a blade to move snow/dirt/other	10 Other (Specify:_________________)
	05 Mowing/brush-hog	77 Don’t know
	06 Plowing/soil preparation	99 Refused
21.	Had he/she completed this task before?
	01 Yes	03 No
22.	Where on the farm or ranch did the injury occur?
	01 Crop Field or Hayfield, Orchard, Nursery	07 Driveway/Sidewalk
	02 Pasture	08 Outdoors, General
	03 In the Farm Yard	09 Other (Specify:_________________)
	04 Farm Roadway	77 Don’t know
	05 Public Roadway	99 Refused
	06 Woods/trails

23.	Now I would like for you to describe, in detail, how the injury occurred. Please include what tasks were being completed at the time, if any other equipment or machinery was involved, if anyone else was on the ATV, and any other factors you think might be important. ENUMERATOR: PROBE FOR DETAILS
Enumerator note: If the injury resulted in a fatality, you may terminate the interview unless the respondent wishes to continue.
Interviewer Checklist
Location
Road, field,etc.
Specific Activity
Extra riders

24.	Would you describe the terrain where the ATV was being driven at the time the injury occurred as level, a medium grade, or a steep grade?
	01 Level ground	77 Don’t know
	02 Medium grade	99 Refused
	03 Steep grade
25.	How would you describe the surface being driven on at the time of the injury? √ all that apply
	01 Dirt	06 Ice
	02 Grass	07 Sand
	03 Loose rock/gravel	77 Don’t know
	04 Asphalt/Concrete/Pavement	99 Refused
	05 Mud
26.	What part of the body was injured? √ all that apply
	01 Head/Skull	08 Hand/Wrist/Fingers
	02 Face	09 Leg
	03 Neck	10 Foot/Ankle/Toes
	04 Shoulder/Chest/Back	11 Internal Injuries
	05 Abdomen	12 Other (Specify: )
	06 Pelvic Region	77 Don’t know
	07 Arm	99 Refused

27.	What type of injury occurred to the __________________ (Specify body part)? √ all that apply
	01 Scrape/Abrasion		09 Crushed/Mangled
	02 Bruise/Contusion		10 Loss of Body Part/Amputation
	03 Sprain/Strain/Torn ligament		11 Nerve Injury
	04 Broken Bone/Fracture		12 Burn/Blister/Scald
	05 Dislocation		13 Concussion, Traumatic Brain Injury
	06 Cut/Laceration		14 Other (Specify: )
	07 Puncture/Stab/Jab		77 Don’t know
	08 Traumatic Rupture		99 Refused
28.	Did this injury require medical attention?
	01 Yes		03 No (Go to question 31)
29.	Did this injury require admission to a hospital?
	01 Yes		03 No (Go to question 31)
30.	How long was the hospitalization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31.	Did the injury result in a permanent disability?
	01 Yes (Go to question 33)		03 No
32.	How long were his/her normal activities restricted as a result of this injury?
	01 No restriction		06 1 month to less than 3 months
	02 Less than 1 day		07 3 months or more
	03 1 day to less than 7 days		77 Don’t know
	04 7 days less than 14 days		99 Refused
	05 14 days to less than 1 month
33.	On a scale of 1 to 5, how would you rate the overall seriousness of this injury, with 1 being minor and 5 being life-threatening?
	01 Minor	04 Severe		77 Don’t know
	02 Moderate	05 Life-threatening		99 Refused
	03 Serious	06 Fatal
		Enumerator: If respondent does not wish to continue, leave note and terminate interview.

Now, that we’ve discussed any ATV-related injuries that have occurred on the farm/ranch. I’d like to know about any ATV overturns that may have occurred that did not result in an injury.
34.	In 2011, did any of the ATVs on your farm/ranch overturn or roll without causing an injury?
	01 Yes	03 No (Go to conclusion)
35.	How many times has an ATV overturned without injury during 2011? . . . . . . . . . . . . . . . . . . .
36.	For the most recent overturn, did the ATV overturn to the side or to the front/rear?
	01 Side	77 Don’t know
	03 Front/Rear	99 Refused
37.	At the time the overturn occurred, would you describe the terrain where the ATV was being driven as level, a medium grade, or a steep grade?
	01 Level ground	77 Don’t know
	02 Medium grade	99 Refused
	03 Steep grade
38.	How would you describe the surface being driven on at the time of the overturn? √ all that apply
	01 Dirt	06 Ice
	02 Grass	07 Sand
	03 Loose rock/gravel	77 Don’t know
	04 Asphalt/Concrete/Pavement	99 Refused
	05 Mud
Those are all the questions I have for you today. Thank you very much for time. We hope this information will help us learn more about ATV use on farms and their related injuries. Have a good day/evening.