Form 22.1 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

IndoorDwellingObservationInstrument

Environmental Sample Collection (Postnatal)

OMB: 0925-0593

Document [docx]
Download: docx | pdf

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Indoor Dwelling Unit VIsual Observation Instrument, Phase 2g

OMB Specification


Indoor Dwelling Unit Visual Observation Instrument


Event Category:

Time-Based

Event:

12M, 36M, 60M

Administration:

N/A

Instrument Target:

Child's Primary Residence

Instrument Respondent:

Primary Caregiver

Domain:

Environmental

Document Category:

Observation

Method:

Data Collector Administered

Mode (for this instrument*):

In-Person, CAI

OMB Approved Modes:

In-Person, CAI;
Web-Based, CAI

Estimated Administration Time:

5 minutes

Multiple Child/Sibling Consideration:

Per Event

Special Considerations:

N/A

Version:

1.0

MDES Release:

4.0


*This instrument is OMB-approved for multi-mode administration, but this version of the instrument is designed for administration in this/these mode(s) only.


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Indoor Dwelling Unit Visual Observation Instrument



TABLE OF CONTENTS





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Indoor Dwelling Unit Visual Observation Instrument



GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:


DATA ELEMENT FIELDS

MAXIMUM CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

100

CHARACTER


UNIT AND PHONE FIELDS

10

CHARACTER


_OTH AND COMMENT FIELDS

255

CHARACTER

  • Limit text to 255 characters

FIRST NAME AND LAST NAME

30

CHARACTER

  • Limit text to 30 characters

ALL ID FIELDS

36

CHARACTER


ZIP CODE

5

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER

  • DISPLAY AS MM/DD/YYYY

  • STORE AS YYYY-MM-DD

  • HARD EDITS:

MM MUST EQUAL 01 TO 12

DD MUST EQUAL 01 TO 31

YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).


POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.



A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.





GENERAL DWELLING UNIT


(TIME_STAMP_GDU_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIMESTAMP.

  • PRELOAD DWELLING_UNIT_ID FOR THE DWELLING UNIT.

  • PRELOAD THE PARTICIPANT ID P_ID FOR THE CHILD AND THE RESPONDENT ID R_P_ID FOR THE CAREGIVER.

  • PRELOAD C_FNAME AND DISPLAY APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

  • OTHERWISE, IF C_FNAME = -1 OR -2, DISPLAY “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

  • PRELOAD MULT_CHILD AND CHILD_NUM (IF MULT_CHILD = 1), FROM PVST INSTRUMENT.

  • IF MULT_CHILD = 1, PRELOAD CHILD_QNUM

  • ADMINISTER INSTRUMENT IF EVENT=36M OR IF EVENT=60M AND PARTICIPANT HAS MOVED SINCE THE 36M EVENT.


GDU01000/(STAFF_ID). ENTER STAFF ID.

__________________________________________

STAFF ID


GDU02000/(DU_OK). We would like to ask you a few questions about your dwelling unit and make a few observations.  Is that okay?


Label

Code

Go To

YES

1

ATTACHED_GARAGE

NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU03000/(DU_REFUSE). RECORD REASON FOR REFUSAL IF GIVEN.


Label

Code

Go To

NONE GIVEN

1

DWELL_COMMENTS

NOT INTERESTED

2

DWELL_COMMENTS

RAN OUT OF TIME

3

DWELL_COMMENTS

OTHER

-5



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU04000/(DU_REFUSE_OTH). SPECIFY:  _________________________________


SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


PROGRAMMER INSTRUCTIONS

  • GO TO  DWELL_COMMENTS.


GDU05000/(ATTACHED_GARAGE). Is there a garage or a carport with an entrance that leads directly into your living space?


Label

Code

Go To

YES

1


NO

2

HEAT_VENTED

REFUSED

-1

HEAT_VENTED

DON'T KNOW

-2

HEAT_VENTED


SOURCE

New


GDU06000/(ATTACHED_GARAGE_USE). Do you park a car or a motorcycle that you drive regularly in your garage?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

New


GDU07000/(HEAT_VENTED). Can you please show me all the sources of heat that you use in this home?


DATA COLLECTOR INSTRUCTIONS

  • AFTER THE RESPONDENT SHOWS SOURCE(S) OF HEAT, INDICATE BELOW ONLY THOSE THAT YOU CAN CONFIRM ARE NOT VENTED TO THE OUTSIDE

  • SELECT ALL THAT APPLY.


Label

Code

Go To

NO SOURCE OF HEAT

1


GAS FURNACE

2


OIL FURNACE

3


ELECTRIC FURNACE

4


HEAT PUMP

5


WOOD BURNING STOVE

6


GAS FIREPLACE

7


WOOD FIREPLACE

8


GAS SPACE HEATER

9


ELECTRIC SPACE HEATER

10


REFUSED

-1


DON’T KNOW

-2


OTHER

-5



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M,12M)


PROGRAMMER INSTRUCTIONS

  • IF HEAT_VENTED = ANY COMBINATION OF 2 THROUGH 10, GO TO DRYER

  • IF HEAT_VENTED = -5 OR ANY COMBINATION OF 2 THROUGH 10 AND -5, GO TO HEAT_VENTED_OTH.

  • IF HEAT_VENTED = 1, -1 OR -2, DO NOT ALLOW THE SELECTION OF ANOTHER RESPONSE AND GO TO DRYER.


GDU08000/(HEAT_VENTED_OTH). SPECIFY: ____________________________________________


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M,12M)


GDU09000/(DRYER). Do you have a clothes dryer in your home?


Label

Code

Go To

YES

1


NO

2

KITCHEN_OBSERVE

REFUSED

-1

KITCHEN_OBSERVE

DON'T KNOW

-2

KITCHEN_OBSERVE


SOURCE

New


GDU10000/(DRYER _VENTED). Can you please show it to me?


Label

Code

Go To

YES

1


NO

2

KITCHEN_OBSERVE

REFUSED

-1

KITCHEN_OBSERVE

DON'T KNOW

-2

KITCHEN_OBSERVE


SOURCE

New


GDU11000/(DRYER_VENT_TYPE). TYPE OF DRYER


Label

Code

Go To

DRYER IS VENTED

1


UNVENTED GAS DRYER

2


UNVENTED ELECTRIC DRYER

3


DON’T KNOW

-2



SOURCE

New


GDU12000/(KITCHEN_OBSERVE). I would like to see your kitchen.  Can you please show it to me?


Label

Code

Go To

YES

1


NO

2

MOST_USED_ROOM_OBSERVE

REFUSED

-1

MOST_USED_ROOM_OBSERVE

DON'T KNOW

-2

MOST_USED_ROOM_OBSERVE


SOURCE

New


GDU13000/(KITCHEN_OPEN). We may need to open drawers/cabinets in the kitchen.  Is that okay?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

New


GDU14000/(MOST_USED_ROOM_OBSERVE). Can you please show me the room where {C_FNAME/the child} spends the most time while awake?


Label

Code

Go To

YES

1


NO

2

BEDROOM_OBSERVE

REFUSED

-1

BEDROOM_OBSERVE

DON'T KNOW

-2

BEDROOM_OBSERVE


SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M, 12M)


GDU15000/(MOST_USED_ROOM_OPEN). We may need to open drawers/cabinets in that room. Is that okay?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

New


GDU16000/(BEDROOM_OBSERVE). Can you show me {C_FNAME/the child}’s bedroom?


Label

Code

Go To

YES

1


NO

2

BATHROOM_OBSERVE

REFUSED

-1

BATHROOM_OBSERVE

DON'T KNOW

-2

BATHROOM_OBSERVE


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M,12M)


GDU17000/(BEDROOM_OPEN). We may need to open drawers/cabinets in {C_FNAME/the child}’s bedroom.  Is that okay?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

New


GDU18000/(BATHROOM_OBSERVE). Can you show me the bathroom where {C_FNAME/the child} bathes?


Label

Code

Go To

YES

1


NO

2

LOWEST_LEVEL

REFUSED

-1

LOWEST_LEVEL

DON'T KNOW

-2

LOWEST_LEVEL


SOURCE

New


GDU19000/(BATHROOM_OPEN). We may need to open drawers/cabinets in {C_FNAME/thechild}’s bathroom.  Is that okay?


Label

Code

Go To

YES

1


NO

2


REFUSED

-1


DON'T KNOW

-2



SOURCE

New


GDU20000/(LOWEST_LEVEL). LEVEL OF LOWEST LIVING AREA IN DWELLING UNIT (DU):

|___|___|___|

FLOOR


DATA COLLECTOR INSTRUCTIONS

  • IF LOWEST LIVING AREA IN DWELLING UNIT IS A BASEMENT, ENTER “000.”


Label

Code

Go To

DON'T KNOW

-2



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU21000/(DWELLING_FLOOR). FLOOR THAT DWELLING UNIT IS ON:

|___|___|___|

FLOOR


Label

Code

Go To

NOT APPLICABLE

-7



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU22000/(HEATING_SYS_TYPES). TYPEOF HEATING SYSTEM:


DATA COLLECTOR INSTRUCTIONS

  • SELECT ALL THAT APPLY.


Label

Code

Go To

NONE

1


FORCED AIR (VENTS)

2


RADIATORS (ANY TYPE)

3


SPACE HEATERS

4


DON’T KNOW

-2


OTHER

-5



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


PROGRAMMER INSTRUCTIONS

  • IF HEATING_SYS_TYPES = ANY COMBINATION OF 2 THROUGH 4, GO TO EXIT_SEALED.

  • IF HEATING_SYS_TYPES = -5 OR ANY COMBINATION OF 2 THROUGH 4 AND -5, GO TO HEATING_SYS_TYPES_OTH.

  • IF HEATING_SYS_TYPES = 1 OR -2, DO NOT ALLOW SELECTION OF ANY OTHER RESPONSE AND GO TO EXIT_SEALED.


GDU23000/(HEATING_SYS_TYPES_OTH). SPECIFY: _____________________________________________


SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU24000/(EXIT_SEALED). EXIT DOORS SEALED TIGHTLY:


Label

Code

Go To

YES

1


NO

2


DON'T KNOW

-2



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU25000/(WEATHERPROOF_WIN). WINDOW WEATHERPROOFING:


DATA COLLECTOR INSTRUCTIONS

  • SELECT ALL THAT APPLY.


Label

Code

Go To

DOUBLE PANE

1


STORM WINDOWS

2


SHRINK FILM

3


SINGLE PANE

4


DON’T KNOW

-2


OTHER

-5



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


PROGRAMMER INSTRUCTIONS

  • IF WEATHERPROOF_WIN = ANY COMBINATION OF 1 THROUGH 4, GO TO CIG_EVIDENCE.

  • IF WEATHERPROOF_WIN = -5 OR ANY COMBINATION OF 1 THROUGH 4 AND -5, GO TO WEATHERPROOF_WIN_OTH.

  • IF WEATHERPROOF_WIN = -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO CIG_EVIDENCE.


GDU26000/(WEATHERPROOF_WIN_OTH). SPECIFY: ___________________________________________


SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU27000/(CIG_EVIDENCE). IS THERE EVIDENCE OF CIGARETTES/SMOKING?


Label

Code

Go To

YES

1


NO

2



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU28000/(PEST_EVIDENCE). IS THERE EVIDENCE OF PESTS?


DATA COLLECTOR INSTRUCTIONS

  • SELECT ALL THAT APPLY.


Label

Code

Go To

NONE SEEN

1


ANTS

2


RODENTS

3


TERMITES

4


COCKROACHES

5


BIRDS

6


BATS

7


OTHER

-5



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


PROGRAMMER INSTRUCTIONS

  • IF PEST_EVIDENCE = 1, DO NOT ALLOW SELECTION OF ANY OTHER RESPONSE AND GO TO SMOKE_DETECTOR.

  • IF PEST_EVIDENCE = ANY COMBINATION OF 2 THROUGH 7, GO TO SMOKE_DETECTOR.

  • IF PEST_EVIDENCE = -5 OR ANY COMBINATION OF 2 THROUGH 7 AND -5, GO TO PEST_EVIDENCE_OTH.


GDU29000/(PEST_EVIDENCE_OTH). SPECIFY: _________________________________________


SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M,12M)


GDU30000/(SMOKE_DETECTOR). IS THERE A SMOKE DETECTOR IN THE HOME?


Label

Code

Go To

YES

1


NO

2

CO_DETECTOR


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


GDU31000/(SMOKE_DETECTOR_WORKING). IS THERE EVIDENCE THAT THE SMOKE DETECTOR WORKS?


Label

Code

Go To

YES

1


NO

2


DON'T KNOW

-2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


GDU32000/(CO_DETECTOR). IS THERE A CARBON MONOXIDE DETECTOR IN THE HOME?


Label

Code

Go To

YES

1


NO

2

DWELL_COMMENTS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


GDU33000/(CO_DETECTOR_WORKING). IS THERE EVIDENCE THAT THE CARBON MONOXIDE DETECTOR WORKS?


Label

Code

Go To

YES

1


NO

2


DON'T KNOW

-2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


GDU34000/(DWELL_COMMENTS). RECORD ANY COMMENTS ABOUT GENERAL DWELLING UNIT OBSERVATIONS:

COMMENTS:______________________________________________________


SOURCE

New


(TIME_STAMP_GDU_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP.

  • IF DU_OKAY = 2, -1 OR -2, GO TO TIME_STAMP_STA_ET

  • IF KITCHEN_OBSERVE = 1, GO TO TIME_STAMP_KIT_ST

  • IF KITCHEN_OBSERVE = 2, -1 OR -2, AND

    • IF MOST_USED_ROOM_OBSERVE = 1, GO TO TIME_STAMP_CMU_ST

    • IF MOST_USED_ROOM_OBSERVE = 2, -1 OR -2, AND BEDROOM_OBSERVE = 1, GO TO TIME_STAMP_CB_ST

    • IF MOST_USED_ROOM_OBSERVE = 2, -1 OR -2, BEDROOM_OBSERVE = 2, -1 OR -2, AND BATHROOM_OBSERVE = 1, GO TO TIME_STAMP_CBA_ST

  • OTHERWISE, GO TO TIME_STAMP_STA_ST.



KITCHEN


(TIME_STAMP_KIT_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


KIT00100/(KITCHEN_CLEAN). HOW CLEAN IS THE KITCHEN?


Label

Code

Go To

VERY CLEAN

1


MODERATELY CLEAN

2


NOT CLEAN

3



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M, 12M)


KIT01000/(KITCHEN_CLUTTER). HOW CLUTTERED IS THE KITCHEN?


Label

Code

Go To

LITTLE OR NO CLUTTER

1


MODERATE CLUTTER

2


VERY CLUTTERED

3



SOURCE

National Children’s Study, Legacy Phase (Dwelling Unit Visual Observations-6M, 12M)


KIT02000/(POSTED_NUMBERS). DID YOU SEE THE FOLLOWING TELEPHONE NUMBERS POSTED IN OR NEAR THE KITCHEN?


DATA COLLECTOR INSTRUCTIONS

  • SELECT ALL THAT APPLY.


Label

Code

Go To

EMERGENCY DEPARTMENT

1


CHILD’S PRIMARY CARE DOCTOR

2


POISON CONTROL

3


NONE SEEN

4



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF POSTED_NUMBERS = 4, DO NOT ALLOW SELECTION OF ANY OTHER RESPONSE.


KIT03000/(STOVE_PRESENT). IS THERE A COOKING STOVE?


Label

Code

Go To

YES

1


NO

2

OVEN_PRESENT


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


KIT04000/(STOVE_VENTED). IS THE STOVE VENTED?


Label

Code

Go To

YES

1


NO

2



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


KIT05000/(STOVE_HEIGHT). IS THE STOVE TOP (BURNERS) LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT06000/(STOVE_PROTECTOR). ARE THERE STOVE TOP PROTECTORS INSTALLED ON ALL ACCESSIBLE SIDES OF THE STOVE?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT07000/(OVEN_PRESENT). IS THERE AN OVEN?


Label

Code

Go To

YES

1


NO

2

KITCHEN_SHARPS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


KIT08000/(OVEN_VENTED). IS THE OVEN VENTED?


Label

Code

Go To

YES

1


NO

2



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


KIT09000/(OVEN_LATCH). DOES THE OVEN HAVE A WORKING DOOR GUARD/LATCH OR HAS A LOCK BEEN INSTALLED ON THE OVEN?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT10000/(KITCHEN_SHARPS). ARE SHARPS VISIBLE ON KITCHEN SURFACES (EXCLUDING KNIFE BLOCKS)?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_SHARPS = 2 AND

  • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FIREARMS.

  • OTHERWISE,GO TO KITCHEN_SHARPS_LOCK.

  • IF KITCHEN_SHARPS = 1, GO TO KITCHEN_SHARPS_LOW.


KIT11000/(KITCHEN_SHARPS_LOW). ARE SHARPS VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FIREARMS.

    OTHERWISE, GO TO KITCHEN_SHARPS_LOCK.


KIT12000/(KITCHEN_SHARPS_LOCK). ARE THERE SHARPS IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

KITCHEN_FIREARMS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT13000/(KITCHEN_SHARPS_LOCK_LOW). ARE THE SHARPS IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT13100/(KITCHEN_FIREARMS). ARE FIREARMS OR AMMUNITION VISIBLE IN THE KITCHEN?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_FIREARMS = 2 AND

  • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FURNITURE.

  • OTHERWISE, GO TO KITCHEN_FIREARMS_LOCK.

  • IF KITCHEN_FIREARMS = 1, GO TO KITCHEN_FIREARMS_LOW.


KIT14000/(KITCHEN_FIREARMS_LOW). ARE FIREARMS OR AMMUNITION VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FURNITURE.

  • OTHERWISE, GO TO KITCHEN_FIREARMS_LOCK.


KIT15000/(KITCHEN_FIREARMS_LOCK). ARE THERE FIREARMS OR AMMUNITION IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

KITCHEN_FURNITURE


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT16000/(KITCHEN_FIREARMS_LOCK_LOW). ARE THE FIREARMS OR AMMUNITION IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT17000/(KITCHEN_FURNITURE). IS THERE FURNITURE IN THE KITCHEN?


Label

Code

Go To

YES

1


NO

2

KITCHEN_GLASS


SOURCE

New


KIT18000/(KITCHEN_FURNITURE_SHARP). DOES THE FURNITURE IN THE KITCHEN HAVE EXPOSED SHARP OR SQUARE EDGES?


Label

Code

Go To

YES

1


NO

2

KITCHEN_GLASS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT19000/(KITCHEN_FURNITURE_SHARP_LOW). ARE THE EXPOSED SHARP OR SQUARE EDGES OF THE FURNITURE LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT20000/(KITCHEN_GLASS). ARE THERE PIECES OF FURNITURE OR DOORS WITH GLASS SURFACES? 


Label

Code

Go To

YES

1


NO

2

KITCHEN_POISON


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT21000/(KITCHEN_GLASS_LOW). ARE THESE GLASS SURFACES ON FURNITURE OR DOORS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT22000/(KITCHEN_POISON). ARE THERE ANY POTENTIAL POISONS VISIBLE ON KITCHEN SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_POISON = 2 AND

    • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FALLS.

    • OTHERWISE, GO TO KITCHEN_POISON_LOCK.

  • IF KITCHEN_POISON = 1, GO TO KITCHEN_POISON_LOW.


KIT23000/(KITCHEN_POISON_LOW). ARE THERE ANY POTENTIAL POISONS VISIBLE ON KITCHEN SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_POISON_LOW = 2 AND

    • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FALLS.

    • OTHERWISE, GO TO KITCHEN_POISON_LOCK.

  • IF KITCHEN_POISON_LOW = 1, GO TO KITCHEN_POISON_SURFACE_SAFETY.


KIT24000/(KITCHEN_POISON_SURFACE_SAFETY). DO POTENTIAL POISONS ON SURFACES LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF KITCHEN_OPEN = 2, -1 OR -2, GO TO KITCHEN_FALLS

  • OTHERWISE, GO TO KITCHEN_POISON_LOCK.


KIT25000/(KITCHEN_POISON_LOCK). ARE THERE POTENTIAL POISONS IN DRAWERS, CABINETS, CLOSETS, ETC. WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

KITCHEN_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT26000/(KITCHEN_POISON_LOCK_LOW). ARE THE POTENTIAL POISONS IN THE UNLOCKED DRAWERS, CABINETS, CLOSETS, ETC. LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2

KITCHEN_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT27000/(KITCHEN_POISON_LOCK_SAFETY). DO THE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, ETC THAT ARE LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT28000/(KITCHEN_FALLS). ARE THERE FREE STANDING FURNITURE OR APPLIANCES IN THE KITCHEN?


Label

Code

Go To

YES

1


NO

2

KITCHEN_RUGS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT29000/(KITCHEN_FALLS_LOW). CAN THE FREE STANDING FURNITURE OR APPLIANCES BE PULLED OVER/CLIMBED BY A CHILD YOUNGER THAN 6 YEARS OLD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT30000/(KITCHEN_RUGS). ARE THERE RUGS OR CARPETS IN THE KITCHEN?


Label

Code

Go To

YES

1


NO

2

KITCHEN_WINDOWS


SOURCE

New


KIT31000/(KITCHEN_RUGS_SLIP). ARE THESE RUGS OR CARPETS SLIP RESISTANT?


Label

Code

Go To

YES

1


NO

2



SOURCE

New


KIT32000/(KITCHEN_WINDOWS). DOES THE KITCHEN HAVE WINDOWS?


Label

Code

Go To

YES

1


NO

2

KITCHEN_CORDS


SOURCE

New


KIT33000/(KITCHEN_WINDOWS_OPEN). DO(ES) THE WINDOW(S) OPEN?


Label

Code

Go To

YES

1


NO

2

KITCHEN_CORDS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


KIT34000/(KITCHEN_WINDOWS_SAFETY). DO ALL THE WINDOWS THAT OPEN HAVE WORKING WINDOW GUARDS, LOCKS, OR RESTRICTED OPENING OF LESS THAN 3 INCHES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT35000/(KITCHEN_CORDS). ARE THERE CORDS IN THE KITCHEN?


Label

Code

Go To

YES

1


NO

2

KITCHEN_OUTLETS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


KIT36000/(KITCHEN_CORDS_ACCESS). ARE ANY OF THESE CORDS ACCESSIBLE TO THE CHILD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT37000/(KITCHEN_OUTLETS). HOW MANY VISIBLE UNCOVERED ELECTRICAL OUTLETS ARE THERE IN THE KITCHEN?

|___|___|___|


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT38000/(KITCHEN_GFCI). ARE THERE OUTLETS WITHIN 3 FEET OF THE SINK WITHOUT GFCI?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT39000/(KITCHEN_HOT_WATER_TEMP). WHAT IS THE TEMPERATURE OF THE HOT WATER?

|___|___|___|. |___| ºF


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


KIT40000/(KITCHEN_COMMENTS). RECORD ANY COMMENTS ABOUT THE KITCHEN OBSERVATIONS:

COMMENTS:______________________________________________________


SOURCE

New


(TIME_STAMP_KIT_ET).


DATA COLLECTOR INSTRUCTIONS

  • INSERT DATE/TIME STAMP.

  • IF MOST_USED_ROOM_OBSERVE = 1, GO TO TIME_STAMP_CMU_ST

  • IF MOST_USED_ROOM_OBSERVE = 2, -1 OR -2, GO TO TIME_STAMP_CMU_ET



CHILD’S MOST USED ROOM


(TIME_STAMP_CMU_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


CMU01000/(MOST_USED_ROOM_TYPE). RECORD WHICH ROOM IS THE MOST USED ROOM


Label

Code

Go To

COMMON LIVING AREA

1

TIME_STAMP_CMU_ET

CHILD'S BEDROOM

2

TIME_STAMP_CMU_ET

MOTHER'S BEDROOM

3

TIME_STAMP_CMU_ET

KITCHEN

4

TIME_STAMP_CMU_ET

OTHER

-5



SOURCE

New


CMU02000/(MOST_USED_ROOM_TYPE_OTH). SPECIFY: __________________________________________


SOURCE

New


CMU03000/(MOST_USED_ROOM_CLEAN). HOW CLEAN IS THE CHILD’S MOST USED ROOM?


Label

Code

Go To

VERY CLEAN

1


MODERATELY CLEAN

2


NOT CLEAN

3



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CMU04000/(MOST_USED_ROOM_CLUTTER). HOW CLUTTERED IS THE CHILD’S MOST USED ROOM?


Label

Code

Go To

LITTLE OR NO CLUTTER

1


MODERATE CLUTTER

2


VERY CLUTTERED

3



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CMU05000/(MOST_USED_SHARPS). ARE SHARPS VISIBLE ON ROOM SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_SHARPS = 2 AND

    • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FIREARMS.

    • OTHERWISE, GO TO MOST_USED_SHARPS_LOCK.

  • IF MOST_USED_SHARPS = 1, GO TO MOST_USED_SHARPS_LOW.


CMU06000/(MOST_USED_SHARPS_LOW). ARE SHARPS VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FIREARMS.

  • OTHERWISE, GO TO MOST_USED_SHARPS_LOCK.


CMU07000/(MOST_USED_SHARPS_LOCK). ARE THERE SHARPS IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

MOST_USED_FIREARMS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU08000/(MOST_USED_SHARPS_LOCK_LOW). ARE THE SHARPS IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU09000/(MOST_USED_FIREARMS). ARE FIREARMS OR AMMUNITION VISIBLE?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_FIREARMS = 2 AND

    • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FURNITURE.

    • OTHERWISE, GO TO MOST_USED_FIREARMS_LOCK.

  • IF MOST_USED_FIREARMS = 1, GO TO MOST_USED_FIREARMS_LOW.


CMU10000/(MOST_USED_FIREARMS_LOW). ARE FIREARMS OR AMMUNITION VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FURNITURE.

  • OTHERWISE, GO TO MOST_USED_FIREARMS_LOCK.


CMU11000/(MOST_USED_FIREARMS_LOCK). ARE THERE FIREARMS OR AMMUNITION IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

MOST_USED_FURNITURE


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU12000/(MOST_USED_FIREARMS_LOCK_LOW). ARE THE FIREARMS OR AMMUNITION IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU13000/(MOST_USED_FURNITURE). IS THERE ANY FURNITURE IN THE ROOM?


Label

Code

Go To

YES

1


NO

2

MOST_USED_GLASS


SOURCE

New


CMU14000/(MOST_USED_FURNITURE_SHARP). DOES THE FURNITURE IN THE ROOM HAVE EXPOSED SHARP OR SQUARE EDGES?


Label

Code

Go To

YES

1


NO

2

MOST_USED_GLASS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU15000/(MOST_USED_FURNITURE_SHARP_LOW). ARE THE EXPOSED SHARP OR SQUARE EDGES OF THE FURNITURE LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU16000/(MOST_USED_GLASS). ARE THERE FURNITURE OR DOORS WITH GLASS SURFACES?


Label

Code

Go To

YES

1


NO

2

MOST_USED_POISON


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU17000/(MOST_USED_GLASS_LOW). ARE THESE GLASS SURFACES ON FURNITURE OR DOORS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU18000/(MOST_USED_POISON). ARE THERE ANY POTENTIAL POISONS VISIBLE ON ROOM SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_POISON = 2 AND

    • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FALLS.

    • OTHERWISE, GO TO MOST_USED_POISON_LOCK.

  • IF MOST_USED_POISON = 1, GO TO MOST_USED_POISON_LOW.


CMU19000/(MOST_USED_POISON_LOW). ARE THERE ANY POTENTIAL POISONS VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_POISON_LOW = 2 AND

    • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FALLS.

    • OTHERWISE, GO TO MOST_USED_POISON_LOCK.

  • IF MOST_USED_POISON_LOW = 1, GO TO MOST_USED_POISON_SURFACE_SAFE.


CMU20000/(MOST_USED_POISON_SURFACE_SAFE). DO POTENTIAL POISONS ON SURFACES LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF MOST_USED_ROOM_OPEN = 2, -1 OR -2, GO TO MOST_USED_FALLS.

  • OTHERWISE, GO TO MOST_USED_POISON_LOCK.


CMU21000/(MOST_USED_POISON_LOCK). ARE THERE POTENTIAL POISONS IN DRAWERS, CABINETS, CLOSETS, ETC. WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

MOST_USED_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU22000/(MOST_USED_POISON_LOCK_LOW). ARE THE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, CLOSETS, ETC. LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2

MOST_USED_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU23000/(MOST_USED_POISON_LOCK_SAFETY). DO THE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, ETC. THAT ARE LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU24000/(MOST_USED_FALLS). ARE THERE FREE STANDING FURNITURE OR APPLIANCES IN THE ROOM?


Label

Code

Go To

YES

1


NO

2

MOST_USED_RUGS


SOURCE

New


CMU25000/(MOST_USED_FALLS_LOW). CAN THE FREE STANDING FURNITURE OR APPLIANCES BE PULLED OVER/CLIMBED BY A CHILD YOUNGER THAN 6 YEARS OLD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU26000/(MOST_USED_RUGS). ARE THERE RUGS OR CARPETS IN THE ROOM?


Label

Code

Go To

YES

1


NO

2

MOST_USED_WINDOWS


SOURCE

New


CMU27000/(MOST_USED_RUGS_SLIP). ARE THESE RUGS OR CARPETS SLIP RESISTANT?


Label

Code

Go To

YES

1


NO

2



SOURCE

New


CMU28000/(MOST_USED_WINDOWS). DOES THE ROOM HAVE WINDOW(S)?


Label

Code

Go To

YES

1


NO

2

MOST_USED_CORDS


SOURCE

New


CMU29000/(MOST_USED_WINDOWS_OPEN). DO(ES) THE WINDOW(S) OPEN?


Label

Code

Go To

YES

1


NO

2

MOST_USED_CORDS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CMU30000/(MOST_USED_WINDOWS_SAFETY). DO ALL THE WINDOWS THAT OPEN HAVE WORKING WINDOW GUARDS, LOCKS, OR RESTRICTED OPENINGS OF LESS THAN 3 INCHES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU31000/(MOST_USED_CORDS). ARE THERE CORDS IN THE ROOM?


Label

Code

Go To

YES

1


NO

2

MOST_USED_OUTLETS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CMU32000/(MOST_USED_CORDS_ACCESS). ARE ANY OF THESE CORDS ACCESSIBLE TO THE CHILD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU33000/(MOST_USED_OUTLETS). HOW MANY VISIBLE UNCOVERED ELECTRICAL OUTLETS ARE THERE IN THE MOST USED ROOM?

|___|___|___|


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CMU34000/(MOST_USED_COMMENTS). RECORD ANY COMMENTS ABOUT THE MOST USED ROOM OBSERVATIONS:

COMMENTS:______________________________________________________


SOURCE

New


(TIME_STAMP_CMU_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP.

  • IF BEDROOM_OBSERVE = 1, GO TO TIME_STAMP_CB_ST

  • IF BEDROOM_OBSERVE = 2, -1 OR -2, GO TO TIME_STAMP_CB_ET



CHILD'S BEDROOM


(TIME_STAMP_CB_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


CB01000/(BED_ROOM_CLEAN). HOW CLEAN IS THE CHILD’S BEDROOM?


Label

Code

Go To

VERY CLEAN

1


MODERATELY CLEAN

2


NOT CLEAN

3



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CB02000/(BED_ROOM_CLUTTER). HOW CLUTTERED IS THE CHILD’S BEDROOM?


Label

Code

Go To

LITTLE OR NO CLUTTER

1


MODERATE CLUTTER

2


VERY CLUTTERED

3



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CB03000/(BED_SHARPS). ARE SHARPS VISIBLE ON BEDROOM SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BED_SHARPS = 2 AND

    • IF BEDROOM_OPEN = 2, -1 OR -2, GO TO BED_FIREARMS.

    • OTHERWISE, GO TO BED_SHARPS_LOCK.

  • IF BED_SHARPS = 1, GO TO BED_SHARPS_LOW.


CB03100/(BED_SHARPS_LOW). ARE SHARPS VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BEDROOM_OPEN = 2, -1 OR -2, GO TO BED_FIREARMS.

  • OTHERWISE, GO TO BED_SHARPS_LOCK.


CB04000/(BED_SHARPS_LOCK). ARE THERE SHARPS IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

BED_FIREARMS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB05000/(BED_SHARPS_LOCK_LOW). ARE THE SHARPS IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB06000/(BED_FIREARMS). ARE FIREARMS OR AMMUNITION VISIBLE IN THE CHILD’S BEDROOM?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BED_FIREARMS = 2 AND

  • IF BEDROOM_OPEN = 2, -1 OR -2, GO TO BED_FURNITURE.

  • OTHERWISE, GO TO BED_FIREARMS_LOCK.

  • IF BED_FIREARMS = 1, GO TO BED_FIREARMS_LOW.


CB07000/(BED_FIREARMS_LOW). ARE FIREARMS OR AMMUNITION VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BEDROOM_OPEN = 2, -1 OR -2, GO TO BED_FURNITURE.

  • OTHERWISE, GO TO BED_FIREARMS_LOCK.


CB08000/(BED_FIREARMS_LOCK). ARE THERE FIREARMS OR AMMUNITION IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

BED_FURNITURE


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB09000/(BED_FIREARMS_LOCK_LOW). ARE THE FIREARMS OR AMMUNITION IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB10000/(BED_FURNITURE). IS THERE ANY FURNITURE IN THE BEDROOM?


Label

Code

Go To

YES

1


NO

2

BED_GLASS


SOURCE

New


CB11000/(BED_FURNITURE_SHARP). DOES THE FURNITURE IN THE ROOM HAVE EXPOSED SHARP OR SQUARE EDGES?


Label

Code

Go To

YES

1


NO

2

BED_GLASS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB12000/(BED_FURNITURE_SHARP_LOW). ARE THE EXPOSED SHARP OR SQUARE EDGES OF THE FURNITURE LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB13000/(BED_GLASS). ARE THERE FURNITURE OR DOORS WITH GLASS SURFACES?


Label

Code

Go To

YES

1


NO

2

BED_POISON


SOURCE

New


CB14000/(BED_GLASS_LOW). ARE THE GLASS SURFACES ON FURNITURE OR DOORS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB15000/(BED_POISON). ARE THERE ANY POTENTIAL POISONS VISIBLE ON BEDROOM SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BED_POISON = 2 AND

    • IF BEDROOM_OPEN = 2, -1 OR -2, GO TO BED_FALLS.

    • OTHERWISE, GO TO BED_POISON_LOCK.

  • IF BED_POISON = 1, GO TO BED_POISON_LOW.


CB16000/(BED_POISON_LOW). ARE THERE ANY POTENTIAL POISONS VISIBLE ON SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BED_POISON_LOW = 2 AND

    • IF BEDROOM_OPEN = 2, -1 OR -2, GO TO BED_FALLS.

    • OTHERWISE, GO TO BED_POISON_LOCK.

  • IF BED_POISON_LOW = 1, GO TO BED_POISON_SURFACE_SAFETY.


CB18000/(BED_POISON_LOCK). ARE THE POTENTIAL POISONS IN DRAWERS, CABINETS, CLOSETS, ETC. WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

BED_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB19000/(BED_POISON_LOCK_LOW). ARE THE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, CLOSETS, ETC. LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2

BED_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB20000/(BED_POISON_LOCK_SAFETY). DO THE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, ETC. THAT ARE LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB21000/(BED_FALLS). ARE THERE FREE STANDING FURNITURE OR APPLIANCES IN THE ROOM?


Label

Code

Go To

YES

1


NO

2

BED_PRESENT


SOURCE

New


CB22000/(BED_FALLS_LOW). CAN THE FREE STANDING FURNITURE OR APPLIANCES BE PULLED OVER/CLIMBED BY A CHILD YOUNGER THAN 6 YEARS OLD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB23000/(BED_PRESENT). IS THERE A BED?


Label

Code

Go To

YES

1


NO

2

BED_RUGS


SOURCE

New


CB24000/(BED_RAIL). DOES THE CHILD’S BED HAVE A RAIL?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB25000/(BED_RUGS). ARE THERE RUGS OR CARPETS IN THE ROOM?


Label

Code

Go To

YES

1


NO

2

BED_WINDOWS


SOURCE

New


CB26000/(BED_RUGS_SLIP). ARE THESE RUGS OR CARPETS SLIP RESISTANT?


Label

Code

Go To

YES

1


NO

2



SOURCE

New


CB27000/(BED_WINDOWS). DOES THE BEDROOM HAVE WINDOWS?


Label

Code

Go To

YES

1


NO

2

BED_CORDS


SOURCE

New


CB28000/(BED_WINDOWS_OPEN). DO(ES) THE WINDOW(S) OPEN?


Label

Code

Go To

YES

1


NO

2

BED_CORDS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M,12M)


CB29000/(BED_WINDOWS_SAFETY). DO ALL THE WINDOWS THAT OPEN HAVE WORKING WINDOW GUARDS, LOCKS, OR RESTRICTED OPENING OF LESS THAN 3 INCHES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB30000/(BED_CORDS). ARE THERE CORDS IN THE BEDROOM?


Label

Code

Go To

YES

1


NO

2

BED_OUTLETS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CB31000/(BED_CORDS_ACCESS). ARE ANY OF THE CORDS ACCESSIBLE TO THE CHILD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB32000/(BED_OUTLETS). HOW MANY VISIBLE UNCOVERED ELECTRICAL OUTLETS ARE THERE IN THE BEDROOM?

|___|___|___|


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB33000/(BED_ESCAPE). ARE THERE ACCESSIBLE FIRE EXITS/ESCAPES?


Label

Code

Go To

YES

1


NO

2


DON'T KNOW

-2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CB34000/(BED_COMMENTS). RECORD ANY COMMENTS ABOUT THE CHILD’S BEDROOM OBSERVATIONS:

COMMENTS:______________________________________________________


SOURCE

New


(TIME_STAMP_CB_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP.

  • IF BATHROOM_OBSERVE = 1, GO TO TIME_STAMP_CBA_ST

  • IF BATHROOM_OBSERVE = 2, -1 OR -2, GO TO TIME_STAMP_STA_ST



CHILD'S BATHROOM


(TIME_STAMP_CBA_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIMESTAMP.


CBA00100/(BATH_ROOM_CLEAN). HOW CLEAN IS THE CHILD’S BATHROOM?


Label

Code

Go To

VERY CLEAN

1


MODERATELY CLEAN

2


NOT CLEAN

3



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CBA01000/(BATH_ROOM_CLUTTER). HOW CLUTTERED IS THE CHILD’S BATHROOM?


Label

Code

Go To

LITTLE OR NO CLUTTER

1


MODERATE CLUTTER

2


VERY CLUTTERED

3



SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CBA02000/(BATH_SHARPS). ARE SHARPS VISIBLE ON BATHROOM SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BATH_SHARPS = 2 AND

    • IF BATHROOM_OPEN = 2, -1 OR -2, GO TO BATH_FURNITURE.

    • OTHERWISE, GO TO BATH_SHARPS_LOCK.

  • IF BATH_SHARPS = 1, GO TO BATH_SHARPS_LOW.


CBA03000/(BATH_SHARPS_LOW). ARE SHARPS VISIBLE ON BATHROOM SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BATHROOM_OPEN = 2, -1 OR -2, GO TO BATH_FURNITURE.

  • OTHERWISE, GO TO BATH_SHARPS_LOCK.


CBA04000/(BATH_SHARPS_LOCK). ARE THERE SHARPS IN DRAWERS, CABINETS, OR CLOSETS WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

BATH_FURNITURE


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA05000/(BATH_SHARPS_LOCK_LOW). ARE THE SHARPS IN UNLOCKED DRAWERS, CABINETS, OR CLOSETS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA05100/(BATH_FURNITURE). IS THERE ANY FURNITURE IN THE BATHROOM?


Label

Code

Go To

YES

1


NO

2

BATH_GLASS


SOURCE

New


CBA05200/(BATH_FURNITURE_SHARP). DOES THE FURNITURE IN THE BATHROOM HAVE EXPOSED SHARP OR SQUARE EDGES?


Label

Code

Go To

YES

1


NO

2

BATH_GLASS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA05300/(BATH_FURNITURE_SHARP_LOW). ARE EXPOSED SHARP OR SQUARE EDGES OF THE FURNITURE LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA06000/(BATH_GLASS). ARE THERE FURNITURE OR DOORS WITH GLASS SURFACES?


Label

Code

Go To

YES

1


NO

2

BATH_POISON


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA07000/(BATH_GLASS_LOW). ARE THESE GLASS SURFACES ON FURNITURE OR DOORS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA08000/(BATH_POISON). ARE THERE POTENTIAL POISONS VISIBLE ON BATHROOM SURFACES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BATH_POISON = 2 AND

    • IF BATHROOM_OPEN = 2, -1 OR -2, GO TO BATH_FALLS.

    • OTHERWISE, GO TO BATH_POISON_LOCK.

  • IF BATH_POISON = 1, GO TO BATH_POISON_LOW.


CBA09000/(BATH_POISON_LOW). ARE THERE ANY POTENTIAL POISONS VISIBLE ON BATHROOM SURFACES LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BATH_POISON_LOW = 2 AND

    • IF BATHROOM_OPEN = 2, -1 OR -2, GO TO BATH_FALLS.

    • OTHERWISE, GO TO BATH_POISON_LOCK.

  • IF BATH_POISON_LOW = 1, GO TO BATH_POISON_SURFACE_SAFETY.


CBA10000/(BATH_POISON_SURFACE_SAFETY). DO POTENTIAL POISONS ON SURFACES THAT ARE LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


PROGRAMMER INSTRUCTIONS

  • IF BATHROOM_OPEN = 2, -1 OR -2, GO TO BATH_FALLS.

  • OTHERWISE, GO TO BATH_POISON_LOCK.


CBA11000/(BATH_POISON_LOCK). ARE THERE POTENTIAL POISONS IN DRAWERS, CABINETS, CLOSETS, ETC. WITHOUT WORKING LOCKS?


Label

Code

Go To

YES

1


NO

2

BATH_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA12000/(BATH_POISON_LOCK_LOW). ARE THE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, CLOSETS, ETC. LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2

BATH_FALLS


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA13000/(BATH_POISON_LOCK_SAFETY). DO THESE POTENTIAL POISONS IN UNLOCKED DRAWERS, CABINETS, ETC. THAT ARE LESS THAN 3 FEET FROM THE FLOOR HAVE SAFETY CAPS/DEVICES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA14000/(BATH_FALLS). ARE THERE FREE STANDING FURNITURE OR APPLIANCES IN THE BATHROOM?


Label

Code

Go To

YES

1


NO

2

BATH_RUGS


SOURCE

New


CBA15000/(BATH_FALLS_LOW). CAN THE FREE STANDING FURNITURE OR APPLIANCES BE PULLED OVER/CLIMBED BY A CHILD YOUNGER THAN 6 YEARS OLD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA16000/(BATH_RUGS). ARE THERE RUGS OR CARPETS IN THE BATHROOM?


Label

Code

Go To

YES

1


NO

2

BATH_WINDOWS


SOURCE

New


CBA17000/(BATH_RUGS_SLIP). ARE THESE RUGS OR CARPETS SLIP RESISTANT?


Label

Code

Go To

YES

1


NO

2



SOURCE

New


CBA18000/(BATH_WINDOWS). DOES THE BATHROOM HAVE WINDOWS?


Label

Code

Go To

YES

1


NO

2

BATH_CORDS


SOURCE

New


CBA19000/(BATH_WINDOWS_OPEN). DO(ES) THE BATHROOM WINDOW(S) OPEN?


Label

Code

Go To

YES

1


NO

2

BATH_CORDS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CBA20000/(BATH_WINDOWS_SAFETY). DO ALL THE WINDOWS THAT OPEN HAVE WORKING WINDOW GUARDS, LOCKS, OR RESTRICTED OPENING OF LESS THAN 3 INCHES?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA21000/(BATH_CORDS). ARE THERE CORDS IN THE BATHROOM?


Label

Code

Go To

YES

1


NO

2

BATH_OUTLETS


SOURCE

National Children’s Study, Legacy Phase (Modified) (Dwelling Unit Visual Observations-6M, 12M)


CBA22000/(BATH_CORDS_ACCESS). ARE THESE CORDS ACCESSIBLE TO THE CHILD?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA23000/(BATH_OUTLETS). HOW MANY VISIBLE UNCOVERED ELECTRICAL OUTLETS ARE THERE IN THE BATHROOM?

|___|___|___|


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA24000/(BATH_GFCI). ARE THERE OUTLETS WITHIN 3 FEET OF THE SINK WITHOUT GFCI?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA25000/(BATH_TREAD). IS THERE A NON-SLIP MAT OR TREAD IN THE SHOWER OR BATHTUB?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA26000/(BATH_HOT_WATER_TEMP). WHAT IS THE TEMPERATURE OF THE HOT WATER?

|___|___|___|. |___| ºF


SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


CBA27000/(BATH_COMMENTS). RECORD ANY COMMENTS ABOUT THE CHILD’S BATHROOM OBSERVATIONS:

COMMENTS:______________________________________________________


SOURCE

New


(TIME_STAMP_CBA_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP.



STAIRS


(TIME_STAMP_STA_ST).


DATA COLLECTOR INSTRUCTIONS

  • INSERT DATE/TIME STAMP


STA01000/(STAIRS). ARE THERE STAIRS IN THE DWELLING UNIT?


Label

Code

Go To

YES

1


NO

2

STAIRS_COMMENTS


SOURCE

New


STA02000/(STAIRS_HEIGHT). IS THE HEIGHT OF THE STEPS CONSISTENT?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA03000/(STAIRS_RAIL). IS THERE A HANDRAIL ON THE STAIRS?


Label

Code

Go To

YES

1


NO

2

STAIRS_CARPET

NOT APPLICABLE

-7

STAIRS_CARPET


SOURCE

New


STA04000/(STAIRS_ROUND). ARE THE EDGES ON THE HANDRAIL ROUNDED?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA05000/(STAIRS_RAIL_LOW). IS THE HANDRAIL ON THE STAIRS LESS THAN 3 FEET FROM THE FLOOR?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA06000/(STAIRS_RAIL_AFFIXED). IS THE HANDRAIL ON THE STAIRS FIRMLY AFFIXED?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA07000/(STAIRS_SPINDLES). ARE THERE SPINDLES ON THE STAIRS?


Label

Code

Go To

YES

1


NO

2

STAIRS_CARPET


SOURCE

New


STA08000/(STAIRS_SPINDLES_DISTANCE). ARE THE SPINDLES LESS THAN 3 INCHES APART?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA09000/(STAIRS_CARPET). IS THERE A CARPET OR RUBBER ON THE STAIRS?


Label

Code

Go To

YES

1


NO

2

STAIRS_LIGHTING


SOURCE

New


STA10000/(STAIRS_CARPET_SECURE). IS THE CARPET OR RUBBER ON THE STAIRS SECURELY INSTALLED?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA11000/(STAIRS_LIGHTING). IS THERE LIGHTING FOR THE STAIRS?


Label

Code

Go To

YES

1


NO

2



SOURCE

Cincinnati Center for Children’s Environmental Health, Home Injury Survey 3.0 (Modified)


STA12000/(STAIRS_COMMENTS). RECORD ANY COMMENTS ABOUT THE STAIRS OBSERVATIONS:

COMMENTS:______________________________________________________


SOURCE

New


(TIME_STAMP_STA_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


Public reporting burden for this collection of information is estimated to average 5 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 may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*).  Do not return the completed form to this address.

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