Form 1 NIOSH Congressional Under-Reporting Questionnaire

Appendix F

Data collection instrument

(Underreporting questionnaire)

NIOSH Congressional Under-Reporting Questionnaire

Interviewer: record before interview

Reported date of ER visit

Date fill for [date – 3 months]

Consent

Hello. My name is (interviewer name). I am calling for the Centers for Disease Control and Prevention. We are gathering information to learn how people decide whether or not to report a workplace injury. You were chosen for this study from emergency department records. I understand that on ____/____/____ you were treated in the emergency room at ________________________________ hospital. Is this correct?

IF YES: Interviewer note: continue with introduction.

IF NO: Were you recently treated on a different day in a hospital emergency room?

IF STILL NO: Thank you for your time.

IF YES: What day was that? ____/____/____

IF DATE IS WITHIN 21 DAYS OF RECORDED DATE: Continue

with introduction.

IF DATE IS GREATER THAN 21 DAYS FROM RECORDED DATE: Thank you for your time.

In the last few weeks you should have received a letter explaining this research study and how we will protect your privacy. I am required to tell you four things that were in this letter:

(1) Taking part in this study involves a small risk to your privacy, but we take many steps to prevent that risk.

(2) There is no direct benefit for taking part in this study.

(3) Your answers to our questions will be kept private to the extent allowed by law. Your name, address, or anything else that could identify you will never be associated with the information you give.

(4) If you have questions about the study or you feel you were harmed, you may call Larry Jackson, the CDC project officer, at 304-285-5980 or Mark Toraason, the chair of the Human Subjects Review Board, at 513-533-8222.

This interview takes about 30 minutes. You do not have to answer any questions you do not want to. You can end the call at any time. Would you please help us by answering some questions?

IF YES: Interviewer note: Begin interview.

IF NO: : I assure you that everything you tell us will be kept private and will only be used

to study how people decide whether or not to report a workplace injury. Your

participation is very important. Would you please reconsider helping us?

Intro_1. I will be asking you questions related to your visit to the emergency room on [date] for [NEISS-Work diagnosis]. These questions refer to the emergency room as the ER.

IIEP. Define IIEP/work for pay

IIEP1. Please tell me about why you went to the ER on [date]? ___________________

Interview note: [If respondent suggests that there was more than one reason] say “Please describe the reason that was related to your job.”]

[If respondent suggests that there was more than one reason related to their job] say “please describe the one you felt was more serious.”]

[If hesitates, ask “What happened that sent you to the ER?”]

IIEP2. Throughout the rest of the interview, we want to use one word to refer to why you went to the ER. Which of these words work best: injury, illness, exposure to a harmful substance, or pain?

INJURY 1

ILLNESS 2 (Go to IIEP5)

EXPOSURE 3

PAIN 4

REFUSED -7 (End Interview)

Interview note: [If hesitates or says DK] say “There is no right or wrong answer. Choose the words you feel best describe why you went to the ER.” If continues to hesitate or says DK, refer to FAQs.

IIEP_Intro_1. I’m now going to ask you for some additional information about your IIEP. I will be asking you questions that refer to a health problem. A health problem can be physical or mental. It may include an injury, illness, pain, disability, or infection.

[If IIEP2=Injury or IIEP2=Exposure or IIEP2=Pain]

IIEP3. Did you go to the ER on [date] for a health problem [or IIEP] that was made worse at work?

* Programming note: the [or IIEP] in IIEP3 and IIEP3a will only be read if IIEP12 is injury or pain

YES 1

NO 2 (Go to IIEP4)

REFUSED -7 (Go to IIEP4)

DON’T KNOW -8 (Go to IIEP4)

IIEP3a. Did this health problem [or IIEP] begin before [date - 3 months]?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

IIEP4. Did the IIEP that you were seen for in the ER on [date] happen at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

* Programming note: If IIEP3=2, -7, -8 (NO, REF, DK) and IIEP4=2, -7, -8 (NO, REF, DK), then Go to Sup_Intro_1;

If IIEP3=1 (YES) or IIEP4=1 (YES), go to IIEP7

[If IIEP2=Illness]

IIEP5. Do you feel the illness that you were seen for in the ER on [date] was related to work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

IIEP6. Did you go to the ER on [date] for a health problem or illness that was made worse at work?

YES 1

NO 2 (Go to IIEP7)

REFUSED -7 (Go to IIEP7)

DON’T KNOW -8 (Go to IIEP7)

IIEP6a. Did this health problem or illness begin before [date - 3 months]?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

* Programming note: If IIEP5=2, -7, -8 (NO, REF, DK) and IIEP6=2, -7, -8 (NO, REF, DK), then Go to Sup_Intro_1

* Programming note: Use responses from above to fill in ACE in the following sections:

If (IIEP2=1 (Injury)) and (IIEP3=2 (NO) and IIEP4=1 (YES)) then ACE=”your injury happened”;

If (IIEP2=2 (Illness)) and (IIEP5=1 (YES) and IIEP6=2 (NO)) then ACE=”your illness happened”;

If (IIEP2=4 (Pain)) and (IIEP3=1 (NO) and IIEP4=1 (YES)) then ACE=”your pain happened”;

If (IIEP2=1 (Injury) or IIEP2=2 (Illness) or IIEP2=4 (Pain)) and (IIEP3=1 (YES) or IIEP6=1 (YES)) then ACE=”your injury/illness/pain was made worse”;

If IIEP2=3 (Exposure) then ACE=”your exposure happened”

IIEP7. When ACE, were you working for pay?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

IIEP8. Some workers are day laborers who wait at a place where employers pick up people to work for a day. When ACE, were you working as a day laborer?

YES 1 (End Interview)

NO 2

REFUSED -7

DON’T KNOW -8

IIEP9. When ACE, were you working on a farm or ranch?

YES 1 (Go to IIEP9a)

NO 2 (Go to IIEP10)

REFUSED -7 (Go to IIEP10)

DON’T KNOW -8 (Go to IIEP10)

IIEP9a. Was the farm or ranch owned by you or your family?

YES 1 (End Section)

NO 2

REFUSED -7

DON’T KNOW -8

IIEP10. When ACE, were you working for a business owned by you or your family?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

* Programming note: If IIEP7=2 AND IIEP9=2 AND IIEP10=2, then End Interview

IIC. Injury/illness characteristics

IIC_Intro_1. Thinking about the reason you went to the ER on [date]…

* Programming note: If IIEP2=Injury, go to IIC1;

If IIEP2=Pain, go to IIC2;

If IIEP2=Exposure OR Illness and ( IIEP3=NO, OR IIEP3a=NO, REF, or DK OR IIEP6=NO, OR IIEP6a=NO, REF, or DK, then End Section);

Else go to IIC3.

[If IIEP2=Injury]

IIC1. What parts of your body were injured?

IIC1a. Body part 1 _______________

IIC1b. Body part 2 _______________

IIC1c. Body part 3 _______________ (If two or more parts, go to IIC1f)

IIC1d. Body part 4 _______________

IIC1e. Body part 5 _______________

IIC1f. Please tell me which part of your body was hurt the worst.

______________________

* Programming note: If (IIEP3=NO, OR IIEP3a=NO, REF, or DK OR IIEP6=NO, OR IIEP6a=NO, REF, or DK) then End Section; Else go to IIC3.

[If IIEP2=Pain]

IIC2. What parts of your body were in pain?

IIC2a. Body part 1 _______________

IIC2b. Body part 2 _______________

IIC2c. Body part 3 _______________ (If two or more parts, go to IIC2f)

IIC2d. Body part 4 _______________

IIC2e. Body part 5 _______________

IIC2f. Please tell me which part of your body was in the most pain. _______________________

* Programming note: If IIEP3=NO, OR IIEP3a=NO, REF, or DK OR IIEP6=NO, OR IIEP6a=NO, REF, or DK, then End Section

[If Health problem was made worse and lasted 3+ months, IIEP3a=YES or IIEP6a=YES]

Chronic Questions:

IIC_Intro_2. Now I would like to ask you some specific questions about your health problem that was made worse before your ER visit on [date]. You may have already mentioned some of this information, but I need to ask all of the questions.

IIC3. Which one of the following health problems were you seen for in the ER?

Repeated trouble with your back, neck, or spine 1

Carpal tunnel syndrome 2

Tendonitis 3

Heart problem 4

A skin problem 5

Lung problem or breathing difficulties 6

Another health problem 7

[If IIC6=Other] Please specify ___________________

REFUSED -7

DON’T KNOW -8

[If IIC3=Tendonitis]

IIC3a. What parts of your body have tendonitis?

IIC3ai. Body part 1 _______________

IIC3aii. Body part 2 _______________ (If none listed, go to IIC4)

IIC3aiii. Body part 3 _______________

IIC3aiv. Body part 4 _______________

[If IIC3=Lung problem or breathing difficulties]

IIC3b. What type of lung problem or breathing difficulties do you have? ________ (Go to IIC4)

[If IIC3=A skin problem]

IIC3c. What type of skin problem do you have? ___________ (Go to IIC4)

* Programming note: Use response from above to fill in the blanks [condition] below

IIC4. Do you feel your [condition] was caused by your current job or some previous job?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

IIC5. Between [date-3 months] and [date], how much has your [condition] limited your ability to do your normal job tasks?

Not at all 1

Very little 2

Somewhat 3

Quite a lot 4

REFUSED -7

DON’T KNOW -8

IIC6. Between [date-3 months] and [date],how much has your [condition] limited your ability to do your activities at home?

Not at all 1

Very little 2

Somewhat 3

Quite a lot 4

REFUSED -7

DON’T KNOW -8

IIC7. Has a doctor or health care provider ever given you a diagnosis for your IIEP?

YES 1

NO 2 (End Section)

REFUSED -7

DON’T KNOW -8

IIC8. Did a doctor or health care provider ever tell you that your [condition] was related to your current job or some previous job?

YES 1 .

NO 2

REFUSED -7

DON’T KNOW -8

Emp. Type of Employment

* Programming note: Use responses from above to fill in ACE in the following sections:

If (IIEP2=1 (Injury)) and (IIEP3=2 (NO) and IIEP4=1 (YES)) then ACE=”your injury happened”;

If (IIEP2=2 (Illness)) and (IIEP5=1 (YES) and IIEP6=2 (NO)) then ACE=”your illness happened”;

If (IIEP2=4 (Pain)) and (IIEP3=1 (NO) and IIEP4=1 (YES)) then ACE=”your pain happened”;

If (IIEP2=1 (Injury) or IIEP2=2 (Illness) or IIEP2=4 (Pain)) and (IIEP3=1 (YES) or IIEP6=1 (YES)) then ACE=”your injury/illness/pain was made worse”;

If IIEP2=3 (Exposure) then ACE=”your exposure happened”

Emp_Intro_1. This next set of questions refers to the job where you were working when ACE. If you had multiple jobs, we are only interested in the job you were working at when ACE.

Emp1. People who are self-employed may work in their own business as a partner in a partnership, as an independent contractor in a trade, or as an owner of a farm. Were you self-employed when ACE?

YES 1

NO 2 (Go to Emp2)

REFUSED -7 (Go to Emp2)

DON’T KNOW -8 (Go to Emp2)

[If Self employed, Emp1=YES]

Emp1a. Was your business incorporated? [FAQ? Interviewer note: Incorporated means it is a legal entity that is effectively recognized as a person under the law.]

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If Self employed, Emp1=YES]

Emp1b. Did you employ other people as part of your business?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If Self employed, Emp1b=YES]

Emp1bi. Did you employ 11 or more people?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

* Programming note: If Self employed, Emp1=YES, End Section, go to section EC

Emp2. Some people are in temporary jobs that last for a limited time. Was your job temporary when ACE?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

Emp3. Some people are in a pool of workers who are called to work as needed. These people are sometimes referred to as on-call workers. Were you an on-call worker when ACE?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

Emp4. Were you performing contract work for another company or organization when ACE?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

EC. Employment Characteristics

EC_Intro_1. I am now going to ask you additional information about the job you were working in when ACE. Although some questions may not seem to apply to you, I have to ask all of the questions.

* Programming note: If Self employed, Emp1=YES, then go to EC2

EC1. Your employer is the company, organization, or person who pays you. Please think about all people who were paid by your employer. When ACE, did your employer have 11 or more employees?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

EC2. In the job where you were working when ACE, how many hours on average did you work during a normal work week?

|___|___|___| Hours

REFUSED -7

DON’T KNOW -8

[If EC2=Ref or EC2=DK]

EC2a. Did you work at least 35 hours a week?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If Self employed, Emp1=YES]

EC3. On the day ACE, had you been self employed for more than one year?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If EC3=YES]

EC3a. How many years had you been self employed?

|___|___|Years |___|___| Months [Include months only if offered by respondent]

REFUSED -7

DON’T KNOW -8

[If EC3=NO]

EC3b. How many months had you been self employed?

|___|___| Months |___|___|Days [Include days only if offered by respondent]

REFUSED -7

DON’T KNOW -8

* Programming note: If Self employed, Emp1=Yes, End Section, go to section ERR

[If Not self employed, Emp1=NO]

EC4. On the day ACE, had you worked for your employer for more than one year?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If EC4=YES]

EC4a. How many years had you worked for that employer?

|___|___|Years |___|___| Months [Include months only if offered by respondent]

REFUSED -7

DON’T KNOW -8

[If EC4=NO]

EC4b. How many months had you worked for that employer?

|___|___| Months |___|___|Days [Include days only if offered by respondent]

REFUSED -7

DON’T KNOW -8

EC5. On the day BEFORE ACE, how secure did you feel about keeping your job?

Very secure 1

Somewhat secure 2

Neither secure nor insecure 3

Somewhat insecure 4

Very insecure 5

REFUSED -7

DON’T KNOW -8

EC6. Were you a member of a labor union at the job where you were working when ACE?

YES 1

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

EC7. Did your labor union encourage you to tell your employer if you were hurt or became sick from something at work?

YES 1 (End Section)

NO 2

REFUSED -7

DON’T KNOW -8

EC7a. Did your labor union discourage you from telling your employer if you were hurt or became sick from something at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

ERR. ER Reporting of current injury/illness

ERR_Intro_1. Now I am going to ask you some questions about your visit to the ER on [DATE]. These questions will ask you to remember events or conversations that happened while you were there.

ERR1. When you arrived at the ER, were you awake and aware of what was going on around you?

YES 1 (Go to ERR2)

NO 2 (Go to ERR2a)

ERR2. [If ERR1=Yes] Were you able to communicate with the people working in the ER?

YES 1 (Go to ERR3)

NO 2 (Go to ERR2a)

[If ERR1=NO OR ERR2=NO]

ERR2a. Did a co-worker, family member, or someone else tell the ER staff how ACE?

YES 1 (Go to ERR2ai)

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

[If ERR2a=YES]

ERR2ai. Did they tell the ER staff that ACE at work?

YES 1 (End Section)

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

ERR3. Did you tell anyone working in the ER that ACE at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

ERR4. While you were checking into the ER, were you asked if ACE at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

NOT APPLICABLE -10

ERR5. When you were being examined in the ER, were you asked if ACE at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

NOT APPLICABLE -10

ERR6. Did anyone at work tell you NOT to tell ER staff that ACE at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

WR. Work Reporting

* Programming note: Use responses from above to fill in ACE in the following sections:

If (IIEP2=1 (Injury)) and (IIEP3=2 (NO) and IIEP4=1 (YES)) then ACE=”your injury happened”;

If (IIEP2=2 (Illness)) and (IIEP5=1 (YES) and IIEP6=2 (NO)) then ACE=”your illness happened”;

If (IIEP2=4 (Pain)) and (IIEP3=1 (NO) and IIEP4=1 (YES)) then ACE=”your pain happened”;

If (IIEP2=1 (Injury) or IIEP2=2 (Illness) or IIEP2=4 (Pain)) and (IIEP3=1 (YES) or IIEP6=1 (YES)) then ACE=”your injury/illness/pain was made worse”;

If IIEP2=3 (Exposure) then ACE=”your exposure happened”

WR_Intro_1. Now I am going to ask you some questions about telling people at work that ACE.

* Programming note: If Temp worker, Emp2=YES, or Contract worker, Emp4=YES, go to WR2

Otherwise go to WR3

[If Self employed, Emp1=YES]

WR1. Self-employed persons may be hired by a client to do work. A client could be an individual, business, or organization. Were you doing work for a client when ACE?

YES 1

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

WR1a. Were you working at the client’s jobsite?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

WR1b. Did the client ask you to tell them if you were hurt or became sick from something at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

WR1c. Did you tell the client that ACE while working for them?

YES 1 (Go to WR1d)

NO 2 (Go to WR1e)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If WR1c=YES]

WR1d. What was the most important reason you told the client?

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR1c=YES, End Section, go to section MC

[If WR1c=No]

WR1e. Did the client find out about your IIEP some other way?

YES 1 (Go to WR1f)

NO 2 (Go to WR1g)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If WR1e=YES]

WR1f. If they had NOT found out some other way, would you have told the client that ACE at work?

YES 1 (Go to WR1fi)

NO 2 (Go to WR1fii)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If WR1f=YES]

WR1fi. What was the most important reason you would have told the client? _____

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR1f=YES, End Section, go to section MC

[If WR1f=NO]

WR1fii. What was the most important reason you would NOT have told the client? ____

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR1f=NO, End Section, go to section MC

[If WR1e=NO]

WR1g. What was the most important reason you did not tell the client? ______

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR1e=NO, End Section, go to section MC

* Programming note: If Self employed, Emp1=YES, End Section, go to section MC

WR_Intro_2. Remember, your employer is the person or company who pays you. These questions refer to the employer you were working for when ACE.

* Programming note: If Not Temp worker, Emp2=NO, AND Not contract worker, Emp4=NO, go to WR3

[If Temp worker, Emp2=YES, OR Contract worker, Emp4=YES]

WR2. Were you working at a client or business location that did not belong to your employer?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

WR3. Many employers give their workers instructions about who they should tell if they are hurt or become sick from something at work. Before ACE, were you given instructions on who to tell?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

DON’T REMEMBER -9

* Programming note:

If WR2=YES (Temp/Contract Workers working at client location) and WR3=YES, go to WR3a;

If (WR2=NO or WR2=Skipped) (Temp/Contract Workers not working at client location OR all other workers) and WR3=YES, go to WR3b;

If WR2=YES (Temp/Contract Workers working at client location) and (WR3=NO or WR3=REF or WR3=DK or WR3=DON’T REMEMBER), go to WR3c;

If (WR2=NO or WR2=Skipped) (Temp/Contract Workers not working at client location OR all other workers) and (WR3=NO or WR3=REF or WR3=DK or WR3=DON’T REMEMBER), go to WR3d

[If Temp or Contract worker working at client location, WR2=YES, AND WR3=YES]

WR3a. Were you supposed to tell your supervisor first?

YES 1 (Go to WR3ai)

NO 2 (Go to WR3aii)

REFUSED -7 (Go to WR3aii)

DON’T KNOW -8 (Go to WR3aii)

WR3ai. Remember, your employer is the person who paid you. Did this supervisor work for your employer?

YES 1 (Go to WR3e)

NO 2 (Go to WR3e)

REFUSED -7 (Go to WR3e)

DON’T KNOW -8 (Go to WR3e)

DON’T REMEMBER - 9 (Go to WR3e)

WR3aii. What was the job title of the person you were supposed to tell first?

Interviewer note: Please do not read response options.

Specific job title__________________________ 1 (Go to WR3aiia)

NO ONE 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

WR3aiia. Interviewer note: Record specific job title given by respondent

____________________________________________________________

(Go to WR3e)

[If Temp or Contract worker not working at client location OR All other workers, WR2=NO or WR2=Skipped, AND WR3=YES]

WR3b. Were you supposed to tell your supervisor first?

YES 1 (Go to WR3e)

NO 2 (Go to WR3bi)

REFUSED -7 (Go to WR3bi)

DON’T KNOW -8 (Go to WR3bi)

WR3bi. What was the job title of the person you were supposed to tell first?

Interviewer note: Please do not read response options.

Specific job title__________________________ 1 (Go to WR3biia)

NO ONE 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

WR3biia. Interviewer note: Record specific job title given by respondent

____________________________________________________________

(Go to WR3e)

[If Temp or Contract worker working at client location, WR2=YES, AND (WR3=NO or WR3=REF or WR3=DK or WR3=DON’T REMEMBER)]

WR3c. Did you think you were supposed to tell your supervisor first?

YES 1 (Go to WR3ci)

NO 2 (Go to WR3cii)

REFUSED -7 (Go to WR3cii)

DON’T KNOW -8 (Go to WR3cii)

WR3ci. Remember, your employer is the person who paid you. Did this supervisor work for your employer?

YES 1 (Go to WR3e)

NO 2 (Go to WR3e)

REFUSED -7 (Go to WR3e)

DON’T KNOW -8 (Go to WR3e)

DON’T REMEMBER - 9 (Go to WR3e)

WR3cii. What was the job title of the person you thought you were supposed to tell first?

Interviewer note: Please do not read response options.

Specific job title__________________________ 1 (Go to WR3ciia)

NO ONE 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

WR3ciia. Interviewer note: Record specific job title given by respondent

____________________________________________________________

(Go to WR3e)

[If Temp or Contract worker not working at client location OR All other workers, WR2=NO or WR2=Skipped, And (WR3=NO or WR3=REF or WR3=DK or WR3=DON’T REMEMBER)]

WR3d. Did you think you were supposed to tell your supervisor first?

YES 1 (Go to WR3e)

NO 2 (Go to WR3di)

REFUSED -7 (Go to WR3di)

DON’T KNOW -8 (Go to WR3di)

WR3di. What was the job title of the person you thought you were supposed to tell first?

Interviewer note: Please do not read response options.

Specific job title__________________________ 1 (Go to WR3diia)

NO ONE 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

WR3ciia. Interviewer note: Record specific job title given by respondent

____________________________________________________________

(Go to WR3e)

* Programming note: Use response from above to fill in the blanks [person supposed to tell] below

WR3e. Did you tell [person supposed to tell] that ACE at work?

YES 1 (Go to WR3f)

NO 2 (Go to WR3g)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If WR3e=YES]

WR3f. What was the most important reason you told [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR3e=YES, End Section, go to section MC

WR3g. Did [person supposed to tell] find out about your IIEP some other way?

YES 1 (Go to WR3h)

NO 2 (Go to WR3i)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If WR3g=YES]

WR3h. If they had NOT found out some other way, would you have told [person supposed to tell] that ACE at work?

YES 1 (Go to WR3hi)

NO 2 (Go to WR3hii)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

DON’T REMEMBER -9 (End Section)

[If WR3h=YES]

WR3hi. What was the most important reason you would have told [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR3h=YES, End Section, go to section MC

[If WR3h=NO]

WR3hii. What was the most important reason you would NOT have told [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR3h=NO, End Section, go to section MC

[If WR3g=NO]

WR3i. What was the most important reason you did not tell [person supposed to tell]?

* Programming note: Space for entering respondent’s answer.

* Programming note: If WR3g=NO, End Section, go to section MC

MC. Medical Coverage and Return to Work

MC_Intro_1. Now I am going to ask you some questions about paying for your ER visit, about any care you have needed since your ER visit, and if you have returned to work.

MC1. Have you heard about worker’s compensation, also called worker’s comp?

YES 1

NO 2 (Go to MC2)

REFUSED -7

DON’T KNOW -8

[If MC1=YES]

MC1a. Were you covered by worker’s comp at the job where ACE?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If Self employed, Emp1=YES, AND MC1a=YES]

MC1ai. Were you required to carry worker’s comp on yourself?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

MC2. Health insurance is one way that people pay medical bills. Health insurance may be purchased on your own, through a family member or partner, through an employer or union, or through a government program. Did you have any kind of health insurance when ACE at work?

YES 1

NO 2

REFUSED…………………………………………………………………………….. -7

DON’T KNOW……………………………………………………………………… -8

MC3. Now I’m going to read you a list of sources people use to pay medical bills. Please tell me which source you think you will use to pay your ER bill?

[Interviewer note: If respondent suggests that they have two or more payers, ask “Which of these do you think will pay the larger part of the bill?”]

[If MC1a=YES] Worker’s Comp 1

[If MC2=YES] Health insurance 2

[If Not Self employed, Emp2=NO] Your employer 3

Yourself, also called out-of-pocket 4

Another source 5

(Specify)_____________________________

None 6

REFUSED -7

DON’T KNOW -8

MC4. Sometimes IIEPs need care in addition to going to the ER. This can include surgery, overnight stays in the hospital, physical therapy, or visits to doctors, nurses, or physician’s assistants. Other than your ER visit on [date], have you HAD any additional care for your IIEP?

YES 1

NO 2 (Go to MC5)

REFUSED -7 (Go to MC5)

DON’T KNOW -8 (Go to MC5)

[If MC4=YES]

MC4a. Please describe the additional care you received. [Probes: If respondent indicates that he/she was hospitalized, ask how long? Anything else?]

* Programming note: Space for entering additional care.

MC5. Have you returned to work for the employer you had when ACE?

YES 1 (Go to MC6)

NO 2

REFUSED -7 (Go to MC6)

DON’T KNOW -8 (Go to MC6)

[If MC5=NO]

MC5a. Which of the following best describes why you have not returned to the employer you had when ACE?

You are still recovering from your IIEP 1 (Go to MC7)

You were fired or let go 2 (End Section)

You changed employers 3 (End Section)

You quit 4 (End Section)

[If Temp worker, Emp2=YES, OR Contract worker, Emp4=YES]

Your job or task ended………………………………………………5 (End Section)

Another reason 6 (Go to MC7)

Please specify_____________________________

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

MC_Intro_2. Calendar days refers to both days that you would normally work and days that you normally would not work, for example, weekends and days off.

MC6. After ACE, how many calendar days passed before you returned to work?

|___|___|___|Days (Go to MC6b)

REFUSED -7

DON’T KNOW -8

[If MC6=REF or DK]

MC6a. Was it….

None, you returned to work on the same day that ACE 1

1-3 days 2

4-10 days 3

11 or more days 4

REFUSED -7

DON’T KNOW - 8

MC6b. When you returned to work did you actually feel well enough to go back to work?

Yes 1

No 2 (Go to MC6d)

[If (MC6=0 or MC6a=1) and MC6b=Yes, go to MC7]

[If MC6b=YES]

MC6c. After ACE, how many calendar days passed until you actually felt well enough to start working again?

|___|___|___|Days (Go to MC7)

REFUSED -7

DON’T KNOW -8

[If MC6c=REF or DK]

MC6ci. Was it….

None, you felt well enough on the same day that ACE 1

1-3 days 2

4-10 days 3

11 or more days 4

REFUSED -7

DON’T KNOW -8

[If MC6b=NO]

MC6d. After you went back to work, how many calendar days passed before you actually felt well enough to start working again?

|___|___|___|Days (Go to MC7)

Still don’t feel well enough -6

REFUSED -7

DON’T KNOW -8

[If MC6d=REF or DK]

MC6ci. Was it….

1-3 days 2

4-10 days 3

11 or more days 4

REFUSED -7

DON’T KNOW -8

* Programming note: If Self employed, Emp1=YES, then End Section

MC7. Paid time off may include sick leave, vacation, or personal leave. When ACE, did you have any paid time off available to you?

YES 1 (Go to MC8a)

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

[End section if MC6=0 or MC6a=1]

[If MC5=YES]

MC8. Have you taken any paid time off because ACE?

YES 1

NO 2 [End section]

REFUSED -7

DON’T KNOW -8

MC8a. Have you taken any unpaid time off because ACE?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC. History of Chronic Health Problems

HC_Intro_1. You already told me about your IIEP that was related to your ER visit on [Date]. Now I am interested in learning about other health problems that were caused by or made worse by any job you’ve had. Remember, a health problem could be physical or mental. It may include an injury, illness, pain, disability, or infection.

HC1. Have you had any health problems that you feel were caused or made worse by your current job or some previous job?

YES 1

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

HC2. Did you have any of these health problems between [date-12 months] and [date]?

YES 1

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

HC3. Of the health problems you had between [date-12 months] and [date], have any lasted 3 months or longer?

YES 1

NO 2 (End Section)

REFUSED -7 (End Section)

DON’T KNOW -8 (End Section)

HC4. Thinking about these health problems that are related to work, do you have…..?

HC4a. Repeated trouble with your back, neck, or spine

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC4b. Carpal tunnel syndrome

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC4c. Tendonitis

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If HC4c=YES]

HC4ci. What parts of your body have tendonitis?

HC4cia. Body part 1 _______________

HC4cib. Body part 2 _______________ (If none listed, go to HC4d)

HC4cic. Body part 3 _______________

HC4cid. Body part 4 _______________

HC4d. Heart problems

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If HC4d=YES]

HC4di. What type of heart problem do you have? ________

HC4dia. Heart problem 1 _______________

HC4dib. Heart problem 2 _______________ (If none listed, go to HC_Intro_2)

HC4dic. Heart problem 3 _______________

HC4did. Heart problem 4 _______________

HC_Intro_2. As a reminder, I am still interested in any health problems that are related to work.

Do you have…

HC4e. Lung problem or breathing difficulties

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If HC4e=YES]

HC4ei. What type of lung problem or breathing difficulties do you have? ________

HC4eia. Lung problem 1 _______________

HC4eib. Lung problem 2 _______________

HC4eic. Lung problem 3 _______________

HC4eid. Lung problem 4 _______________

HC4f. A skin problem

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If HC4f=YES]

HC4fi. What type of skin problem is it? ___________

HC4g. Hearing loss

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC4h. Cancer

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If HC4h=YES]

HC4hi. What type of cancer do you have? _____

[If any of the above are Yes]

HC4i. Keeping in mind that I am interested in health problems that lasted for three months or more, do you have any other health problems that were caused by or made worse by any job you ever had?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

[If HC4i=Yes]

HC4ii. What is it?

HC4iia. Health problem 1 _______________

HC4iib. Health problem 2 _______________ (If none listed, go to HC_Intro_3)

HC4iic. Health problem 3 _______________

HC4iid. Health problem 4 _______________

[If all of the above are No]

HC4j. I would like to know what your health problem is. What is it?

HC4ja. Health problem 1 _______________

HC4jb. Health problem 2 _______________ (If none listed, go to HC5)

HC4jc. Health problem 3 _______________

HC4jd. Health problem 4 _______________

[Interview note: if unsure of correct category, please fill in HC4ii OR HC4j field with a description of their health condition.]

HC_Intro_3. I’d like to get more detail about each of the health problems you just told me you had. For each health problem, I’m going to ask you a few questions. The first question is,

* Programming note: Ask questions HC5 through HC14 for each item above with a “yes” response:

HC5. Do you feel your [health problem] was caused by your current job or some previous job?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC6. At any time between [date-12 months] and [date], was your [health problem] made worse at work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

* Programming note: 1) If HC5=No and HC6=No, allow both questions to be repeated saying “I want to make sure I recorded your answers to the last two questions correctly.”;

2) If after repeating, HC5 and HC6 are both still No then either go to next health problem OR End Section

HC7. Do you still have symptoms from your [health problem]?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC8. Have you ever reported your [health problem] to any employer?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC9. Have you ever filed a worker’s compensation claim for your [health problem]?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC10. Between [date-12 months] and [date], how much has your [health problem] limited your ability to do your normal job tasks?

Not at all 1

Very little 2

Somewhat 3

Quite a lot 4

REFUSED -7

DON’T KNOW -8

HC11. Between [date-12 months] and [date], how much has your [health problem] limited your ability to do your activities at home?

Not at all 1

Very little 2

Somewhat 3

Quite a lot 4

REFUSED -7

DON’T KNOW -8

HC12. Has a doctor or health care provider ever told you that you have [health problem]?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

HC13. Did a doctor or health care provider ever tell you that your [health problem] was related to your current job or some previous job?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

* Programming note: If HC4h=1 (Cancer), End Section

HC14. Did a doctor or health care provider ever tell you that your [health problem] was made worse by work?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

Dem. Demographic

Dem_Intro_1. Finally, I would like to ask you a few basic questions about your employer, the type of work you do, and about yourself. These questions relate to the IIEP you were seen for on [date]. Please remember that all information will only be used for research and will be kept private.

[If Working on farm or ranch, IIEP7=YES, OR Working for family business, IIEP8=YES, OR Self employed, Emp1=YES, then go to Dem2]

Dem1. Your employer is the person or company who pays you. Which of the following best describes who you worked for when ACE at work:

A private company or organization 1

Federal, State, or Local Government 2

Other 3

_______________________________

REFUSED -7

DON’T KNOW -8

Dem2. In a few words please describe the type of business or organization that you worked for when ACE?

Interview note: we want to record at least two or three words here.

_____________________________________________

REFUSED -7

DON’T KNOW -8

Dem3. What was your job title when ACE?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If hesitates or Dem3=DK] say “What was your job title? Examples could be a high school teacher, a residential construction worker, or a registered nurse.”

Dem4. What were your primary job duties?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

[If Not Self employed, Emp1=NO]

Dem5. What was the name of the employer you were working for when ACE?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If Dem5=REF] say “We will use the name to classify the industry you were working in. We will not contact your employer for any reason.”

[If Not Self employed, Emp1=NO]

Dem6. In which state was your employer located? If your employer has offices or locations in multiple states, please give the state of the location where you work from.

*Programmer note: Insert state options in CATI system.

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If Dem6=REF] say “We will use the state to help us classify the industry you were working in. We will not contact your employer for any reason.”

* Programmer note: If Not Self employed, Emp1=NO, go to Dem9

[If Self employed, Emp1=YES]

Dem7. When ACE, what was the name of your company?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If Dem7=REF] say “We will use the name to classify the industry you were working in. We will not contact your employer for any reason.”

[If Self employed, Emp1=YES]

Dem8. In which state was your company located?

*Programmer note: Insert state options in CATI system.

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If Dem8=REF] say “We will use the state to help us classify the industry you were working in.”

Dem9. Please tell me which of the following best describes the highest level of education you completed:

Did not complete high school 1

High School Diploma or GED 2

Some College 3

College Degree 4

Graduate Degree 5

OTHER 6

(Specify)______________________________________

REFUSED -7

DON’T KNOW -8

Dem10. What year were you born?

|___|___|___|___|

REFUSED -7

DON’T KNOW -8

Dem11. Are you of Hispanic, Latino or Spanish origin?

YES 1

NO 2

REFUSED -7

DON’T KNOW -8

Interviewer note: [If hesitates or Dem7=DK] say “This includes people from, or descended from, Spain, Mexico, Puerto Rico, Cuba, The Dominican Republic, or from Central or South America. Hispanics or Latinos may be of any race.”

Dem12. Which of the following race or races describe you? (Select one or more)

American Indian or Alaska Native 1

Asian 2

Black or African-American 3

Native Hawaiian or Pacific Islander 4

White 5

Other 6

REFUSED -7

DON’T KNOW -8

Dem13. Were you born in the United States or in a US territory? (US territories include Midway Islands, Puerto Rico, American Samoa, Virgin Islands, Federated States of Micronesia, Marshall Islands, Northern Mariana Island, Palau, and Guam.)

YES 1 (Go to Dem11)

NO 2 (Go to Dem10a)

REFUSED -7 (Go to Dem11)

DON’T KNOW -8 (Go to Dem11)

[If Dem10=NO]

Dem10a. What country were you born in?

_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If Dem10a=REF] say “We will only use the country of your birth for research.”

Dem14. We are interested in your family’s total yearly income. Family income is your income PLUS the income of all family members living in your household. Please be assured that, like all other information you have provided, these answers will be kept private. Please stop me when I read the category that best matches what your total family income was between January 20__ and December 20__:

Less than $15,000 1

Between $15,000 and $30,000 2

Between $30,000 and $50,000 3

Between $50,000 and $75,000 4

Between $75,000 and $100,000 5

More than $100,000 6

REFUSED -7

DON’T KNOW -8

* Programming note: These questions will only be asked if [IIEP2=NO, REF, or DK and IIEP3=NO, REF, or DK] OR [IIEP4=NO, REF, or DK and IIEP5=NO, REF, or DK]

Sup. Non-work-related supplemental questions

Sup_Intro_1. Thinking about the reason you went to the ER on [date]…

Sup1. Could you please describe how the IIEP happened?

[Prompts: Where were you when the IIEP occurred? What were you doing when your IIEP happened or was made worse?]

* Programming note: Space for entering respondent’s description of the incident.

Sup2. I’m going to read you a list of sources people use to pay medical bills. Please tell me which source you think you will use to pay your ER bill?

[Interviewer note: If respondent suggests that they have two or more payers, ask “Which of these do you think will pay the larger part of the bill?”]

Health insurance 1

Your employer 2

Yourself, also called out-of-pocket 3

Another source 4

(Specify)_____________________________

No one 5

REFUSED -7

DON’T KNOW -8

Sup_Intro_2. I understand that your IIEP was not related to work but I would like to ask you four final questions about the employer and the job that you had at the time of your ER visit.

Sup3. In a few words can you please describe the type of business or organization that you worked for when ACE?

Interview note: We want to record at least two or three words here.

_____________________________________________

REFUSED -7

DON’T KNOW -8

Sup4. What was your job title?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interview note: [If hesitates or Sup4=DK] say “What was your job title? Examples could be a high school teacher, a residential construction worker, or a registered nurse.”

Sup5. What were your primary job duties?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Sup6. What was the name of the employer you were working for at the time of your ER visit?

­­_____________________________________________

REFUSED -7

DON’T KNOW -8

Interviewer note: [If Sup6=REF] say “We will use the name to classify the industry you were working in. We will not contact your employer for any reason.”

Thank you for your time. We appreciate your cooperation.