Form 1 Appendix B - General Population Survey

OMB No.: 0915-0343

Expiration Date: XX/XX/20XX

POISON HELP

GENERAL POPULATION SURVEY

INTRO 1. Hello, this is [INTERVIEWER] and I’m calling from KRC Research on behalf of the Health Resources and Services Administration (HRSA) an agency within the U.S. Department of Health and Human Services. We are contacting households across the nation to conduct a brief survey to learn how people get safety information. This interview will take about 10 minutes, and the information you give will be completely anonymous and all of your responses will be kept confidential. Your participation in this interview is voluntary, so you do not have to answer any questions you are uncomfortable answering.

[IF RESPONDENT WANTS TO VERIFY LEGITIMACY OF SURVEY] You can speak to my supervisor now, or you can contact the project director at KRC Research. Which would you like?

[IF CELL PHONE, ADD THE FOLLOWING]

I am calling you on a cell phone. If you are driving or doing anything that requires your full attention, I will call you back.

[ALL]

If you’re ready, let’s begin.

[INTERVIEWER NOTE: IF RESPONDENT ANSWERS TELEPHONE IN SPANISH OR REQUESTS SPANISH-LANGUAGE, READ INTRODUCTION IN SPANISH]

INTERVIEWER RECORD LANGUAGE:

1. English

2. Spanish

R1. First, I’m going to read descriptions of situations that might happen. Please tell me what you would do if that happened to you. What if:

[RANDOMLY ASSIGN RESPONDENTS TO FOUR SCENARIOS]

1. A young child swallowed several adult vitamin pills;

2. An older person visiting your household says that he may have taken his high blood pressure medication twice by mistake;

3. A neighbor runs in and says she needs help because her child drank windshield wiper fluid;

4. You think you have an insect bite and your arm becomes very swollen from wrist to elbow;

5. You are looking for general information about ways to prevent poisoning;

6. A teenager in your household says he doesn’t feel good and admits he has taken prescription painkillers with alcohol;

7. The alarm on your carbon monoxide detector goes off in the middle of the night;

8. You were using pesticides in your garden and now you are feeling ill;

9. You hear on the radio that the water supply in your city has been contaminated and you are worried about whether it is safe to drink and use;

10. Your spouse was helping you with cleaning the house, but is now having difficulty breathing.

[INTERVIEWER PROMPT: “What would you do first if this happened?”]

[DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

1. Poison Center/Poison Control Center/PCC

2. 1-800-222-1222 / Poison Help Line / Poison 1-800 Number / Poison Hotline

3. 911/Rescue Squad/EMT

4. Fire Department

5. Police Department

6. Doctor/Nurse/Health Professional

7. Pharmacist/Pharmacy

8. Hospital/Emergency Room

9. Urgent Care

10. Family Member

11. Friend

12. Internet/Online (Specify: _____)

13. Nothing/Would Not Seek Help

14. Other (DNR) Specify: _____)

15. Don’t Know (DNR)

16. Refused (DNR)

R2. In the past year, have you sought information or help related to a poisoning?

1. Yes

2. No

3. Don’t Know (DNR)

4. Refused (DNR)

[IF R2:1 YES, ASK R4. ALL OTHERS SKIP TO R5]

R3. NO QUESTION

R4. Please tell me where you sought information or help. [DO NOT READ/CODE ALL THAT APPLY]

1. Poison Center/Poison Control Center/PCC

2. 1-800-222-1222 / Poison Help Line / Poison 1-800 Number / Poison Hotline

3. 911/Rescue Squad/EMT

4. Fire Department

5. Police Department

6. Doctor/Nurse/Health Professional

7. Pharmacist/Pharmacy

8. Hospital/Emergency Room

9. Urgent Care

10. Family Member

11. Friend

12. Insurance Company/Insurance Advice Line/Nurse Help Line

13. Internet Online (Specify Web Site: _______)

14. Other (DNR) (Specify: _____)

15. Don’t Know (DNR)

16. Refused (DNR)

R4.1 Have you or someone in your household ever had a bad reaction or emergency situation related to prescription pain medication?

[DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

1. Yes

2. No

3. Don’t Know (DNR)

4. Refused (DNR)

R4.2 Have you or someone in your household ever had a bad reaction or emergency situation related to a possible heroin overdose?

[DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

1. Yes

2. No

3. Don’t Know (DNR)

4. Refused (DNR)

[IF R2:2-99 DID NOT SEEK HELP OR INFORMATION OR R4:3-99 DID NOT CONTACT POISON CONTROL CENTER, ASK R5]

R5. In the past year, did you contact a poison control center for information or help related to a poisoning?

1. Yes

2. No

3. Don’t Know (DNR)

4. Refused (DNR)

[IF R4:1-2 OR R5:1 RESPONDENT CONTACTED POISON CONTROL CENTER, ASK R6]

R6. If a poison control center had not been available, what would you have done?

[RECORD RESPONDENT ANSWER EXACTLY]

1. Don’t Know (DNR)

2. Refused (DNR)

[IF R4:1-2 OR R5:1 RESPONDENT CONTACTED POISON CONTROL CENTER, AND IF R4.1 AND/OR R4.2, ASK R6.1]

R6.1. Was your call to the poison control center with regard to the negative reaction or emergency situation related to [INSERT BASED ON RESPONSE TO R4.1: prescription drugs to treat pain; AND/OR R4.2: the possible heroin overdose]?

1. Yes

2. No

3. Don’t Know (DNR)

4. Refused (DNR)

[IF R6.1-1, ASK R6.2]

R6.2. When you called the poison control center, were you given helpful information or referred to a medical facility for additional help and treatment?

1. Yes

2. No

3. Don’t Know (DNR)

4. Refused (DNR)

[ASK ALL RESPONDENTS]

R7. What telephone number would you use to contact a poison control center? [DO NOT READ, WAIT FOR RESPONSE]

1. 1-800-222-1222/ Poison Help Line/Poison 1-800 Number/ Poison Hotline

2. Other 800 Or 888 Number (Specify: __________)

3. Other 800 Or 888 Number, Not Specified

4. Other Number, Not 800 (Specify: __________)

5. Other Number, Not 800, Not Specified

6. 911

7. Don’t Know

8. Refused

[IF R7 NOT PUNCH 1, DID NOT NAME 1-800-222-1222, ASK]

R8. If you needed to contact a poison control center immediately, where would you look for the telephone number? [DO NOT READ / CODE ALL THAT APPLY]

1. Poison Prevention Materials/Magnet/Stickers

2. Telephone Book

3. 411/Directory Assistance

4. 911

5. Programmed In My Cellular Phone

6. HRSA Web Site

7. Poison Control Center Web Site

8. Google/Yahoo/Another Search Engine

9. Other Internet or Online/Specify: _____

10. Other/Specify: _____

11. Don’t Know

12. Refused

[IF R7:1 WOULD CALL 1-800-222-1222 TO CONTACT A POISON CONTROL CENTER, ASK]

R9. How or where did you learn about the poison control center toll-free number 1-800-222-1222? [DO NOT READ/CODE ALL THAT APPLY]

1. Local Poison Control Center

2. Public Service Announcement/TV/Radio

3. Brochure/Magnet/Stickers

4. Poster

5. Newspaper Article/Magazine Article

6. Newspaper Advertisement

7. Outdoor Advertising/Billboard/Bus Advertisement

8. Telephone Book

9. 411/Information/Director Assistance

10. Doctor/Nurse/Health Professional

11. Hospital/Emergency Room pharmacist/Pharmacy

12. Daycare/School/Teacher

13. HRSA Web Site

14. Poison Control Center Web Site

15. Google/Yahoo/Search Engine

16. Fire Department

17. Police Department

18. Store

19. Library

20. Relative/Spouse/Parent/Sibling

21. Friend/Neighbor/Coworker

22. Community Event

23. Other Advertising/Specify: ______

24. Other Internet Or Online/Specify: _____

25. Other/Specify: ____

26. Don’t Know

27. Refused

[ASK ALL] [DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

R11. Do you have a cellular or wireless telephone?

1. Yes

2. No

3. Don’t Know

4. Refused

[IF R11:1 YES, OWN WIRELESS TELEPHONE, ASK] [DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

R12. Do you have a poison control center number programmed in that telephone?

1. Yes

2. No

3. Don’t Know

4. Refused

[ASK ALL, DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

R13. Do you have a poison control center number posted in your home?

1. Yes

2. No

3. Don’t Know

4. Refused

INTERVIEWER: Now, I would like to ask you some questions about poison control centers. Please answer based on what you know. If you do not know the answer, please tell me and we’ll move on to the next question.

R15. When are poison control centers open to respond to your call? [RANDOMIZE]

1. 24 hours a day, 7 days per week, 365 days a year

2. Monday through Friday, 9am to 5pm

3. Weekends only OR

4. Don’t know

5. Refused

R16. Who answers calls to poison control centers? [ROTATE]

1. Expert medical professionals

2. Trained volunteers OR

3. Don’t know

4. Refused

R17. If you do not speak English, can a poison control center still help you? [ROTATE]

1. Yes

2. No

3. Don’t know

4. Refused

R18. When you call a poison control center about a person who may have been poisoned, how much does it cost to receive information? [ROTATE]

1. Nothing, the call is free

2. A maximum of $25 (twenty-five dollars) OR

3. Don’t know

4. Refused

R19. When you call a poison control center, what other organizations or individuals have access to the information you provided? [RANDOMIZE, CHECK ALL THAT APPLY]

1. No one, it is kept confidential

2. Your health care provider

3. Your insurance company

4. Law enforcement

5. Social services

6. Don’t Know

7. Refused

R20. Who do you think uses poison control services? Please select all that apply [RANDOMIZE / ACCEPT MULTIPLE RESPONSES]

1. Anyone/ Everyone

2. Law Enforcement Officers

3. Health Care Providers

4. Individuals who care for young children

5. Someone else [SPECIFY: _____]

6. None of the Above

7. 98 Don’t Know

8. 99 Refused

[ASK R20.1 IF HAVE NOT MENTIONED NUMBER TO THIS POINT, MEANING DID NOT SELECT R1=2 (ANY), R4=2, OR R7=1] [DO NOT READ ANSWER CHOICES; SELECT ONLY ONE RESPONSE]

R20.1. Before today, were you aware that there is a Poison Control Hotline, 1-800-222-1222, that you can call to receive more information about poison prevention or to assist you in the event of a possible poisoning emergency?

1. Yes

2. No

3. Don’t know

4. Refused

R21 INTRO Now, just a few questions about you and your household.

R21. [READ IF NECESSARY] Are you male or female?

1. Male

2. Female

3. Don’t Know

4. Refused

R22. How old are you? Are you… [READ EACH CATEGORY]

1. 18-24

2. 25-34

3. 35-44

4. 45-54

5. 55-64

6. Age 65 Or Older

7. Don’t Know

8. Refused

R23. What is the highest grade or level of school you have completed? [DO NOT READ, CODE ONLY ONE RESPONSE]

1. No Schooling or Grades 1-8

2. Some High School or Grades 9-11

3. Grade 12, High School Diploma, or GED

4. Vocation/Technical School or Some College, But No Bachelor’s Degree

5. Bachelor’s Degree, B.A. Or B.S.

6. More Than A Bachelor’s Degree, Post-Graduate Courses, M.D., Phd, Law School, Etc.

7. Don’t Know

8. Refused

[IF R23:1-3 HIGH SCHOOL DIPLOMA, EQUIVALENT OR LESS, ASK]

R24. Do you have a high school diploma or its equivalent, a GED?

1. Yes

2. No

3. Don’t Know

4. Refused

R25. Are you of Spanish, Hispanic, or Latino origin?

1. Yes

2. No

3. Don’t Know

4. Refused

R26. How would you describe your race? You may choose more than one. [RANDOMIZE, READ CHOICES, CODE ALL THAT APPLY.]

1. White

2. Black Or African-American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Pacific Islander

6. Don’t Know

7. Refused

Now I have just a few questions about your household.

R27. Do any people under age 18 live in this household?

1. Yes

2. No

3. Don’t Know

4. Refused

[IF R27:1 YES ASK]

R28. Do any people age 5 or younger live in this household?

1. Yes

2. No

3. Don’t Know

4. Refused

[IF R28:1 YES ASK]

R29. Are you a parent or guardian of any of these children age 5 and younger?

1. Yes

2. No

3. Don’t Know

4. Refused

R30. Which of the following best describes your health insurance coverage? You may choose more than one. [RANDOMIZE 1-5, READ 6 LAST, ACCEPT MULTIPLE RESPONSES]

1. Health insurance offered through your employer or union

2. Health insurance purchased yourself

3. Medicare

4. Medicaid

5. Health savings account, or HSA

6. No health insurance coverage

7. Something Else (Specify: ______)

8. Don’t Know

9. Refused

R31. What was the total income of all persons in your household over the past year, including salaries or other earnings, interest, retirement, and so on for all household members? Was it... [READ IN ORDER UNTIL RESPONSE CHOSEN]

1. Less Than $25,000

2. $25,000 To $50,000

3. $50,001 To $75,000

4. $75,001 To $100,000

5. $100,001 To $150,000

6. $150,001 Or More

7. Don’t Know

8. Refused

R32. What is your zip code? [RECORD]

ZIP CODE __ __ __ __ __

[R33: LANDLINE ONLY]

R33. Do you or someone else in your household have a working cell phone?

1. Yes

2. No

3. Don’t Know/Refused

[R34: CELL PHONE ONLY]

R34. Now thinking about your phone usage, do you have a working home phone?

1. Yes

2. No

3. Don’t Know/Refused

[ASK R36 IF R11, R33, OR R34=1]

R35. Of all the phone calls you and your household receive, are:

1. All or most calls received on your cell phone;

2. Some calls received on your cell phone and some on your home phone, or

3. Very few or no calls received on your cell phone?

4. Don’t Know/Refused

THANK Those are all the questions I have for you. Thank you very much for your time. I would like to give you a telephone number in case you are interested in receiving more information about poison prevention or the ways that poison control centers can help in a poison emergency. The number you can call is 1-800-222-1222. This number works from any place in the country and connects you to a local poison control center where health care professionals and other poison experts provide treatment advice about poisonings and poison prevention information 24 hours a day, every day of the year. There is no cost for the service. It is free and confidential. Translation services are available in over 160 languages.

Public Burden Statement: 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. The OMB control number for this project is 0915-0343. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.