Questionnaire provided for review purposes only. Not for public dissemination.
Law Enforcement Officer Injuries
Form Approved:
OMB No. xxxx-xxxx
Exp. Date xx/xx/20xx
Questionnaire # ___________________
This is the Law Enforcement Officer Injury Survey
Tasknum – Enter task number
__________________________
Instruct_1. Bold type indicates what should be read to the respondent. Instructions for the interviewer or frequently asked questions will be prefaced by “Interviewer:” and are written in non-bold type.
Interviewer: Please do not read choices to yes/no questions or give examples unless explicitly instructed to do so. Do not read the “Refused” or “Don’t Know” choices. If the respondent is unsure, read applicable interviewer notes if available. Otherwise, say, “Please give me the answer you think is best.”
Instruct_2. Interviewer: Prior to calling the respondent, please review their case and complete the following.
Name - Interviewer: Complete before dialing.
What is your name? (Interviewer's first and last name)
___________________________________________________________________________________
tx_date - Interviewer: Complete before dialing.
Enter the month, day, year of treatment.
Month (MM) ____
Day (DD) ____
Year (YY) ____
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, gathering the information needed, and completing the interview. If you have any comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton Road, MS-D-74, Atlanta, GA 30333; ATTN:PRA xxxx-xxxx. Do not send the completed phone call form to this address. Please do not complete and return this form; you will be contacted by telephone to collect this information. Persons are not required to respond to the work history questions unless a currently valid OMB number is display.
Interview Introduction
Hello. My name is (interviewer name). I am calling for the National Institute for Occupational Safety and Health, also known as NIOSH. In the last few weeks, we sent you a letter explaining a research study about law enforcement officers and their experiences with injuries. As the letter said, we are gathering information among officers who were injured or exposed while performing law enforcement duties. This study has no connection to workers’ compensation, disability claims, or your agency’s internal affairs process. You were chosen for this study from emergency department records. Our records show that on ___/____/____ you were treated in the emergency department for an incident that occurred at work.
1) Is this correct?
Yes
No
*Programming note: If 1 = a, SKIP to 4
*Programming note: If 1 = b, GOTO 2
2) Were you recently treated in a hospital emergency department on a different day?
Yes
No
*Programming note: If 2 = a, GOTO 3
*Programming note: If 2 = b, END interview
3) What day was that?
Month (MM) ____
Day (DD) ____
Year (YY) ____
*Programming note: If date is within 21 days of recorded date, GOTO 4
*Programming note: If date is greater than 21 days from recorded date, END interview
4) Regardless of what you were doing when the injury or exposure happened, at the time of the incident that brought you to the emergency department, were you employed as a sworn law enforcement officer?
Yes
No
*Programming note: If 4 = a, GOTO 5
*Programming note: If 4 = b, END INTERVIEW
5) At the time of the incident, were you working as a corrections officer?
Yes
No
*Programming note: If 5 = a, END INTERVIEW
*Programming note: If 5 = b, GOTO 6
6) Were you working under the scope of your law enforcement agency when the incident occurred?
Yes
No
*Programming note: If 6 = a, GOTO CONSENT
*Programming note: If 6 = b, GOTO 7
7) Were you participating in department directed physical fitness or recreation activities when the incident occurred?
Yes
No
*Programming note: If 6 = a, GOTO to Consent
*Programming note: If 6 = b, END interview
Consent - The letter you received explained how we will protect your privacy. I am required to tell you four things that were mentioned in this letter:
First, taking part in this study involves a small risk to your privacy, but we take many steps to prevent that risk.
Second, there is no direct benefit or reimbursement for taking part in this study.
Third, your answers will be kept private to the extent allowed by law. The information you give us will never be associated with your name, address, or anything else that could identify you nor will it be in any records held by NIOSH.
Fourth, if you have questions about the study or you feel you were harmed, you may call Hope Tiesman, NIOSH project officer, at 304-285-6067. For questions about your rights, your privacy, or harm to you, contact the Chair of the NIOSH Institutional Review Board at 513-533-8591.
I would like to ask you some questions about your incident. Your participation is important to us. This interview takes about 20 minutes. The information that you provide will be used for prevention purposes and does not have any bearing on the worker’s compensation process, disability claims, or your agency’s internal affairs process. This study is voluntary. You may choose to be in the study or not. You do not have to answer any questions you do not want to. You can end the call at any time without any consequences.
8) Would you please help us by answering some questions?
Yes
No
*Programming note: If 8 = a, SKIP to Instruct_3
*Programming note: If 8 = b, GOTO 9
9) I assure you that everything you tell us will be kept private and will only be used to study how to prevent on-duty injuries to law enforcement officers. Your participation is very important and will benefit other officers. Would you please reconsider helping us?
Yes
No
*Programming note: If 9 = a, SKIP to Instruct_3
*Programming note: If 9 = b, GOTO 10
10) I understand that this may be a bad time. May I call back another time?
Yes
No
*Programming note: If 10 = a, note preferred time and call back later
*Programming note: If 10 = b, END interview
Instruct_3. This first series of questions asks about the incident that caused you to seek care in the emergency department on [date]. These questions refer to the emergency department as the ED.
Injury description
Throughout the rest of the interview, we want to use one word to refer to why you went to the ED. Which of these words works best: injury, exposure, or illness?
Interviewer: If the respondent hesitates or says don’t know, say the following: There is no right or wrong answer. Choose the word that best describes why you went to the ED.
Interviewer: If the respondent asks for a definition of exposure, say the following: An exposure may include contact with a harmful chemical or substance. It may also include exposure to extreme heat or cold, or contact with the body fluids such as blood.
Injury
Exposure
Illness
REFUSED
*Programming note: This answer will be used as fill-in for the rest of the survey [IE]. It will not be used for data analysis.
*Programming note: If 1 = d, END interview
What was your [IE]?
_____________________________________________________________________________
Would you please describe in your own words how your [IE] occurred?
Interviewer: If respondent hesitates, ask the following: “What happened that sent you to the ED?”
Interviewer: If respondent suggests that there was more than one reason, ask the respondent to describe the reason that was related to their law enforcement duties.
Interviewer: If respondent suggests that there was more than one reason related to their duties, ask the respondent to describe the reason they felt was the most serious.
Interviewer: If not included in the description, use the following questions as prompts:
What were you doing when your [IE] happened?
Where were you? Inside your department, on a highway, or in your car?
What specific task or activity were you engaged in at the time of the [IE]?
Other persons such as other officers and suspects could have been involved in the incident that sent you to the ED. Who else was present when your [IE] happened?
What equipment, if any, were you using?
_____________________________________________________________________________
What part of your body was most affected by your [IE]?
_____________________________________________________________________________
Were any other parts of your body affected?
_____________________________________________________________________________
What treatment did you receive in the ED?
_____________________________________________________________________________
Did your agency have a policy that required you to visit the ED for your [IE]?
Yes
No
DON’T KNOW
Instruct_4. Thank you for telling me why you went to the ED. I would now like to ask you some questions about your duties at the time of your [IE].
When your [IE] occurred, what type of law enforcement agency were you employed by? (Read categories.)
Federal
State
County
Municipal
Another type (GOTO 2)
DON’T KNOW
*Programming note: If 1 = a, b, c, d, or f, SKIP to 3
[If 1 = e] What type of agency was it?
_____________________________________________________________________________
At the time of your [IE], which unit or division were you working in? (Read categories.)
Patrol
Command
Specialized Unit
Administrative
Investigations
Reserve
Another type of unit or division (GOTO 3)
DON’T KNOW
*Programming note: If 3 = a, b, c, d, e, f, or h, SKIP to 5
[If 3= g] What type was it?
_____________________________________________________________________________
At the time of your [IE], ABOUT how many actual sworn officers were in your agency?
_____________________________________________________________________________
At the time of your [IE], what was the APPROXIMATE size of the population your agency served?
_____________________________________________________________________________
In hours, how long was your scheduled shift?
___________________________________________________________________________
About how many hours of your shift had you worked when your [IE] occurred?
_____________________________________________________________________________
At approximately what time did your [IE] occur?
Interviewer: If time is given in military time, ask respondent to specify using A.M. or P.M.
_____________________________________________________________________________
Were you wearing a standard department issued uniform when your [IE] occurred?
Yes
No
DON’T KNOW
At the time of your [IE], were you on a dispatched call?
Yes (GOTO 12)
No
DON’T KNOW
*Programming note: If 11 = b or c, SKIP to 13
Calls could include shoplifting, theft, or domestic dispute. At the time of your [IE], what type of call was it?
_____________________________________________________________________________
[If 11 = b or c] What type of activity were you engaged in when your [IE] occurred? (Read categories.)
Routine patrol
A self-initiated activity
A special operation
A citizen alerted or flagged you down
Transportation of an offender or inmate
Training
Another activity (GOTO 14)
Don’t Know
*Programming note: If 13 = a, b, c, d, e, or h, SKIP to 15
*Programming note: If 13 = f, SKIP to 19
[If 13 = g] What was the activity?
_____________________________________________________________________________
Did your [IE] occur while you were interacting with a suspect?
Yes (GOTO 16)
No
*Programming note: If 15 = b, SKIP to 17
Please describe the interaction.
_____________________________________________________________________________
Did your [IE] occur while you were pursuing a suspect?
Yes (GOTO 18)
No
*Programming note: If 17 = b, SKIP to 19
What type of pursuit was it? (Read categories.)
A foot pursuit
A vehicle pursuit
Both a foot and vehicle pursuit
DON’T KNOW
At the time of your [IE], were other officers present?
Yes (GOTO 20)
No
DON’T KNOW
*Programming note: If 19 = b or c, SKIP to 21
About how many? Count officers that were in the room, at the scene, or in the vehicle with you.
_____________________________________________________________________________
Which of the following best describes where you were when your [IE] occurred? (Read categories.)
At the station
In a vehicle
In the field
At a correctional facility or jail
Another location (GOTO 22)
DON’T KNOW
*Programming note: If 21 = a, b, c, d, or f, SKIP to Instruct_5
[If 21 = e] Please tell me where you were.
_____________________________________________________________________________
*Programming note: GOTO Instruct_5
Instruct_5: Thank you for sharing the details about your duties and [IE]. Thinking about the event that sent you to the ED on [date], I am going to ask you a series of questions to help me determine how your injury occurred. Some questions may or may not be applicable to your event. Some questions may repeat the information you’ve just given me, but I need to ask them as they appear.
Officers may be exposed to potentially hazardous substances. These may include bodily fluids, smoke, chemicals, or drugs. Were you exposed to a hazardous substance?
Interviewer: If the respondent asks whether exposure to hazardous substances would include a needle stick, say the following: An exposure includes being stuck by a used or clean needle.
Yes
No
DON’T KNOW
Assaults include being hit, kicked, punched, or shot. Assaults also include being bit by a person or animal. Was your [IE] caused by an assault?
Yes
No
DON’T KNOW
A motor vehicle collision includes events where your vehicle was struck by another vehicle or struck an object, person, or animal. Collisions also include events where your vehicle overturned. Was your [IE] caused by a motor vehicle collision?
Yes
No
DON’T KNOW
*Programming note: If 3 NE a, GOTO 4
*Programming note: If 1 = a AND 3 = a, SKIP to Instruct_6
*Programming note: If 1 NE a AND 2 = a AND 3 = a, SKIP to Instruct_7
*Programming note: If 1 NE a AND 2 NE a AND 3 = a, SKIP to Instruct_8
You may have been struck by a vehicle when you were outside of your vehicle, directing traffic, or conducting a traffic stop. Were you struck by a vehicle when your [IE] occurred??
Yes
No
DON’T KNOW
*Programming note: If 4 NE a, GOTO 5
*Programming note: If 1 = a AND 4 = a, SKIP to Instruct_6
*Programming note: If 1 NE a AND 2 = a AND 4 = a, SKIP to Instruct_7
*Programming note: If 1 NE a AND 2 NE a AND 3 NE a, SKIP to Instruct_8
*Programming note: If 1 NE a AND 2 NE a AND 3 NE a AND 4 = a, SKIP to Instruct_9
Slips, trips, or falls can occur when you fall off something, slip on something wet, trip on an object, or fall when chasing a suspect. Was you [IE] caused by a slip, trip, or fall?
Yes
No
DON’T KNOW
*Programming note: If 5 NE a, GOTO 6
*Programming note: If 1 = a AND 5 = a, SKIP to Instruct_6
*Programming note: If 1 NE a AND 2 = a AND 5 = a, SKIP to Instruct_7
*Programming note: If 1 NE a AND 2 NE a AND 3 NE a AND 4 NE a AND 5 = a, SKIP to Instruct_10
Your [IE] may have been caused by your own physical effort, awkward body posture, or repetitive motion. These injuries could occur while taking down a suspect or moving a heavy object. Was your [IE] caused by your own physical effort, awkward body posture, or repetitive motion?
Yes
No
DON’T KNOW
*Programming note: If 1 = a, SKIP to Instruct_6
*Programming note: If 1 NE a AND 2 = a, SKIP to Instruct_7
*Programming note: If 1 NE a AND 2 NE a AND 3 NE a AND 4 NE a AND 5 NE a AND 6 = a, SKIP to Instruct_11
*Programming note: If 1 NE a AND 2 NE a AND 3 NE a AND 4 NE a AND 5 NE a AND 6 NE a, SKIP to Instruct_12
Instruct_6. You told me that you were exposed to a hazardous substance. I am now going to ask you questions related to this exposure. As a reminder, you do not have to answer any questions you do not feel comfortable answering.
Exposure to potentially harmful substances
I am going to read you a list of ways you may have been exposed. As I read each one, please tell me whether your exposure occurred in that way. (Read categories.)
|
Yes |
No |
Don’t know |
Refused |
a) Being stuck by a needle |
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b) Being coughed or spit on |
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c) Inhaling a potentially hazardous substance |
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*Programming note: if (1 = a, b, or c) AND (1 NE d), SKIP to 3
*Programming note: if 1 = d only or with any other response, GOTO 2
[If 1 = d] Please describe how the exposure occurred.
_____________________________________________________________________________
I am going to read you a list of substances you may have been exposed to. As I do, please tell me whether you were exposed to that substance. (Read categories.)
|
Yes |
No |
DON’T KNOW |
Refused |
a) Blood |
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b) Spit |
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c) Biological waste such as urine or feces |
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e) Some other substance |
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*Programming note: if (3 = a, b, c, or d) AND (3 NE e), SKIP to 5
*Programming note: if 3 = e only or with any other response, GOTO 4
[If 3 = e] Please describe the substance.
_____________________________________________________________________________
I am going to read you a list of possible parts of your body that may have been exposed. As I read each part of your body, please tell me whether it was exposed. (Please select all that apply) (Read categories.)
|
Yes |
No |
DON’T KNOW |
a) Eyes |
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b) Mouth or nose |
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c) Arms and hands |
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*Programming note: If (5 = a, b, or c) AND (5 NE d), SKIP to 7
*Programming note: If 5 = d only or with any other response, GOTO 6
[If 5 = d only or with any other response] Please describe the parts of your body that were exposed.
_____________________________________________________________________________
I am going to read you a list of activities. Please tell me whether you were doing any of these activities when your exposure occurred. (Please select all that apply) (Read categories.)
|
Yes |
No |
Don’t know |
a) Restraining or detaining a suspect |
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b) Attending to an unconscious civilian |
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c) Searching a car |
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d) Searching a suspect |
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e) Searching a residence |
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Please tell me whether or not you were wearing any of the following personal protective equipment. (Please select all that apply) (Read categories.)
|
Yes |
No |
Don’t Know |
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Did you need any personal protective equipment that was NOT available?
Yes (GOTO 10)
No
DON’T KNOW
*Programming note: If 9 = b or c, SKIP to 11
Please describe the personal protective equipment that you needed.
_____________________________________________________________________________
Were there any problems with any of the personal protective equipment that you were wearing that may have contributed to your [IE]?
Yes (GOTO 12)
No
DON’T KNOW
*Programming note: If (11 = b or c) AND (2 (pg = 9) = 1), SKIP to Instruct_7
*Programming note: If (11 = b or c) AND (2 (pg = 9) NE 1) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (11 = b or c) AND (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (11 = b or c) AND (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (11 = b or c) AND (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (11 = b or c) AND (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
Please describe the problems.
_____________________________________________________________________________
*Programming note: If 2 (pg = 9) = 1, SKIP to Instruct_7
*Programming note: If (2 (pg = 9) NE 1) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (2 (pg = 9) NE 1) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
Instruct_7. You told me that your [IE] was caused by an assault. I’d like to ask you a few questions about the assault. As a reminder, you do not have to answer any questions you do not feel comfortable answering.
Violence
Was your [IE] caused by an animal bite?
Yes (GOTO 2)
No
DON’T KNOW
REFUSED
*Programming note: If 1 = b, c, or d, SKIP to 4
Was the animal a dog?
Yes (GOTO 3)
No
DON’T KNOW
REFUSED
*Programming note: If (2 = b, c, or d) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (2 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (2 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (2 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (2 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
Was the dog a K-9 officer?
Yes
No
DON’T KNOW
REFUSED
*Programming note: If (3 = a, b, c, or d) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (3 = a, b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (3 = a, b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (3 = a, b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (3 = a, b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
Were you injured by another officer?
Yes (GOTO 5)
No
DON’T KNOW
REFUSED
*Programming note: If (4 = b, c, or d) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (4 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (4 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (4 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (4 = b, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
In your own words, please describe how you were injured by another officer?
_____________________________________________________________________________
*Programming note: If (4 = a) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (4 = a) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (4 = a) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (4 = a) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (4 = a) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
Did more than one person assault you?
Yes (GOTO 7)
No
DON’T KNOW
REFUSED
*Programming note: Response to this question will be used to populate [numperson].
*Programming note: If 6 = b, SKIP to 8 (set numperson to suspect)
*Programming note: If (6 = c or d) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (6 = c or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (6 = c or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (6 = c or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (6 = c or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
How many people assaulted you?
_____________________________________________________________________________
Bodily force includes punching, kicking, scratching, or biting. Did the [numperson] use bodily force to assault you?
Yes (GOTO 9)
No
DON’T KNOW
REFUSED
*Programming note: If 8 = b, c, or d, SKIP to 10
I am going to read you a list of types of bodily force. As I read each one, please tell whether it occurred when the [numperson] used bodily force on you? (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) You were punched |
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b) You were kicked |
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c) You were scratched |
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d) You were bit |
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e) Another type of bodily force was used |
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*Programming note: If (9 = a, b, c, or d) AND (9 NE e), SKIP to 11
*Programming note: If (9 = e only or with any other response), GOTO 10
(If 9 = e only or with any other response) What type of bodily force did the [numperson] use?
_____________________________________________________________________________
Did the [numperson] who assaulted you use any weapons?
Yes (GOTO 12)
No
DON’T KNOW
REFUSED
*Programming note: If 11 = b, c, or d, SKIP to 13
As I read each type of weapon, please tell me whether the [numperson] used it during the assault. (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) A firearm |
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b) A knife or sharp object |
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c) A baseball bat, club, or blunt object |
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d) A conductive energy device, such as a TASER |
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e) Another type of weapon |
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*Programming note: If (12 = a, b, c, d,) AND (12 NE e), SKIP to 14
*Programming note: If 12 = e only or with any other response, GOTO 13
[If 12 = e only or with any other response] What type of weapon did the [numperson] use?
_____________________________________________________________________________
Did the [numperson] offer any level of resistance before you were assaulted?
Yes (GOTO 15)
No
DON’T KNOW
REFUSED
*Programming note: If 14 = b, c, or d, SKIP to 17
I am going to read a list of different types of resistance. As I read each one, please tell me whether it was used by the [numperson] who assaulted you. (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) They passively resisted |
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b) They verbally threatened you |
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c) They tried to escape |
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d) They actively resisted with bodily force |
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e) They attempted to gain or gained possession of a weapon |
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f) They used another type of resistance |
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*Programming note: (If 15= a, b, c, d, or e), AND (15 NE f), SKIP to 17
*Programming note: If 15 = f only or with any other response, GOTO 16
[If 14 = f only or with any other response] What type of resistance did the [numperson] use?
_____________________________________________________________________________
I am going to read you a list of factors that may have contributed to your assault. As I read each one, please tell me whether you believe the factor contributed to your assault? (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) The [numperson] [was/were] under the influence of drugs or alcohol |
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c) The [numperson] [was/were] mentally ill or had a medical condition |
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d) The [numperson] had a known history of violence against law enforcement officers |
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e) The [numperson] [was/were] in possession of a weapon |
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f) The [numperson] had committed a felony |
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We recognize that civilian encounters may require the use of several tactics. I am going to read you a list of tactics, as I read each one, please tell me whether you used any of the following during the encounter. As a reminder, you may refuse to answer any of these questions.
|
Yes |
No |
DON’T KNOW |
REFUSED |
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*Programming note: If (18 = a, b, c, d, e, f, g, h, i, j, k, l, or m), AND (18 NE n), SKIP to 20
*Programming note: If 18 = n only or with any other response, GOTO 19
[If 18 = n] What tactic did you use?
_____________________________________________________________________________
Was there enough light for you to clearly see in the location where your assault occurred?
Yes
No
DON’T KNOW
REFUSED
Were you wearing body armor or a bullet proof vest at the time of your assault?
Yes
No (GOTO 22)
DON’T KNOW
REFUSED
*Programming note: If (21 = a, c, or d) AND (3 (pg = 9) = 1), SKIP to Instruct_8
*Programming note: If (21 = a, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (21 = a, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (21 = a, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (21 = a, c, or d) AND (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
[If 21 = b] Why were you not wearing body armor?
_____________________________________________________________________________
*Programming note: If 3 (pg = 9) = 1, SKIP to Instruct_8
*Programming note: If (3 (pg = 9) NE 1 AND (4 (pg = 9) = 1), SKIP to Instruct_9
*Programming note: If (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) = 1), SKIP to Instruct_10
*Programming note: If (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) = 1), SKIP to Instruct_11
*Programming note: If (3 (pg = 9) NE 1 AND (4 (pg = 9) NE 1) AND (5 (pg = 9) NE 1) AND (6 (pg = 10) NE 1), SKIP to Instruct_12
Instruct_8. You told me that your [IE] was caused by a motor vehicle collision. I’d like to ask you a few questions about the collision. As a reminder, you do not have to answer any questions you do not feel comfortable answering.
Motor vehicle collision
I am going to read you a list of events. Please stop me when you hear the option that best describes the collision. (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
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*Programming note: If 1 = a or b, GOTO 2
*Programming note: If 1 = c, SKIP to 3
*Programming note: If 1 = d, SKIP to 4
*Programming note: If 1 = e, SKIP to 5
[If 1 = a or b] What type of collision was it? (Read categories.)
Head-on
Broadside
T-boned
Rear-end
Some other type
DON’T KNOW
REFUSED
*Programming note: If 1 = a, b, f, or g, SKIP to 6
[If 1 = c] What did the vehicle strike?
_____________________________________________________________________________
*Programming note: If 1 = c, SKIP to 6
[If 1 = d] What caused the vehicle to roll over or run off the road?
_____________________________________________________________________________
*Programming note: If 1 = d, SKIP to 6
[If 1 = e] Please tell me what happened during the collision.
_____________________________________________________________________________
9What type of vehicle was being operated? (Read categories.)
A marked patrol vehicle
An unmarked department vehicle
A motorcycle
Another type of vehicle (GOTO 7)
DON’T KNOW
REFUSED
*Programming note: If 6 = a , b, or c, SKIP to 8
*Programming note: If 6 = e or f, SKIP to 9
[If 6 = d] What type of vehicle was it?
_____________________________________________________________________________
What was the make and model of the vehicle?
_____________________________________________________________________________
I am going to read you a list of factors that may have contributed to your collision. As I read each one, please tell me whether or not it contributed. (Read categories.)
|
Yes |
No |
Don’t Know |
REFUSED |
a) Weather conditions |
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b) Road conditions |
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c) Lighting conditions |
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d) Some other factor |
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*Programming note: If 9 = a, GOTO 10
*Programming note: If (9 NE a) and (9 = b), SKIP to 11
*Programming note: If (9 NE a) and (9 NE b) and (9 = c), SKIP to 12
*Programming note: If (9 NE a) and (9 NE b) and (9 NE c) and (9 = d), SKIP to 13
*Programming note: If (9 NE a) and (9 NE b) and (9 NE c) and (9 NE d), SKIP to 14
[If 9 = a] Please describe the weather conditions.
_____________________________________________________________________________
*Programming note: If 9 = b, GOTO 11
*Programming note: If (9 NE b) and (9 = c), SKIP to 12
*Programming note: If (9 NE b) and (9 NE c) and (9 = d), SKIP to 13
*Programming note: If 9 NE b, c, or d, SKIP to 14
[If 9 = b] Please describe the road conditions.
_____________________________________________________________________________
*Programming note: If 8 = c, GOTO 11
*Programming note: If (8 NE c) and (8 = d), SKIP to 12
*Programming note: If 8 NE c, or d, SKIP to 13
[If 9 = c] Please describe the lighting conditions.
_____________________________________________________________________________
*Programming note: If 9 = d, GOTO 13
*Programming note: If 9 NE d, SKIP to 14
[If 9 = d] Please describe the mechanical problems.
_____________________________________________________________________________
*Programming note: GOTO 14
At the time of the collision, what was the vehicle you were in doing? (Read categories.)
It was moving
It was stopped in traffic
It was parked on the side of the road
It was parked somewhere else
It was doing something else (GOTO 15)
DON’T’ KNOW
*Programming note: If 14 = a, SKIP to 16
*Programming note: If 14 = b, c, d, or f, SKIP to 19
[If 14 = e] Please describe the vehicle’s actions.
_____________________________________________________________________________
*Programming note: If 14 = e, SKIP to 19
I am going to read you activities that your vehicle may have been doing at the time of the collision. As I read each one, please tell me whether it describes the activity of your vehicle. (Read categories.)
|
Yes |
No |
Don’t know |
REFUSED |
a) Moving straight ahead |
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b) Turning right or left |
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c) Backing |
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d) Changing lanes, overtaking, or passing |
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e) Making a U-turn |
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f) Negotiating a curve |
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At the time of the collision, what was the approximate speed of the vehicle?
_____________________________________________________________________________
At the time of the collision, what was the posted speed limit?
_____________________________________________________________________________
At the time of the collision, were emergency lights being used?
Yes
No
DON’T KNOW
REFUSED
Was a siren being used?
Yes
No
DON’T KNOW
REFUSED
At the time of the collision, were you pursuing a vehicle?
Yes
No
DON’T KNOW
REFUSED
*Programming note: If 6 = c or d, SKIP to Instruct_12
Were you the driver of the vehicle?
Yes
No
DON’T KNOW
REFUSED
*Programming note: Response will be used to populate [Were you/Was the driver]
Was the vehicle equipped with a radio?
Yes (GOTO 24)
No
DON’T KNOW
REFUSED
*Programming note: If 23 = b, c, or d, SKIP to 25
[Were you/Was the driver] using the radio at the time of the collision?
Yes
No
DON’T KNOW
REFUSED
Was the vehicle equipped with a mounted computer device?
Yes (GOTO 26)
No
DON’T KNOW
REFUSED
*Programming note: If 25 = b, c, or d, SKIP to 27
[Were you/Was the driver] using the mounted computer device at the time of the collision?
Yes
No
DON’T KNOW
REFUSED
[Did you/Did the driver] have a cell phone in the vehicle?
Yes (GOTO 28)
No
DON’T KNOW
REFUSED
*Programming note: If 27 = b, c, or d, SKIP to 28
[Were you/Was the driver] using a cell phone at the time of the collision?
Yes
No
DON’T KNOW
REFUSED
At the time of the collision, were you wearing a seatbelt?
Yes
No (GOTO 30)
DON’T KNOW
REFUSED
*Programming note: If 29 = a, c, or d, SKIP to Instruct_12
I am going to read you a list of reasons why an officer may not wear a seatbelt. As I read each one, please tell me whether it describes why you were not wearing a seatbelt? (Read categories.)
|
Yes |
No |
Don’t know |
REFUSED |
a) You did not have time to put it on |
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|
b) You could not buckle the belt due to your duty belt or gun holster |
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|
c) You believe the seatbelt is uncomfortable |
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d) Another reason |
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*Programming note: If 30 = a, b, or c, SKIP to Instruct_12
*Programming note: If 30 = d, GOTO 31
[If 30 = d] Please tell me why you weren’t wearing a seatbelt.
_____________________________________________________________________________
*Programming note: SKIP to Instruct_12
Instruct_9. You told me that you were struck by a vehicle when your [IE] occurred. I’d like to ask you a few questions about when you were struck. As a reminder, you do not have to answer any questions you do not feel comfortable answering.
Struck-by incidents
I am going to read you a list of activities that you may have been doing when you were struck. As I read each one, please tell me whether or not it was an activity that you were doing. (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) Directing traffic |
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|
b) Setting up cones or other traffic control devices |
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|
c) Performing a traffic stop |
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d) Investigating a disabled vehicle |
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e) Working a motor vehicle crash |
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f) Assisting a stranded motorist |
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g) Performing a pedestrian stop |
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h) Doing some other activity |
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*Programming note: If (1 = a, b, c, d, e, f, or g), AND (1 NE h), SKIP to 3
*Programming note: If 1 = h only or with any other response, GOTO 2
[If 1 = h] Please tell me what you were doing when you were struck.
_____________________________________________________________________________
At the time you were struck, were you standing next to a vehicle?
Yes (GOTO 4)
No
DON’T KNOW
REFUSED
*Programming note: If 3 = b, c, or d, SKIP to 5
Was it your vehicle?
Yes
No
DON’T KNOW
REFUSED
At the time you were struck, were you on the shoulder of the road?
Yes
No (GOTO 6)
DON’T KNOW
REFUSED
*Programming note: If 5 = a, c, or d, SKIP to 8
Were you on the roadway?
Yes
No (GOTO 7)
DON’T KNOW
REFUSED
*Programming note: If 6 = a, c, or d, SKIP to 8
Please tell me where you were when you were struck.
_____________________________________________________________________________
In your opinion, did the vehicle intentionally strike you?
Yes
No
DON’T KNOW
REFUSED
I am going to read a list of factors that could contribute to being stuck by a vehicle. As I read each one, tell me whether you BELIEVE the factor contributed to you being struck? (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) The driver of the vehicle was under the influence of drugs or alcohol |
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|
b) The driver of the vehicle was speeding |
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|
c) The driver of the vehicle was distracted |
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|
d) The driver had a known history of violence against law enforcement officers |
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|
e) There were mechanical problems with the vehicle that struck you |
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|
f) Weather conditions |
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g) Road conditions |
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h) Lighting conditions |
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i) Some other factor |
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*Programming note: If 9 = e, GOTO 10
*Programming note: If (9 NE e) and (9 = f), SKIP to 11
*Programming note: If (9 NE e) and (9 NE f) and (9 = g), SKIP to 12
*Programming note: If (9 NE e) and (9 NE f) and (9 NE g) and (9 = h), SKIP to 13
*Programming note: If (9 NE e) and (9 NE f) and (9 NE g) and (9 NE h) and (9 = i), SKIP to 14
*Programming note: If 9 NE e, f, g, h, or i, SKIP to 15
[If 9 = e] Please describe the vehicle problems.
_____________________________________________________________________________
*Programming note: If 9 = f, GOTO 11
*Programming note: If (9 NE f) and (9 = g), SKIP to 12
*Programming note: If (9 NE f) and (9 NE g) and (9 = h), SKIP to 13
*Programming note: If (9 NE f) and (9 NE g) and (9 NE h) and (9 =i), SKIP to 14
*Programming note: If 9 NE f, g, h, or i, SKIP to 15
[If 9 = f] Please describe the weather conditions.
_____________________________________________________________________________
*Programming note: If 9 = g, GOTO 12
*Programming note: If (9 NE g) and (9 = h), SKIP to 13
*Programming note: If (9 NE g) and (9 NE h) and (9 = i), SKIP to 14
*Programming note: If 9 NE g, h, or i, SKIP to 15
[If 9 = g] Please describe the road conditions.
_____________________________________________________________________________
*Programming note: If 9 = h, GOTO 13
*Programming note: If (9 NE h) and (9 = i), SKIP to 14
*Programming note: If 9 NE h or i, SKIP to 15
[If 9 = h] Please describe the lighting conditions.
_____________________________________________________________________________
*Programming note: If 9 = i, GOTO 14
*Programming note: If 9 = NE i, SKIP to 15
[If 9 = i] Please describe any other factors.
_____________________________________________________________________________
Were you wearing a reflective vest at the time of your injury?
Yes
No (GOTO 16)
REFUSED
*Programming note: If 15 = a or c, SKIP to 17
[If 15 = b] What was the reason you were not wearing a reflective vest?
_____________________________________________________________________________
*Programming note: If 1 = c, GOTO 17
*Programming note: If 1 = a, b, or e, SKIP to 19
*Programming note: If 1 = d, f, g, or h, SKIP to Instruct_12
[If 1 = c] You told me you were performing a traffic stop when you were struck. Before approaching the vehicle, how did you position the police car? (Read categories)
Directly in line with the other vehicle
Off set or Angled
DON’T KNOW
REFUSED
During the traffic stop, when you approached the vehicle, which side of the car did you approach? (Read categories)
Driver side
Passenger side
DON’T KNOW
REFUSED
*Programming note: If 1 = c, SKIP to Instruct_12
[If 1 = a, b, or e] I am going to read you a list of traffic control strategies. As I read each one, please tell me if it was being used when you were struck? (Read categories.)
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) A temporary traffic control pattern |
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b) Cones |
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|
c) A temporary barrier or barricade |
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d) Road blocks |
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|
e) Spike strips |
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|
f) Flares, warning lights, or warning devices |
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*Programming note: SKIP to Instruct_12
Instruct_10. You told me that your [IE] was caused by a slip, trip, or fall. I’d like to ask you a few questions about this incident.
I am going to read you a list of activities. Please tell me whether or not you were doing each of these activities when your slip, trip, or fall occurred. (Read categories)
|
Yes |
No |
Don’t Know |
a) Going up or down stairs, steps, or a curb |
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|
b) Getting into or out of a vehicle |
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|
c) Turning a corner or negotiating a turn |
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|
d) Walking on a rough or uneven surface such as an uneven floor |
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|
e) Running or jumping |
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|
f) Walking or stepping on a surface that was not dry |
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|
g) Carrying, lifting, pushing, or pulling something |
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|
*Programming note: If 1 = f only or with any other response, GOTO 2
*Programming note: If (1 NE f) AND (1 = g only or with any other response), SKIP to 4
*Programming note: If (15 (page 7) = a) AND 1 NE f or g, SKIP to 5
*Programming note: if (15 (page 7) = b) AND 1 NE f or g, SKIP to 7
[If 1 = f only or with any other response] You told me that the surface you were walking on was not dry. Which of the following was on the surface? (Read categories.) (Select all that apply)
Water
Ice or snow
Grease
Another substance (GOTO 3)
DON’T KNOW
*Programming note: If (2 = a, b, c, or e) AND (1 = g), SKIP to 4
*Programming note: If (15 (page 7) = a) AND (2 = a, b, c, or e) AND (1 NE g), SKIP to 5
*Programming note: If (15 (page 7) = b) AND (2 = a, b, c, or e) AND (1 NE g), SKIP to 6
[If 2 = d] Please describe the substance.
_____________________________________________________________________________
*Programming note: If 1 = g, GOTO 4
*Programming note: If (15 (page 7) = a) AND 1 NE g, SKIP to 5
*Programming note: If (15 (page 7) = b) AND 1 NE g, SKIP to 7
[If 1 = g only or with any other response] Please describe what you were carrying, lifting, pushing or pulling.
_____________________________________________________________________________
*Programming note: If 15 (page 7) = a, GOTO 5
*Programming note: If 15 (page 7) = b, SKIP to 7
Earlier you told me you were in the act of interacting with or pursuing a suspect. Were you interacting with or pursuing more than one person?
Yes
No
DON’T KNOW
*Programming note: Response will be used to populate [Was the suspect/were the suspects]
[Was the suspect/were the suspects] in possession of a weapon?
Yes
No
DON’T KNOW
Was there enough light for you to clearly see in the location where your slip, trip, or fall occurred?
Yes
No
DON’T KNOW
*Programming note: SKIP to Instruct_12
Instruct_11. You told me that your [IE] was caused by your physical effort, awkward body posture, or repetitive motion. I’d like to ask you a few questions related to this incident.
Overexertion and strains
*Programming note: If 15 (pg = 7) = a, SKIP to 4
*Programming note: If (17 (pg = 8) = a, SKIP 1b, 1e, and 1f
I am going to read you a list of activities. As I read each one, please tell me whether or not you were doing the activity when your [IE] occurred. (Read categories)
|
Yes |
No |
Don’t know |
a) Going up or down stairs, steps, or a curb |
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b) Lifting or carrying something heavy or awkward |
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|
c) Walking on a rough, uneven, or wet surface |
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|
d) Running or jumping |
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|
e) Using an awkward posture because of the space you were in |
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|
f) Performing physical training such as lifting weights, performing drills, or running obstacle courses |
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*Programming note: If 1 = b only or with any other response, GOTO 2
*Programming note: If (1 NE b) AND (1 = f only or with any other response), SKIP to 3
*Programming note: if 17 (page 8) = a, SKIP to 4
*Programming note: If (17 (page 8) = b) AND (1 NE b or f), SKIP to 10
[If 1 = b only or with any other response] What were you were lifting or carrying?
_____________________________________________________________________________
*Programming note: If 1 = f, GOTO 3
*Programming note: if 1 NE f, SKIP to 13
[If 1 = f only or with any other response] What type of physical training were you performing?
_____________________________________________________________________________
*Programming note: SKIP to 13
*Programming note: If 2(pg = 9) = a, SKIP to 10
Earlier you told me you were in the act of interacting with or pursuit. Were you interacting with or pursuing more than one person?
Yes
No
DON’T KNOW
*Programming note: Response will be used to populate [numperson]
Did the [numperson] use any weapons?
Yes
No
DON’T KNOW
Did the [numperson] offer any level of resistance?
Yes (GOTO 9)
No
Don’t Know
*Programming note: If 5 = b or c, SKIP to 8
I am going to read a list of different types of resistance. As I read each one, please tell me whether the [numperson] used the resistance. (Read categories.)
|
Yes |
No |
DON’T KNOW |
a) They passively resisted |
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b) They verbally threatened you |
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|
c) They tried to escape |
|
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|
d) They actively resisted with bodily force |
|
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|
e) They attempted to gain or gained possession of a weapon |
|
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|
f) They used another type of resistance |
|
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|
*Programming note: (If 6= a, b, c, d, or e), AND (9 NE f), SKIP to 8
*Programming note: If 6 = f only or with any other response, GOTO 7
[If 6 = f] Please describe the resistance that was used
_____________________________________________________________________________
We recognize that civilian encounters may require the use of several tactics. I am going to read you a list of tactics, as I read each one, please tell me whether you used any of the following during the encounter. As a reminder, you may refuse to answer any of these questions.
|
Yes |
No |
DON’T KNOW |
REFUSED |
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*Programming note: If (8 = a, b, c, d, e, f, g, h, i, j, k, l, or m), AND (8 NE n), SKIP to 10
*Programming note: If 8 = n only or with any other response, GOTO 9
[If 8 = n] What tactic did you use?
__________________________________________________________________________________
Prior to this [IE], did you previously have a sprain, strain, or repetitive motion injury to the same part of your body?
Yes
No
DON’T KNOW
Instruct_12. I’m now going to ask you some questions about possible follow-up medical care and your return to your law enforcement duties.
After your ED visit, did you have any follow up care from a healthcare provider for your [IE]?
Yes (GOTO 2)
No
DON’T KNOW
*Programming note: If 1 = b or c, SKIP to 3
[If 1 = a] Please describe the follow up care you received.
_____________________________________________________________________________
After an injury or exposure, officers are not always able to return to their law enforcement duties right away. Have you returned to your law enforcement duties?
Yes (GOTO 4)
No
DON’T KNOW
*Programming note: If 3 = b, SKIP to 7
*Programming note: If 3 = c, SKIP to 10
[If 3=a] Prior to returning to your law enforcement duties, was medical clearance required?
Yes
No
DON’T KNOW
Were you ever on light or restricted duty as a result of your [IE]?
Yes
No
DON’T KNOW
After your [IE], when did you feel well enough to return full-duty to your law enforcement duties? (Read categories.)
a. The same day your [IE] occurred
b. The day following your [IE]
c. One to two weeks following your IE
e. More than 2 weeks
f. DON’T KNOW
*Programming note: If 6 = a or b, SKIP to 9
*Programming note: If 6 = c, d, e, or f, SKIP to 10
[If 3 = b] What is the reason you have not returned? Is it because you….? (Read categories.)
Are still recovering
Were fired or let go
Quit
Haven’t returned for another reason (GOTO 8)
DON’T KNOW
*Programming note: If 6 = a, b, c, or e, SKIP to 10
[If 7 = d] Please specify the reason you have not returned.
_____________________________________________________________________________
*Programming note: If 7 = d, SKIP to 10
In the 7 days after your [IE], how much did your [IE] limit your ability to do your normal law enforcement duties? (Read categories.)
Not at all
Very little
Somewhat
Quite a lot
DON’T KNOW
Normal activities that you may do at home include cooking, chores, or child care. In the 7 days after your [IE], how much did your [IE] limit your ability to do your normal activities at home? (Read categories.)
Not at all
Very little
Somewhat
Quite a lot
DON’T KNOW
*Programming note: If 9 = a AND 10 = a, SKIP to 13
Some people will experience permanent disability, long-term pain, or limited movement due to their [IE]. As of today, do you continue to have any of these effects from your [IE]?
Yes (GOTO 12)
No
DON’T KNOW
*Programming note: If 11 = b or c, SKIP to 13
[If 11 = a] Please describe the effects you are experiencing as a result of your [IE].
_____________________________________________________________________________
In your opinion, could your agency have taken steps to prevent your [IE]?
Yes (GOTO 14)
No
DON’T KNOW
*Programming note: If 13 = b or c, SKIP to Instruct_13
[If 13 = a] What recommendation would you make to your agency to prevent other officers from experiencing an [IE] like yours?
_____________________________________________________________________________
Demographics
Instruct_13. Next, I am going to ask a few questions about yourself and your job history.
What was your rank when your [IE] occurred?
_____________________________________________________________________________
At the time of your [IE], about how many total years had you worked as a law enforcement officer? (Enter ‘0’ for less than one year)
Years _____________
How many years had you worked with the agency you were with? (Enter ‘0’ for less than one year)
Years _____________
In what month and year were you born?
Month (MM) _____________
Year (YYYY) _____________
Did you serve in the military?
Yes
No
DON’T KNOW
In the past 12 months, have you had any other injuries related to your duties as a law enforcement officer that required more than first aid?
Yes
No
DON’T KNOW
About how much do you weigh without your duty gear? (Unknown = 999)
Weight _____________
About how tall are you without your shoes? (Unknown = 999)
Feet _____________
Inches _____________
Please tell me which of the following best describes the highest level of education you completed. (Read categories.)
High school, GED, or less than a high school education
Some college, including current college student
College degree
Graduate degree
Other (GOTO 10)
DON’T KNOW
*Programming note: If 9 = a, b, c, d, or f, SKIP to Instruct_14
[If 9 = e] Please tell me the highest level of education you completed.
_____________________________________________________________________________
Instruct_14. Thank you for telling me about yourself and your [IE]. Before we close, I would like to ask five more questions. These questions address two emerging health and safety issues. They will help us to better understand both sleep quality and exposures to opioids within the law enforcement community. As a reminder, you do not have to answer any questions you do not feel comfortable answering.
Sleep Questions
On average, how many hours of sleep do you get in a 24-hour period, including naps?
_____________________________________________________________________________
How satisfied are you with your amount of sleep? (Read categories.)
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
DON’T KNOW
REFUSED
How would you rate your sleep quality? (Read categories.)
Very good
Good
Neither good nor bad
Bad
Very bad
DON’T KNOW
REFUSED
Instruct_14A. The next questions are related to possible opioid contact exposure that may have occurred outside of routine handling. These questions may repeat the information you’ve just given me, but I need to ask them as they appear.
During the course of your law enforcement duties, have you been exposed to opioids such as heroin or synthetics such as fentanyl in any of the following ways?
|
Yes |
No |
DON’T KNOW |
REFUSED |
a) You inhaled particles or vapors |
|
|
|
|
b) You had skin contact |
|
|
|
|
c) You inadvertently ingested opioids |
|
|
|
|
|
|
|
|
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|
|
|
|
*Programming note: If 4 = e only or with any other response, GOTO 5
*Programming note: If (4 = a, b, c, or d) AND (4 NE e), SKIP to 6
*Programming note: If 4 NE a, b, c, d, or e, SKIP to END interview
How did the exposure occur?
Interviewer: If respondent reports multiple exposures, say the following: “Please tell me about your most recent exposure.”
_____________________________________________________________________________
Did you have any health effects due to your contact?
Yes
No
DON’T KNOW
REFUSED
Thank you for your participation. We greatly appreciate your cooperation.
End interview
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | smm2 |
File Modified | 0000-00-00 |
File Created | 2021-01-20 |