Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Public reporting burden of this collection of information is estimated to average 23 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).
Attachment E-3. Adult-Proxy Survey - English
Table of Contents
Respondent Selection – LL (calltype=1) 5
Respondent Selection – Cell (calltype=2) 11
Medical Care Adult or Proxy 35
Child and Adult Return to Play 38
Variables used in Programming:
CALLTYPE denotes if the sample is for a landline or cell phone number
1 = LANDLINE
2 = CELL
INTTYPE denotes who the interview is being conducted with
A = Adult, non-parent interview
P = Proxy interview with adult
D = Direct adolescent interview
NOTE: All responses in caps will not be read to the respondent. They are for interviewer coding only.
INTRO1. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries in children and adults. You may have heard about head injuries in the news, in particular those experienced by children who play sports or military veterans. Let me assure you that this is not a sales call. Your phone number has been chosen at random to represent thousands of others in the country.
01 CONTINUE
CFM00026. if ***([CALLTYPE#2])*** goto cell
CALL BACK AND RESUME INTRODUCTIONS
please display term screen with intro
/CALL BACK SELECTED ADULT if ADLTS=2/
/if calltype=1 and CALLA=01 and ADLTS=2/
INTRO2A.
Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries. When we called previously we spoke to an adult in your household about this study. Are you the adult we spoke with?
YES
NO [SKIP TO CONEADLT]
/ask if intro2a=01/
INTRO2B. If you recall we selected the other adult in the household to participate in the study. Is that adult available now?
YES, COMING TO PHONE [SKIP TO CONEADLT]
NO [SKIP TO CALLBACK SCREEN]
if INTRO2b=01 THEN SKIP TO CONEADLT. PICK UP AT TRANS1 ASK QUESTIONS WHERE INTTYPE=A
/CALL BACK SELECTED ADULT if ADLTS>2/
/if calltype=1 and CALLA=01 and ADLTS>2/
INTRO3A.
Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries. When we called previously we selected the adult in your household with the next birthday to participate. Can I speak to him or her.
YES, COMING TO PHONE [SKIP TO CONEADLT]
NO [SKIP TO CALLBACK SCREEN]
if INTRO3A=01 THEN SKIP TO CONEADLT. PICK UP AT TRANS1 ASK QUESTIONS WHERE INTTYPE=A
/CALL BACK KNOWLEDEGABLE ADULT/
/if calltype=1 and SPEAKTOP=02/
INTRO4.
Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries. When we called previously we conducted an interview with an adult in the household who was unable to answer questions about the health and activities of the [*TEXTSUB- IF NUMC>1 or CNUMC>1 then “children in the household” IF NUMC=1 or CNUMC=1 then “child in the household”. I need to speak to a parent or guardian who knows this information. Is a parent or guardian available?
YES, GUARDIAN ON THE LINE [SKIP TO CPROXY]
YES, GUARDIAN COMING TO PHONE [REASK INTRO4]
NO [SKIP TO CALLBACK SCREEN]
IF INTRO4=01 THEN SKIP to CPROXY. PICK UP AT TRANS1 ASK QUESTIONS WHERE INTTYPE=P
/RESUMED INTERVIEW WHEN INTTYPE=a,p/
Resume1
Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries. When we called previously we started an interview with an adult in your household. Was that person you?
YES
NO
/ask if resume1=01/
RESUME1A
Is now a good time to finish the interview?
YES
NO [SKIP TO CALLBACK SCREEN]
/ASK IF RESUME1=02/
RESUME1B. Are there any other adults we may have spoken to in this household?
YES, COMING TO PHONE [SEND BACK TO RESUME1]
NO [SKIP TO CALLBACK SCREEN]
/ASK IF INTTYPE=p and resume1A=01/
RPROXY
These questions are about your [insert age] year old [IF MALE=”son” IF FEMALE=”daughter”]. We will pick up now where we previously left off.
CONTINUE
/RESUMEd INTERVIEW WHEN INTTYPE=D/
Resume2
Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries. When we called previously we received permission to conduct an interview with your [AGE] year old [IF MALE then “son” if FEMALE then “daughter”]. May we speak to that child?
YES, RESPONDENT ON LINE
YES, COMING TO PHONE [REASK RESUME2]
NO, NOT AVAILABLE [SKIP TO CALLBACK SCREEN]
NO, REFUSED
/ASK IF RESUME2=01/
RESUME2A
Is now a good time to finish the interview?
YES
NO [SKIP TO CALLBACK SCREEN]
ASK if calltype = 1 and intro1=01
ISADLT. Are you at least 18 years old and a resident of the United States?
01 YES
02 NO
98 DON’T KNOW [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO ]
IF ISADLT=98, 99
TERM_ISADLT. We are only interviewing adults 18 years and older at this time.
ASK IF CALLTYPE=1 AND ISADLT=2
GETADLT. May we please speak with an adult, 18 years of age or older?
01 YES
02 NO [schedule call back]
99 REFUSED [TERMINATE, ASSIGN DISPO]
IF GETADLT=99
TERM_GETADLT. We are only interviewing adults 18 years and older at this time.
ASK IF CALLTYPE=1 and getadlt=1
INTRO1A. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries in children and adults. You may have heard about head injuries in the news, in particular those experienced by children who play sports or military veterans. Let me assure you that this is not a sales call. Your phone number has been chosen at random to represent thousands of others in the country.
CONTINUE
ASK if calltype=1
PRIVRES. Is this a private residence?
01 YES
02 NO [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=1 ISADLT=01 OR INTRO1A=01
ADLTS. We need to gather some information about each household member, 18 years or older, so the computer can pick someone at random for the interview. How many members of your household, including yourself, are 18 years of age or older?
__ Number of adults [RANGE=0-18]
[TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=1 AND ADLTS=1
ONEADLT. So you are the adult in this household?
01 YES, AND RESPONDENT IS MALE
02 YES, AND RESPONDENT IS FEMALE
03 NO [REASK SERIES AT ISADLT TO DETERMINE IF ADULT OR NOT ]
04 YES, UNABLE TO TELL IF MALE OR FEMALE
CFM00028. RESET TO REASK_ADULT IF: ***([CALLTYPE#1] AND ONEADLT is NO )***
ASK IF CALLTYPE=1 AND ONEADLT=4
GENDER. What is your sex? 01 MALE
02 FEMALE
99 REFUSED
ASK IF CALLTYPE=1 AND adlts=2-18
WOMEN. How many of those adults are women?
ENTER NUMBER /RANGE = 0-9/
cALCULATE MEN = ADLTS-WOMEN
ASK IF CALLTYPE=1 AND adlts=2-18
V_MEN. How many of those adults are men?
ENTER NUMBER /RANGE = 0-9/
CFM00029. RESET TO PREADLTS IF: ***(V_MEN is NO )***
ASK IF CALLTYPE=1
PRENUMC. To help us ensure that we are talking to a representative selection of households in the United States, we have just a few additional questions about your household.
01 CONTINUE
ASK IF CALLTYPE=1
NUMC. How many children 17 years of age or younger are in your household?
ENTER NUMBER:
99 REFUSED
ASK IF calltype=1 and NUMC> 0 and < 99
ISPARNT. Are you the parent or guardian of [IF NUMC = 1 READ “this child” //IF NUMC >1 READ “one or more of these children”]?
01 YES
02 NO
99 REFUSED
ASK IF NUMC=1
AGESC1X. I’d like to ask a few questions about this child. How old is this child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC=1 and AGESC1X=01
AGESC1. ENTER AGE: [Range 0-17]
ASK IF NUMC=1
GENDC1. Is this child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>1 AND <99
CFM00031. I’d like to ask a few questions about each child. How old is the oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>1 AND CFM00031=01
CFM00032. ENTER AGE: [0-17]
ASK IF NUMC>1 AND <99
CFM00033. Is the oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>1
AGESC2_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>1 AND AGESC2_x=01
AGESC2X. ENTER AGE: [Range 0-17]
ASK IF NUMC>1
GENDC_2. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>2
AGESC3_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>2 AND AGESC3_x=01
AGESC3X. ENTER AGE: [Range 0-17]
ASK IF NUMC>2
GENDC_3. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>3
AGESC4_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>3 AND AGESC4_x=01
AGESC4X. ENTER AGE: [Range 0-17]
ASK IF NUMC>3
GENDC_4. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>4
AGESC5_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>4 AND AGESC5_x=01
AGESC5X. ENTER AGE: [Range 0-17]
ASK IF NUMC>4
GENDC_5. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>5
AGESC6_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>5 AND AGESC6_x=01
AGESC6X. ENTER AGE: [Range 0-17]
ASK IF NUMC>5
GENDC_6. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF NUMC>6
AGESC7_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF NUMC>6 AND AGESC7_x=01
AGESC7X. ENTER AGE: [Range 0-17]
ASK IF NUMC>6
GENDC_7. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF calltype = 1 and isparnt = 01
INFOR. This survey asks about health information and activities that children participate in. I need to speak to someone living in your household who knows this information for each child. Are you able to answer these questions about children in the household?
01 YES
02 NO
88 NO CHILDREN IN HH
ASK IF CALLTYPE = 1 AND ONEADLT=01 or oneadlt=02 AND NUMC=0,99
ONEADLT2. You are the person I need to speak with.
01. CONTINUE
ASK IF CALLTYPE = 1 and adlts=2
programmer: screener adult is selected 50% of the time.
if screener adult is selected and no children in hh or infor=2 then send to CONEADLT consent and complete adult interview
if screener adult is selected continue with adult portion of interview. if infor=1 continue with proxy interviews too. use proxy consent.
if selected adult is not screener adult ask to speak with 2nd adult. If 2nd adult available send to intro1B. if second adult is not available and infor=1 complete proxy interview with adult on phone (use proxy consent) and then schedule cb with selected adult. if selected adult not available and no knowledgeable adult available schedule cb to contact 2nd adult
SELADLT : [Select randomly]
Screener adult
Other adult [Adult with most recent birthday if ADLTS>2 ]
TWOADLT. The person in your household I need to speak with is [EITHER SCREENER RESPONDENT OR OTHER RESPONDENT]. [IF NON-SCREENER RESPONDENT, READ “May I speak with him or her?]
01. SCREENER IS SELECTED ADULT
02. ADULT COMING TO THE PHONE [SEND TO INTRO1B]
03. SELECTED ADULT NOT AVAILABLE [IF INFOR=2 OR ISPARNT=2 SEND TO SPEAKTO]
04. SELECTED ADULT IS NOT AVAILABLE [IF INFOR=1 THEN SEND TO PROXY CONSENT AND COMPLETE PROXY INTERVIEW; SCHEUDLE CB TO CONTACT SELECTED ADULT]
ASK IF CALLTYPE = 1 and adlts=3-18
programmer: screener adult is selected 1/aTH of the time, where A is the number of adults.
IF CALLTYPE = 01 AND TWOADLT=03
SPEAKTO. I also need to speak to a parent or guardian living in your household who knows health and activities information for each child. Because the selected adult is not available, may I speak to the person who knows this information?
KNOWLEDGEABLE ADULT COMING TO THE PHONE
02. KNOWLEDGEABLE ADULT NOT AVAILABLE [SKIPTO TSTAT160]
If calltype = 01 and speakto = 01
INTRO1B. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head or neck injuries in children and adults. You may have heard about head injuries in the news, in particular those experienced by children who play sports or military veterans. Let me assure you that this is not a sales call.]
INFOR2. This survey asks about health information and activities that children participate in. I need to speak to parent or guardian living in your household who knows this information for each child. Are you able to answer these questions about children in the household?
01 YES [GO TO CPROXY]
02 NO [GO TO CONEADLT]
00 NO CHILDREN IN HH
CALC SELECTED = PERSON ON PHONE 1/Ath OF TIME, WHERE A IS THE NUMBER OF ADULTS
IF SELECTED IS PERSON ON PHONE, CONTINUE ADULT PORTION OF INTERVIEW. IF SELECTED CAN REPORT ON CHLDREN (INFOR=01), CONTINUE WITH PROXY INTERVIEWS, TOO.
IF SELECTED IS NOT PERSON ON PHONE, ASK FOR ADULT WITH MOST RECENT BIRTHDAY.
IF THAT ADULT AVAILABLE, ASK IF HE/SHE CAN REPORT ON CHILDREN. IF SO, DO ADULT AND PROXY WITH THE SELECTED ADULT.
IF THAT ADULT NOT AVAILABLE, AND PERSON ON PHONE CAN REPORT ON CHILDREN, GET SCREENER ADULT (ONE ON THE PHONE) TO PROVIDE PROXY INFORMATION FOR CHILDREN. THEN SCHEDULE CALLBACK FOR SELECTED ADULT.
THREEADLT. Our study requires that we randomly select one person who lives in your household to be interviewed. The person from your household who has been randomly selected is [IF SELECTED ADULT IS SCREENED ADULT READ: you.] [IF SELECTED ADULT IS NOT SCREENED ADULT READ: the adult, not including yourself, with the next birthday.
May I speak with him or her?
01. SCREENER IS SELECTED ADULT
02. ADULT COMING TO THE PHONE [SEND TO INTRO1B THEN INFOR2 IF CHILDREN IN HH] [IF NO CHILDREN SEND TO INTRO1 B THEN CONEADLT]
03. SELECTED ADULT NOT AVAILABLE [IF INFOR=2 OR ISPARNT=2 SEND TO SPEAKTO]
04. SELECTED ADULT IS NOT AVAILABLE [IF INFOR=1 THEN SEND TO CPROXY CONSENT AND COMPLETE PROXY INTERVIEW; SCHEUDLE CB TO CONTACT SELECTED ADULT]
05. SELECTED ADULT NOT AVAILABLE AND NO CHILDREN IN HH [schedule CB]
INTTYPE denotes who the interview is being conduct with
A = Adult, non-parent interview
P = Proxy interview with adult
D = Direct adolescent interview
ASK if calltype = 2 and intro1=01
CISADLT. Are you at least 18 years old and a resident of the United States?
01 YES
02 NO [TERMINATE, ASSIGN DISPO]
98 DON’T KNOW [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=2 and CISADLT=2,98,99
TERM. We are only interviewing adults 18 years and older at this time.
ASK if calltype=2 AND CISADLT=01
CPRIVRES. Do you live in a private residence?
01 YES
02 NO [TERMINATE, ASSIGN DISPO]
99 REFUSED [TERMINATE, ASSIGN DISPO]
ask if calltype=2 and cprivres=01
CADLTS. How many adults 18 years of age or older, including yourself, are in your household?
__ Number of adults [RANGE=0-18]
[TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE =2
SAFE. Your safety is important. Are you driving in a car, or in a place where talking on the phone might distract you or jeopardize your safety or confidentiality?
01 YES
02 NO
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=2 AND SAFE=01
UNSAFE. I would like to call you at a more convenient time. What day and time would be best?
01 SCHEDULE CALLBACK
99 REFUSED [TERMINATE, ASSIGN DISPO]
ASK IF CALLTYPE=2
CPRENUMC. To help us ensure that we are talking to a representative selection of households in the United States, we have just a few additional questions about the members of your household.
CONTINUE
ASK IF CALLTYPE=2
CNUMC. How many children 17 years of age or younger are in your household?
ENTER NUMBER:
99 REFUSED
ASK IF calltype=2 and CNUMC> 0 and < 99
CISPARNT. Are you the parent or guardian of [IF CNUMC = 1 READ “this child” //IF CNUMC >1 READ “one or more of these children”]?
01 YES
02 NO
99 REFUSED
ASK IF calltype=2 and CNUMC> 0 and < 99
ASK IF CNUMC=1
CAGESC1X. I’d like to ask a few questions about this child. How old is this child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC=1 and cagesc1x=01
CAGESC1. ENTER AGE:[ Range 0-17]
ASK IF CNUMC=1
CGENDC1. Is this child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>1 AND <99
CFM00044. I’d like to ask a few questions about each child. How old is the oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>1 AND <99 AND CFM00044=01
CFM00045. ENTER AGE:[Range 0-17]
ASK IF CNUMC>1 AND <99
CFM00046. Is the oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>1
CAGESC2_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IFC NUMC>1 AND CAGESC2_x=01
CAGESC2X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>1
CGENDC_2. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>2
CAGESC3_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>2 AND CAGESC3_x=01
CAGESC3X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>2
CGENDC_3. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>3
CAGESC4_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>3 AND CAGESC4_x=01
CAGESC4X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>3
CGENDC_4. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>4
CAGESC5_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>4 AND CAGESC5_x=01
CAGESC5X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>4
CGENDC_5. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>5
CAGESC6_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>5 AND CAGESC6_x=01
CAGESC6X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>5
CGENDC_6. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF CNUMC>6
CAGESC7_X. How old is the next oldest child?
01. RECORD AGE
99. REFUSED
ASK IF CNUMC>6 AND CAGESC7_x=01
CAGESC7X. ENTER AGE: [Range 0-17]
ASK IF CNUMC>6
CGENDC_7. Is the next oldest child male or female?
01. MALE
02. FEMALE
99. REFUSED
ASK IF calltype = 2 and Cisparnt = 01
CINFOR. This survey asks about health information and activities that children participate in. I need to speak to someone who knows this information for each child. Are you able to answer these questions about children in the household?
01 YES
02 NO
88 NO CHILDREN IN HOUSEHOLD
ASK IF noT A PARENT/GUARDIAN OF children in household
CONEADLT. You have been randomly chosen to participate in an important study. The Centers for Disease Control and Prevention (CDC) is sponsoring this telephone study of up to 10,000 people in the United States to find out about their experiences with head injuries in the past 12 months. Even if you haven’t had an injury in the past 12 months, you can still participate in this important study.
The data we are collecting are very important, and will be used to guide national policies. The majority of respondents will complete the survey in less than 14 minutes.
There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your information private, your name will never be connected to your answers. CDC will keep the information that you provide private and secure to the extent permitted by the law. You can skip any question or stop the survey at any time. If you have questions or concerns about participating in the study, you may contact ICF, the independent health research company hired to conduct this survey. They can be reached toll-free at -1-844-604-4399. If you have any questions about your rights as a research participant, please contact Sophia Zanakos at 301-572-0239. This call may be monitored for quality assurance purposes.
May we begin?
1. YES [SKIP TO TRANS1]
2. NO [SCHEDULE CALLBACK]
ASK IF PARENT/GUARDIAN OF children in household
CPROXY. You have been randomly chosen to participate in this important study. The Centers for Disease Control and Prevention (CDC) is sponsoring this telephone study of up to 10,000 people in the United States to find out about their experiences with head injuries in the past 12 months.
We will also ask you about the [IF NUMC=1 READ “child’s” / IF NUMC >1 READ “children’s”] experiences with head injuries in the past 12 months. Even if you or the [IF NUMC=1 READ “child has” / IF NUMC>1 READ “children have”] not had an injury in the past 12 months, you can still participate in this important study.
The data we are collecting are very important, and will be used to guide national policies. The majority of respondents will complete the survey in less than 20 minutes.
There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your information private, your name will never be connected to your answers. CDC will keep the information that you provide about you and the children private and secure to the extent permitted by the law. You can skip any question or stop the survey at any time. If you have questions or concerns about participating in the study, you may contact ICF, the independent health research company hired to conduct this survey. They can be reached toll-free at -1-844-604-4399. If you have any questions about your rights as a research participant, please contact Sophia Zanakos at 301-572-0239. This call may be monitored for quality assurance purposes.
May we begin?
1. YES [SKIP TO TRANS1]
2. NO [SCHEDULE CALLBACK]
ASK if INTTYPE=a or P
TRANS1. Thank you. Before we continue with the rest of the survey, we have just a few questions for background purposes only.
ASK if INTTYPE=a
AGE. What is your age?
01. GIVES AGE
99. REFUSED
ASK IF age=01
AGE1. ENTER AGE:
ASK IF CALLTYPE=1 or 2 AND (ADLTS or CADLTS>1)
GENDER2. INTERVIEWER CODE RESPONDENT SEX
21 MALE
22 FEMALE
04 UNABLE TO TELL IF MALE OR FEMALE
aSK IF GENDER2=04
GENDER2A. What is your sex?
01 MALE
02 FEMALE
99 REFUSED
ASK if INTTYPE=a or p
HISPA. Are you Hispanic, Latino/a, or of Spanish origin?
01. No, not Hispanic, Latino or of Spanish origin
02. Yes, Hispanic, Latino, or of Spanish origin
97. DON’T KNOW
99. REFUSED
ASK if INTTYPE=a or p
/programmer: mul=5/
RACEA. Which one or more of the following would you say is your race?
INTERVIEWER: IF RESPONDENT SAYS “HISPANIC OR LATINO” SAY, “THANK YOU – I HAVE RECORDED THAT YOU ARE HISPANIC/LATINO. WOULD YOU SAY THAT YOU ARE WHITE, BLACK OR AFRICAN AMERICAN, AMERICAN INDIAN OR ALASKA NATIVE, ASIAN, NATIVE HAWAIIAN OR PACIFIC ISLANDER, OR MORE THAN ONE OF THESE?”
01 White
02 Black or African American
03 American Indian or Alaska Native
04 Asian, or
05 Native Hawaiian or other Pacific Islander
INTERVIEWER: DO NOT READ THE FOLLOWING OPTIONS
95 OTHER
97 DON’T KNOW
99 REFUSED
ASK if inttype=A or P
EDUC. What was the highest grade or year in school that you completed?
[DO NOT READ]
01. Didn’t graduate from high school
02. Received GED (high school equivalency)
03. Graduated from high school
04. Technical/vocational schooling beyond high school
05. Attended some college (but no degree)
06. Associate’s degree (2-year college degree)
07. 4-year college degree
08. Graduate or professional school beyond 4-year degree
97 DON’T KNOW
99 REFUSED
ASK if inttype=a or p
OWNRENT. Do you currently own or rent your residence?
01. OWN
02. RENT
97. DON’T KNOW
99. REFUSED
ASK if inttype=A or P
MARITAL. What is your marital status? Are you currently…
01. Married
02. Living with a partner, or have a common-law marriage
03. Widowed
04. Divorced
05. Married, but separated, or
06. Never married?
97. Don’t
know
99. Refused
ASK if inttype=a and calltype=2
LANDLINE: Do you also have a landline telephone in your home that is used to make and receive calls?
Read only if necessary: “By landline telephone, we mean a “regular” telephone in your home that is used for making or receiving calls.” Please include landline phones used for both business and personal use.”
INTERVIEWER NOTE: Telephone service over the internet counts as landline service (includes vonage, magic jack and other home-based phone services.).
01 YES
02 NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a and calltype=1
PHONES1: Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine.
01 YES
02 NO
97. DON’T KNOW
99. REFUSED
ask if PHONES1=1
PHONES2: How many of these telephone numbers are residential numbers?
Residential telephone numbers [6 = 6 or more] RANGE=1-6
97. DON’T KNOW
99. REFUSED
ASK if inttype=a OR P and calltype=1
CELLPH: Including phones for business and personal use, do you have a cell phone for personal use?
01 YES
02 NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a, p, or d
When adult or proxy reports for child display: “Now I'd like to ask some questions about your [insert age] year old [IF MALE= “son” IF FEMALE=”daughter”].”
RECALL. We are interested in learning about times, in the last year, when [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experienced a head injury. This might have been from a bump, blow or jolt to [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head.
CONTINUE
ASK if inttype=a, p or d
INJ. In the last year, that is since [insert date 1 year ago from today], [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] examined in a doctor’s office, clinic, hospital or elsewhere because of a head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJ =1
INJN. Since [insert date 1 year ago from today], how many head injuries did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] have that caused [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] to go to a doctor’s office, clinic, or hospital or to be examined elsewhere?
ENTER COUNT: ______[1-96]
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d
PREJOG. Now I’d like for you to think about (IF YES TO TREATED TBI “other”) times in the last year when [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] may have experienced an injury to the head. I would like you to tell me about a head injury even if [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] did not go to see a doctor for care. This might have happened while playing a sport for fun or competition, or while [IF INTTYPE=A READ “you were”/ IF INTTYPE=P READ “your child was”] doing something physically active like bicycling. It might have happened as a result of a car accident or because someone hurt [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”]. Or, it could have happened because [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] tripped, slipped, or fell down.
CONTINUE
ASK if inttype=a, p or d
INJ2. In the last year, that is since [insert date 1 year ago from today], did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience any other injuries to [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head that you did not see a doctor about?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJ2 =1
INJN2. Since [insert date 1 year ago from today], how many head injuries did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience that you did not see a doctor about?
ENTER COUNT: ______[1-96]
97. DON’T KNOW
99. REFUSED
PROGRAMMER: CREATE INJNUM= INJN + INJN2 IF INJN < 97 AND INJN2 <97. if injn and injn2 are both dk/refused, create sysinjn=1. Set sysinjn=injnum so that respondents move thru the survey as if they have had one injury
if inj and inj2=2 (no injuries) skip to adult demographics or cycle through proxy interview(s)
ASK if inttype=a, p or d and injn and injn2 =1-96. So we only confirm the number if we have a number.
/if INJNUM=1 then *textsub=injury/lesión; if injnum>1 then *textsub=injuries/lesiones /
INJNTOT. So to confirm, [IF INTTYPE=A OR D READ “you have”/ IF INTTYPE=P READ “your child has”] had [INSERT INJNUM] IF INJNUM>1 READ “separate”] head *textsub* in the past 12 months?
01. YES
02. NO (REASK AND CORRECT)
97. DON’T KNOW
99. REFUSED
programmer: first loop begins here from preintx to monthb for up to three injuries.
/if one injury do not display We will begin with your most recent head injury.
ASK if inttype=a, p or d and INJn >=1
PREINTX. Thank you. Now we have some more questions about [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “your child’s”] head [IF INJN + INJN2 =1 READ “injury”/ IF INJN + INJN2 >1 READ “injuries”]. We will begin with your most recent head injury.
01. CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >1
Loop2 read: second most recent; loop 3 read: third most recent
INJOPNB. Can you provide a very brief two or three word description of your [IF INTTYPE=P READ “child’s”] most recent head injury? For example, “car accident” or “soccer injury”. We will talk about your other head injuries next.
INTERVIEWER: write brief DESCRIPTION
01. _______ [ENTER RESPONSE TEXT RANGE= XXXX]
97 DON’T KNOW
99 REFUSED
ASK if inttype=a, p or d and INJN + INJN2 =>1 (need year even if it is only one injury)
QYEAR. In what year did the head injury occur?
XXXX [ENTER FOUR DIGIT YEAR]
9997 DON’T KNOW
99999 REFUSED
ask if year not in 2016, 2017
YEARVAL [insert response to year] is outside the range of years we are asking about. We are interested in head injuries that occurred since [insert date 1 year ago].
[IF ONLY ONE INJURY GO TO LIFETBIDX]
[IF MORE THAN ONE INJURY GO TO NEXT LOOP]
ASK if inttype=a, p or d and INJN + INJN2 =>1 (need month even if it is only one injury)
QMONTH. In what month did the head injury occur?
01. JANUARY
02. FEBRUARY
03. MARCH
04. APRIL
05. MAY
06. JUNE
07. JULY
08. AUGUST
09. SEPTEMBER
10. OCTOBER
11. NOVEMBER
12. DECEMBER
97. DON’T KNOW
99. REFUSED
ask if year + month does not determine if injury occurred within past 6 months.
MONTHA. Did the head injury occur before or after [interview date – 180 Days]?
BEFORE
AFTER
97. DON’T KNOW
99. REFUSED
ask if year +month does not determine if injury occurred within past year
MONTHB. Did the head injury occur before or after [interview date – 365 Days]?
BEFORE
AFTER
97. DON’T KNOW
99. REFUSED
ask if year or month is 97, 99
ONEYR. Did the head injury occur before or after [interview date –365 Days]?
BEFORE
AFTER
97. DON’T KNOW
99. REFUSED
ask if year or month is 97,99
SIXMO. Did the head injury occur before or after [interview date – 180 Days]?
BEFORE
AFTER
if injury happened more than one year ago (If monthb = 1 OR ONEYR=1) and there are no more injuries, respondent goes to lifetime TBI section.
programmer: second loop starts here from presymmu to actselx if INJN + INJN2 >= 1
refer to each injury using INJOPNb to remind the respondent which injury you are asking about
IF INJNUM>1 AND YEAR OR MONTH IS DK/REF FOR ANY INJURY IN THE LOOP THEN LOOP1 REPRESENTS THE MOST RECENT INJURY, LOOP2 REPRESENTS THE SECOND MOST RECENT INJURY, AND LOOP3 REPRESENTS THE THIRD MOST RECENT INJURY.
IN THESE CASES OF MISSING YEAR OR MONTH BECAUSE RESPONDENT ANSWERED DK/REF PRESYMMU SHOULD REFERENCE INJOPNB IF POPULATED AND MONTH IF POPULATED AS FOLLOWS
IF INJOPNB IS MISSING -
PRESYMMU. Now I’d like to discuss the injuries you told me about. [IF INJOPNB IS MISSING REFER TO LOOP NUMBER FOR TEXT INSERT.] LOOP1 READ: Please tell me about the injury you reported as the most recent injury [IF MONTH IS POPULATED INSERT MONTH AS FOLLOWS ELSE DO NOT DISPLAY ] that occurred in [MONTH]. LOOP2 READ: Please tell me about the injury you reported as your second most recent injury [IF MONTH IS POPULATED INSERT MONTH AS FOLLOWS ELSE DO NOT DISPLAY TEXT] that occurred in [MONTH]. LOOP3 READ: Please tell me about your injury you reported as your third most recent injury [IF MONTH IS POPULATED INSERT MONTH AS FOLLOWS ELSE DO NOT DISPLAY TEXT] that occurred in [MONTH].
IF MONTH IS MISSING AND INJOPNB POPULATED
PRESYMMU. Now I’d like to discuss the injuries you told me about. Please tell me about the injury you described as the [INJOPNB].
ASK if inttype=a, p or d and INJN + INJN2 >1
PRESYMMU. Now I’d like to discuss [IF SECOND AND THIRD LOOP display the next injury. [IF FIRST LOOP DISPLAY: the injuries you told me about]. [IF INJOPNB IS POPULATED READ “Let’s discuss the one you described as [INJOPNB]// IF MONTHN IS POPULATED READ “that occurred in [MONTHN].
CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >= 1
PRESYM. In the next set of questions, I will be asking what happened to [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] immediately or in the minutes after this head injury. For each one I read, please tell me if it happened to [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] or not. We only want to know about things caused by the head injury or made worse by the head injury. [IF INTTYPE =P, READ “If you are unsure about whether your child experienced the symptom in relation to the head injury, it is okay to say that you don’t know.]
CONTINUE
ASK if inttype=a, p, or d and INJN + INJN2 >= 1
SYM1. [IF INTTYPE=A READ “Were you dazed, confused or did you have trouble thinking straight?” / [IF INTTYPE= P READ “Did your child have trouble thinking straight or appear to be out of it?” / [IF INTTYPE= D READ “Did you have trouble thinking straight or feel out of it?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p, or d and INJN + INJN2 >= 1
SYM2. [IF INTTYPE=A OR D READ “Did you have difficulty remembering what happened just before or after the head injury?” / [IF INTTYPE= P READ “Did your child have difficulty remembering what happened just before or after the head injury?”
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p, or d and INJN + INJN2 >= 1
SYM3. [IF INTTYPE=A OR D READ “Were you knocked out or did you lose consciousness, even briefly?” / [IF INTTYPE= P READ “Was your child knocked out or did your child lose consciousness, even briefly?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p, or d and sym3=1
SYM3A. For how long? Was it…
INTERVIEWER: IF RESPONDENT IS UNSURE, SAY, “It is okay to give your best guess.”]
INTERVIEWER: Read [INJOPNB] if needed.
01. A few seconds
02. More than a few seconds, up to 5 minutes
03. 6 to 30 minutes
04. 31 minutes to 24 hours, or
05. More than 24 hours
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
PRESYM4. Now we’d like to ask you about things that happen to some people after a head injury. Some of these develop immediately or minutes after a head injury and some do not happen until later. Again, we only want to know about things caused by the head injury or made worse by the head injury. [IF INTTYPE =P, READ “If you are unsure about whether your child experienced the symptom in relation to the head injury, it is okay to say that you don’t know.]
01. CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM4. [IF INTTYPE=A OR D READ “Did you feel sick to your stomach or did you vomit?” / [IF INTTYPE= P READ “Did your child complain of feeling sick to his or her stomach or did he or she vomit?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and SYM4=1
SYM4A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM5. Did [IF INTTYPE=A OR D READ “you have a headache?” / [IF INTTYPE=P READ “your child complain of a headache?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and SYM5=1
SYM5A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM6. [IF INTTYPE=A OR D READ “Was there ever a time when you were dizzy, clumsy or had balance problems?” / IF INTTYPE=P READ, “Did your child appear dizzy or complain of dizziness, appear to move in a clumsy way, or have balance problems?”
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1 AND SYM6=1
SYM6A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM7. [IF INTTYPE=A OR D READ “Did you have blurred or double vision, or other changes in your vision?” / IF INTTYPE=P READ “Did your child have or complain about blurred or double vision, or other changes in vision?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1AND SYM7=1
SYM7A. Did this start…
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM8. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] have trouble concentrating?
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1 and SYM8=1
SYM8A. Did this start..
INTERVIEWER: Read [INJOPNB] if needed.
01. Immediately or minutes after, or
02. Later on
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
PRESYM9. Earlier we asked about things that might have started immediately or minutes after a head injury. The next questions are about things that might happen to people sometime after. Again, we are only interested in things caused by the head injury, or made worse by the head injury. [IF INTTYPE=P, READ “If you are unsure about whether your child experienced the symptom in relation to the head injury, it is okay to say that you don’t know.]
01. CONTINUE
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM9. [IF INTTYPE=A READ “Did you have difficulty learning or remembering new things?” / IF INTTYPE=P READ “Did your child become confused with directions or tasks or answer questions more slowly than usual?” / IF INTTYPE=D READ “Did you become confused with directions or tasks, or answer questions more slowly than usual?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM10. [IF INTTYPE=A OR D READ “Were you” / IF INTTYPE=P READ “Was your child”] more sensitive than usual to either light or noise?
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM11. [IF INTTYPE=A OR D READ “Did you experience a change in mood or temperament such as irritability, or feel more emotional than usual?” / IF INTTYPE=P READ “Was there a change in your child’s mood or temperament, were they more irritable, or otherwise more emotional than usual?”]
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYM12. [IF INTTYPE=A OR D READ “Did you have trouble sleeping or were you more tired than usual?” / IF INTTYPE = P READ “Did your child have trouble sleeping or appear more tired than usual?”
INTERVIEWER: Read [INJOPNB] if needed.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=a, p, or d and INJN + INJN2 >= 1
SRRX. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience this head injury while playing a sport, or while engaged in physical fitness or a recreational activity for fun or competition?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a, p or d and srrX=1
ACTSELX. Which activity [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] doing at the time of the head injury?
Aerobics, cardio
Balance beam
Balance rope
Ballet
Barrel racing
Base jumping
Baseball
Basketball, shooting hoops
Bicycling Biking or Cycling
Boxing, Sparring
Bungee jumping
Burpees
Calisthenics
Canoeing
Cheerleading
Circuit training
Climbing (ice, rock)
Climbing wall, net, bars
Conditioning, warm-up (gymnastics)
Crew
Cross fit
Dancing (any kind)
Diving, jumping into water
Dodgeball
Elliptical
Equestrian
Floor exercises
Football
Foursquare
Guns, firearms
Gym equipment
Gymnastics
Hang gliding
Heptathlon
High bar
Hiking
Hockey (field, ice)
Hopscotch
Horse (riding, racing)
Hover boarding
Hunting
Inner-tubing (water)
Javelin
Jiu-jitsu
Judo
Jumping jacks
Jungle gym
Karate
Kayaking
Lacrosse
Lifting weights, free weights
Long jump, high jump, triple jump
Martial arts (Mixed, MMA)
Monkey bars
Motor vehicle (car, truck, offroad, dirt bike, motorcycle)
Muay thai
Parachuting, paragliding, parasailing
Parallel bar or uneven bars
Parkour
Pilates
Ping pong/ table tennis
Playground activity
Pole bending (rodeo)
Pole vaulting
Polo
Pommel horse
Racquetball
Rafting (water)
Red rover
Riding stock
Rings (still)
Rodeo
Roping
Rowing machine
Rugby
Running, jogging
Sailing
Scuba diving
Shooting skeet, targets or for competition
Shot put
Skateboarding/long boarding
Skating, ice or figure
Skating, inline
Skating, roller
Ski jumping
Skiing
Sledding (snow)
Slide, slide pole, sliding
Snorkeling
Snowboarding
Snow tubing
Soccer
Softball
Squash
Stair climber
Stationary bike
Steer wrestling
Stretching, flexibility
Surfing
Swimming
Swings, swinging
Tae Kwon Do
Tag
Teeter totter, see-saw
Tennis
Tetherball
Track and field
Treadmill
Triathlon
Ultimate frisbee
Vault
Volleyball, indoor
Volleyball, outdoor
Walking
Water Polo
Water Tubing
Wrestling
Yoga
Zip lining
Zumba
None of these/other: ENTER: XXXXXXX
ask if inttype=p and srrX=1
SRRSET1X. When your child sustained this head injury, was your child participating in a school based team sport, not including PE or recess?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=p AND SRRSET1X = 2, 97, or 99
SRRSET3X. When your child sustained this head injury, was your child participating in a non-school based sports league?
01. YES
02. NO
97. DON’T KNOW
ask if (inttype = P and srrset1x=1)
SSRSET1BX. What was the level of play? Was it…
01. High school
02. Middle school (junior high), or
03. Grade school (elementary school)
97. DON’T KNOW
99. REFUSED
ASK IF SRRX=1 AND (IF INTTYPE = P AND SRRSET1X=1 OR SRRSET3X=1)
SRRPCPX. Did the head injury occur as part of a…
01. Practice or training,
02. Competition, or
03. Performance
97. DON’T KNOW
99. REFUSED
CASE DEFINITION: if there is one injury with symptoms, goto intentx. if there is one injury without symptoms, goto txmostns. IF > 1 For either, refer to the MOST RECENT injury.
programmer: the order we need for people and injuries is as follows:
Beginning with RECALL, the randomly selected adult answers thru ACTSELX (if SRR=1) for injury #1. If there is a second injury, the selected adult answers from INJOPNB thru ACTSELX. If there is a third injury, the adult answers INJOPNB thru ACTSEL.
Randomly order children so the loops don’t always ask about the olders child in loop1 and youngest in last loop.
Then we move to Child1 and adult answers as proxy starting with RECALL. If head injury positive, go thru SRRSET3X (if applicable) for injury #1. If there is a second injury for Child1, the adult answers from INJOPNB thru SRRSET3X. If there is a third injury, that loop is repeated again (INJOPNB thru ACTSEL).
Then we move to Child2 and adult answers as proxy starting with RECALL. If head injury positive, go thru SRRSET3X (if applicable) for injury #1. If there is a second injury for Child2, the adult answers from INJOPNB thru SRRSET3X. If there is a third injury, that loop is repeated again (INJOPNB thru ACTSEL).
Then we move to Child3, 4, Nth using above structure.
Once injuries established for everyone in the house, interview picks up at INTENTX (if applicable) for the last/most recent child for whom injuries were established. Starting with INTENTX, questions pertain to only the most recent injury for that child. Interview goes through the remaining demographics [CRACEA] for this child.
Move through each child [RECALL TO CRACEA]
Then complete remaining adult injury data [INTENTX] and remaining adult demographics.
programmer: if there is more than one injury, go back through signs/symptoms to actselx for the next injury for up to three injuries per A, P or D.
MOST RECENT INJURY NO SYMPTOMS
TXMOSTNS.
This part of the survey is about [IF INTTYPE=A or D READ “your”; IF INTTYPE=P READ “your [AGE] year old” IF MALE “son” IF FEMALE “daughter]’s injury [IF INJOPNB IS POPULATED READ “, which you described as the [INSERT INJOPNB]”] {IF MONTH POPULATED DISPLAY: “that occurred in [MONTH]”} [IF MONTH and INJOPNB missing (DK OR REF) “{IF INJURY IN LOOP1: “most recent injury you reported”; IF INJURY IN LOOP2 “second most recent injury you reported”; IF INJURY IN LOOP3 “third most recent injury you reported”].
ask if inttype = a or p and if INJN + INJN2 >= 1 (This question ONLY includes MOST RECENT INJURY with no symptoms)
PREMEDN. We have some questions about medical care [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] may have received because of this head injury. First, [IF INTTYPE=A READ “were you”/ IF INTTYPE=P READ “was your child”] ever examined by a medical professional, paramedic or an athletic trainer?
INTERVIEWER: PARAMEDIC INCLUDES EMTs
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and INJN + INJN2 >= 1 and premed=1 (This question ONLY includes MOST RECENT INJURY with no symptoms)
TBIDXN. Following this head injury, did a medical professional diagnose [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] with a concussion or traumatic brain injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and (premed=2) (This question ONLY includes MOST RECENT INJURY with no symptoms)
WHYNOCRXN. Sometimes it is very difficult for people to receive the health care that they need or want [IF INTTYPE=P READ “for their child”]. Please select the primary reason [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] did not receive health care for this head injury.
You had difficulty paying for it
02. You did not have transportation
03. You could not take time off work
04. You did not think the injury [IF INTTYPE=A READ “to your head”/IF INTTYPE=P READ “to your child’s head”] was serious, or
95. Was there another reason? [ENTER RESPONSE [TEXT RANGE = XXX]]
97. DON’T KNOW
99. REFUSED
ask if inttype = D (This question ONLY includes MOST RECENT INJURY with no symptoms)
DASSESSEDN. Did anyone check you out to see if you were injured?
01. YES
02. NO
97. DON’T KNOW/NOT SURE
99. REFUSED
ask if inttype = D and if DASSESSED =2 (This question ONLY includes MOST RECENT INJURY with no symptoms)
PRETELLN. Although you were not checked out for your head injury, did you tell anyone?
01. YES
02. NO
97. DON’T KNOW/NOT SURE
99. REFUSED
ask if inttype = D and PRETELL = 2 (This question ONLY includes MOST RECENT INJURY with no symptoms)
mult=4 [Note select all that apply instructions below]
NOTELLWHYN. Why did you choose not to tell anyone? Was it because you…
interviewer: select all that apply.
Did not realize you were injured
Did not think the head injury was serious
Did not want to be removed from your sport
95. Some other reason [ENTER RESPONSE [TEXT RANGE = XXX]
97. DK/NR
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >=1(This question ONLY includes MOST RECENT INJURY with no symptoms)
FUNCSN. To what extent did the head injury interfere with [IF INTTYPE=A or D READ “your”; IF INTTYPE=P READ “your child’s”] normal social activities with family, friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
97. DON’T KNOW
99. REFUSED
ASK if inttype=a and INJN + INJN2 >=1 (This question ONLY includes MOST RECENT INJURY with no symptoms)
FUNCWN. To what extent did the head injury interfere with your normal work (including work outside the home and housework)?
Not at all
Slightly
Moderately
Quite a bit
Extremely
97. DON’T KNOW
99. REFUSED
ASK if inttype= p or d and INJN + INJN2 >=1 (This question ONLY includes MOST RECENT INJURY with no symptoms)
FUNCSAN. To what extent did the head injury interfere with [IF INTTYPE=D READ “your”; IF INTTYPE=P READ “your child’s”] normal school activities (including extracurricular activities such as sports, band or clubs)?
Not at all
Slightly
Moderately
Quite a bit
Extremely
DON’T KNOW
REFUSED
MOST RECENT INJURY SYMPTOMS
ask if inttype=a, p, or D and INJN + INJN2 >= 1 AND SRRX=2,97
INTENTX. We have additional questions about your [IF INJN+INJN2 = 1, READ injury//IF INJN+INJN2>1, READ “most recent injury, IF INJOPNB_1 IS POPULATED READ “which you described as the [INSERT INJOPNB_1]. Which of the following best describes how the head injury happened? Would you say that…
01. Someone else was trying to injure [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] on purpose
02. [IF INTTYPE=A OR D READ “You”/ IF INTTYPE=P READ “Your child”] tried to injure [IF INTTYPE=A OR D READ “yourself”/ IF INTTYPE=P READ “him or herself”] on purpose
03. It was an accident—no one intended to injure [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”], or
95. Something else happened? [ENTER RESPONSE TEXT RANGE=XXXX]
97. DON’T KNOW
99. REFUSED
ASK IF inttype = a, p, or d and INJN + INJN2 >1 AND SRRX<>2
TXMOST. This part of the survey is about [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “your AGE year old GENDER child’s”] most recent injury [IF INJOPNB IS POPULATED READ “, which you described as the [INSERT INJOPNB]”].
ASK IF inttype = p and INJN + INJN2 = 1 AND SRRX=1 and there’s more than one child with AN INJURY
TXMOST2.
This part of the survey is about [IF INTTYPE=P READ “your AGE year old GENDER child’s”] most recent injury [IF INJOPNB IS POPULATED READ “, which you described as the [INSERT INJOPNB]”].
ask if inttype=a, p, or d and INJN + INJN2 >= 1 and srrX = 2,97 and intentx=3,95,97
BIKEX. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience this head injury while on a bicycle?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=a, p, or d and BIKEX=1 or (srrx=1 and actselX=9)
BIKE1X. How did the head injury happen? Was it initially due to a…
01. Collision with a moving motor vehicle
02. Collision with another bicycle
03. Collision with a person
04. Collision with a stationary object
05. Fall from a bicycle to a surface like the road, or
95. Something else?
97. DON’T KNOW
99. REFUSED
ask if inttype=a, p, or d and BIKEX=1 and srrx <>1
BIKE4X. What was the PRIMARY reason [IF INTTYPE=A OR D READ “you were”/ IF INTTYPE=P READ “your child was”] bicycling at the time of the head injury? [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”]…
01. Riding primarily as a means of transportation--for example to get to work or school
02. Riding primarily for recreation, physical fitness, or competition
03. BOTH
97. DON’T KNOW
99. REFUSED
programmer: if bike4x =2, create variable “BIKESRRact”=1
ask if inttype=a, p, or d and INJN + INJN2 >= 1 and srrX = 2,97 and bikex=2,97
MVX. Did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience this head injury while on or in a motorized vehicle, such as a car, bus, truck, motorcycle, dune buggy, or all-terrain vehicle (ATV)?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype=a, P, or d and mvX=1 and srrx<>1 and MV3X = 3, 4, or 5
MV7X. Why [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] riding or driving at the time of the head injury? [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”]
01. Riding or driving as a means of transportation-- for example to get to work or school
02. Riding or driving for fun, for pleasure, or for competition
97. DON’T KNOW
99. REFUSED
programmer: if MV7X =2, create variable “MVSRRact”=1
ask if inttype=a, p, or D and INJN + INJN2 >= 1 and srrx=2,97 and bike = 2,97 and mvx = 2,97 and INTENTX <>2
CAUSEX. Would you say that the head injury occurred because …
[IF INTTYPE=A OR D READ “You were”/ IF INTTYPE=P READ “Your child was”] hit by an object or person, or were pushed against something
IF INTTYPE=A OR D READ “You”/ IF INTTYPE=P READ “Your child”] fell without being struck or pushed, or
95. Something else happened [ENTER RESPONSE TEXT RANGE=XXXX]
97. DON’T KNOW
99. REFUSED
ask if MV3X=3,4 or bikex=1, or ACTSELX =6, 7, 9, 93, 28, 37, 5, 26, 39, 63, 65, 70, 72, 73, 97, 33, 57, 81, OR 119
HELMETX. [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”] wearing a helmet at the time of the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if ACTSELX =85, 86, 87, 90, or 91
HELMET1X. [IF INTTYPE=A OR D READ “Were you”/ IF INTTYPE=P READ “Was your child”] wearing a helmet or headgear at the time of the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1
SYMSTILL. [IF INTTYPE=A OR D READ “Are you”/ IF INTTYPE=P READ “Is your child”] still experiencing any of the head injury-related symptoms that we’ve talked about?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if inttype=a, p or d and INJN + INJN2 >= 1 and SYMstill=2
/Validate against date of injury if provided and restrict number of days, weeks, months accordlingly/
/if month and YEAR missing display:
Earlier you reported your head injury occurred within the past 12 months. Please provide the number of months it took for your symptoms to go away; your answer should be 12 months or less.
/IF MONTH and YEAR POPULATED DISPLAY:
Earlier you reported your head injury occurred within the past 12 months. How many months since [MONTH] [YEAR] did it take for your head injury-related symptoms to go away?
SYMRECA. How long did it take for all of [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head injury-related symptoms to go away? You can report either the number of days, weeks, or months.
01. NUMBER OF DAYS
02. NUMBER OF WEEKS
03. NUMBER OF MONTHS
97. DON’T KNOW
99. REFUSED
ASK if inttype= p and INJN + INJN2 >= 1
CHILDPRES. Did you ask your child about any of their signs or symptoms during our call?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and if INJN + INJN2 >= 1 (This question now includes injuries with no symptoms)
PREMED. We have some questions about medical care [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] may have received because of this head injury. First, [IF INTTYPE=A READ “were you”/ IF INTTYPE=P READ “was your child”] ever examined by a medical professional, paramedic or an athletic trainer?
INTERVIEWER: PARAMEDIC INCLUDES EMTs
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and premed=1
EVWHOX. Which of these first examined [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] after this head injury? Was it…
01. A nurse
02. A doctor
03. An EMT or paramedic
95. Some other medical professional
04. An athletic trainer
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and premed=1 AND EVWHOX=97
EVWHOXA. We realize you are unsure about who examined [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”]. In your opinion, was the person a medical professional?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and premed=1
EVTIMEX. How long after the head injury [IF INTTYPE=A READ “were you”/ IF INTTYPE=P READ “was your child”] first evaluated by [IF EVWHOX <=4, INSERT EVWHOX // IF EVWHOX=95 OR EVWHOXA=1 INSERT “this medical professional.”]? Was it…
01. At the time and place of the head injury
02. After the time of the head injury, but within 24 hours
03. Within 1 week
04. More than 1 week later
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and evtimeX=2, 3, or 4
EVWHEREX. Where did the first evaluation by [IF EVWHOX <=4, INSERT EVWHOX // IF EVWHOX=95 OR EVWHOXA=1 INSERT “this medical professional”] take place?
01. In a doctor’s office or clinic
02. At a hospital or emergency department, or
95. Somewhere else? [ENTER RESPONSE [TEXT RANGE = XXX]
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and evwhereX=1 or 95
DOCX. Did the first evaluation by [IF EVWHOX <=4, INSERT EVWHOX // IF EVWHOX=95 OR EVWHOXA=1 INSERT “this medical professional”] take place at…?
01. [IF INTTYPE=A READ “Your”/ IF INTTYPE=P READ “your child’s”] regular doctor or primary care physician’s office
02. An urgent care clinic
03. A clinic in a pharmacy or grocery store
04. A sports medicine clinic
05. A concussion clinic, or
95. Some other place? [ENTER RESPONSE [TEXT RANGE = XXX]
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and evwhereX=2
HOSPX. Did the first evaluation by [IF EVWHOX <=4, INSERT EVWHOX // IF EVWHOX=95 OR EVWHOXA=1 INSERT “this medical professional”] take place at…?
01. An emergency room
02. An outpatient clinic in a hospital
03. A sports medicine clinic in a hospital
04. An urgent care clinic in a hospital, or
05. At another location in a hospital [ENTER RESPONSE [TEXT RANGE = XXX]
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and INJN + INJN2 >= 1 and premed=1
CAREX. After the initial examination by [IF EVWHOX <=4, INSERT EVWHOX // IF EVWHOX=95 OR EVWHOXA=1 INSERT “this medical professional”], did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] have another healthcare visit for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if carex = 1
CAREAX. Did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] visit [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] regular doctor or primary care physician for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if carex = 1
CAREBX. Did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] visit an urgent care clinic for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury…
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if carex = 1
CARECX. Did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] visit a clinic in a pharmacy or grocery store for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if carex = 1
CAREDX. Did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] visit a sports medicine clinic for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if carex = 1
CAREEX. Did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] visit a concussion clinic for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if carex = 1
CAREFX. Did [IF INTTYPE = A READ “you”/ IF INTTYPE = P read “your child”] visit a hospital or emergency department clinic for [IF INTTYPE = A READ “your”/ IF INTTYPE = P read “their”] head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and INJN + INJN2 >= 1and premed=1 (This question now includes injuries with no symptoms)
TBIDX. Following this head injury, did a medical professional diagnose [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] with a concussion or traumatic brain injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and (premed=2) (This question now includes injuries with no symptoms)
WHYNOCRX. Sometimes it is very difficult for people to receive the health care that they need or want [IF INTTYPE=P READ “for their child”]. Please select the primary reason [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] did not receive health care for this head injury.
You had difficulty paying for it
02. You did not have transportation
03. You could not take time off work
04. You did not think the injury [IF INTTYPE=A READ “to your head”/IF INTTYPE=P READ “to your child’s head”] was serious, or
95. Was there another reason? [ENTER RESPONSE [TEXT RANGE = XXX]]
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and INJN + INJN2 >= 1 and (evwherex=2 or carefx=1)
HOSPSTAX. [IF INTTYPE=A READ “Were you”/ IF INTTYPE=P READ “Was your child”] admitted to a hospital for the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and HOSPSTAx=1
HOSPNITEX. How many nights did [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] stay in the hospital because of the head injury?
001. GAVE ANSWER [ENTER RESPONSE MIN TO MAX DAYS]
997. DON’T KNOW
999. REFUSED
ask if inttype = a or p and HOSPSTAx=1
HOSPTRX. After [IF INTTYPE=A READ “you were”/ IF INTTYPE=P READ “your child was”] discharged from the hospital, [IF INTTYPE=A READ “were you”/ IF INTTYPE=P READ “was your child”] admitted to a rehabilitation center or nursing care facility because of this head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a or p and INJN + INJN2 >= 1 and premed=1 and hospstayx=1,2,97,99
RECSERVX. [IF HOSPSTAX=1 AND INTTYPE=A READ “After your hospitalization” / IF HOSPSTAX=1 AND INTTYPE=P READ “After your child’s hospitalization” //IF HOSPSTAX = 2, 97 OR 99 OR NULL, READ “After this head injury], did [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] receive services to help get well? Some examples might include physical therapy, speech therapy, vocational rehabilitation, neuropsychological services, or counseling.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if (inttype = p and SRRSET1X=1) or (age1 =18-22 and SRRSET1XX=1)
REMPLAYX. [IF INTTYPE=A READ “Were you”/ IF INTTYPE=P READ “Was your child”] removed from the game, performance, or practice as a result of the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p and REMPLAYX = 1
RETURNX. [IF INTTYPE=A READ “Have you”/ IF INTTYPE=P READ “Has your child”] returned to full sports or recreation activity following the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p or age1 =18-22 and returnX= 1
RETWHENX. How long was it before [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] returned to full sports or recreation activity? You can report the number of days, weeks, or months.
01. NUMBER OF DAYS
02. NUMBER OF WEEKS
03. NUMBER OF MONTHS
97. DON’T KNOW
99. REFUSED
ask if inttype = p and INJN + INJN2 >= 1
INSCHO. Was your child injured during the “school year,” or when school was in session? Please include summer school.
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p and INJN + INJN2 >= 1 and inscho=1
SCHOMISS. Did your child miss any school due to the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p and schomiss=1
SCHOMISSA. How many days?
INTERVIEWER: For this question, it is okay to give your best guess.
__________ENTER RESPONSE [RANGE = 1-XX]
97. DON’T KNOW
99. REFUSED
ask if inttype = p and INJN + INJN2 >= 1
EXTHELP. Did your child receive extra help, support, or services at school due to the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p and EXTHELP=1
RETLNGHT For how long did your child receive this help? You can report the number of days, weeks, or months.
01. NUMBER OF DAYS
02. NUMBER OF WEEKS
03. NUMBER OF MONTHS
97. DON’T KNOW
99. REFUSED
ask if inttype = p and INJN + INJN2 >= 1
PREACPERF. Was your child in a class where they received letter or number grades for their work at the time of the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p and preacperf = 1
ACPERF. Have your child’s grades declined since the head injury?
01. YES
02. NO
03. TOO SOON TO TELL/NOT EVALUATED YET
97. DON’T KNOW
99. REFUSED
ask if inttype = p and acperf = 1
ACPERF2. In your opinion, is the decline in grades due to the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = p and acperf = 2
ACPERF3. In your opinion, is your child having to work harder for the grades he or she had prior to the head injury?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a and INJN + INJN2 >= 1
PREWKMISSX. Were you employed, including self-employed, when you had this head injury? We are not asking if you were at work or working at the time of the head injury—just your employment status. Were you employed at the time?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ASK if INJN + INJN2 >= 1 and inttype = a and PREWKMISSX=1
WORK Were you working for pay when the head injury occurred?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
ask if inttype = a and INJN + INJN2 >= 1 and prewkmissx = 1
WKMISSX. Did the head injury cause you to miss or stop this work, even for an hour or so?
01. YES
02. NO
97. DON’T KNOW
99. REFUSED
Functioning (ThESE questionS include injuries with no symptoms)
ASK if inttype=a, p or d and INJN + INJN2 >=1
FUNCS. To what extent did the head injury interfere with your/your child’s normal social activities with family, friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
ASK if inttype=a and INJN + INJN2 >=1
FUNCW. To what extent did the head injury interfere with your normal work (including work outside the home and housework)?
Not at all
Slightly
Moderately
Quite a bit
Extremely
ASK if inttype= p or d and INJN + INJN2 >=1
FUNCSA. To what extent did the head injury interfere with your/your child’s normal school activities (including extracurricular activities such as sports, band or clubs)?
Not at all
Slightly
Moderately
Quite a bit
Extremely
To help us ensure that we are talking to a representative selection of households in the United States, we have just a few questions for classification purposes only.
ASK if inttype=a and INJN+INjN2>= 1
HINS. What kind(s) of health insurance do you have?
(CODE ALL THAT APPLY).
[INTERVIEWER: IF RESPONDENT GIVES A SPECIFIC PLAN NAME NOT LISTED BELOW, PROBE “Who pays for the insurance: an employer, the government, or you?” AND CODE ACCORDINGLY]
01 Private health insurance through an employer (IF NEEDED: either your own or through a spouse’s or parent's employer, either past or present)
02 Medicare (IF NEEDED: an insurance plan funded by Social Security for people who are disabled or are over age 65)
03 Medicaid (IF NEEDED: for example MediCal-California, HCCCS-Arizona, HealthWave-Kansas)
04 Federal Health Plans such as TriCare (IF NEEDED: for military personnel and families) or the VA (IF NEEDED: Veterans Administration),
05 Private health insurance or Medicare supplemental insurance that you pay for yourself, or
95 Some other insurer?
96 DON’T HAVE HEALTH INSURANCE
97 DON’T KNOW
99 REFUSED
IF CALLTYPE = 01 and CONEADLT=01 and numc>0 and ADLTS>1 and [(SELADLT=01 and infor=02) or (seladlt=02 and infor2=02) or (seladlt=01 and isparnt=02)]
SPEAKTOP. I also need to speak to a parent or guardian living in your household who knows about the health and activities of each child. May I speak to the person who knows this information?
KNOWLEDGEABLE ADULT COMING TO THE PHONE
KNOWLEDGEABLE ADULT NOT AVAILABLE [SCHEDULE CB]
IF SPEAKTOP=01 PICK UP AT CPROXY. ASK TRANS1 THROUGH CRACEA WHERE INTTYPE=P
ASk if inttype=p and (NUMC or CNUMC>1) and INJN+INjN2=0
PROXYINT
These next few questions are about your [INSERT AGE] year old [INSERT GENDER] child.
ASK if INTTYPE=P
RELATION: What is your relationship to this child?
INTERVIEWER: READ ONLY IF NECESSARY
01 Parent or legal guardian
02 Grandparent
03 Other relative
04 Non-relative
05 Other
97. DON’T KNOW
99 REFUSED
ASK if inttype=Pand INJN+INjN2 >= 1
CHINS. What kind(s) of health insurance does your child have?
(CODE ALL THAT APPLY).
[INTERVIEWER: IF RESPONDENT GIVES A SPECIFIC PLAN NAME NOT LISTED BELOW, PROBE “Who pays for the insurance: an employer, the government, or you?” AND CODE ACCORDINGLY]
01 Private health insurance through an employer (IF NEEDED: either your own or through a spouse’s or parent's employer, either past or present)
02 Other Federal Health Plans such as TriCare (IF NEEDED: for military personnel and families) or the VA (IF NEEDED: Veterans Administration),
03 Private health insurance or Medicare supplemental insurance that you pay for your child, or
95 Some other insurer?
96 DON’T HAVE HEALTH INSURANCE FOR CHILD
97 DON’T KNOW
99 REFUSED
ASK if INTTYPE= P
CHISPA. Is your child Hispanic, Latino/a, or of Spanish origin?
01. No, not Hispanic, Latino or of Spanish origin
02. Yes, Hispanic, Latino, or of Spanish origin
97. DON’T KNOW
99. REFUSED
ASK if INTTYPE= P
CRACEA. Which one or more of the following would you say is your child’s race?
INTERVIEWER: IF RESPONDENT SAYS “HISPANIC OR LATINO” SAY, “THANK YOU – I HAVE RECORDED THAT YOUR CHILD IS HISPANIC/LATINO. WOULD YOU SAY THAT YOUR CHILD IS WHITE, BLACK OR AFRICAN AMERICAN, AMERICAN INDIAN OR ALASKA NATIVE, ASIAN, NATIVE HAWAIIAN OR PACIFIC ISLANDER, OR MORE THAN ONE OF THESE?”
01 White
02 Black or African American
03 American Indian or Alaska Native
04 Asian, or
05 Native Hawaiian or other Pacific Islander
DO NOT READ
95 OTHER
97 DON’T KNOW
99 REFUSED
IF CALLTYPE = 01 and CPROXY=01 and [SELADLT=02 and (twoadlt=04 or threeadlt=04)]
CALLA Thank you very much for participating in this important research study. When would be a good time to call back the adult selected to complete this interview?
SCHEUDLE CALL BACK [SEND TO CALLBACK SCREEN]
DON’T KNOW [ASSIGN DISPO C4 / UNSCHEDULED CALLBACK]
REFUSED [PNCLOSE].
ASK if inttype=P and proxy age 13-17 (randomly select 1 if there is more than 1)
ADOL
Thank you so much for providing information about your [“child’s” OR “children’s”] experiences with head injuries in the past 12 months.
We would like your permission to speak to your [AGE] year old child directly to ask him or her some questions about their experience, if any, with head injuries. Allowing your child to participate in this study will add to the CDC’s knowledge about the circumstances surrounding head injuries and the groups most at risk for such injuries. There are minimal risks, and no known direct benefits to being in this voluntary study. To keep your child’s information private, their name will never be connected with their answers. CDC will keep the information that your child provides private and secure to the extent permitted by the law.
Even if you agree now, your child may choose not to participate.
CONTINUE
ASK if inttype=P
ASKADOL
May we conduct an interview with your [AGE] year old child?
01 YES
02 NO
ASK IF ASkadol=01
SPST2. Is your child available now? If so, we can conduct the survey right now over the phone.
01 YES, AVAILABLE NOW
02 NO, NOT AVAILABLE
02. NO
ask if SPST2=1
ADOL1. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries in children and adults.
You may have heard about head injuries, especially those experienced by children who play sports.
Even if you haven’t had an injury in the past 12 months, you can still participate in this important study. We have asked your parents to give their permission for you to participate; they have said “yes.” However, even though your parents said “yes,” you can still say “no” and not participate. And you can skip any question or stop the survey at any time. The majority of respondents will complete the survey in less than 7 minutes.
There are minimal risks, and no known direct benefits to being in this voluntary study. CDC will keep the information that you provide private and secure to the extent permitted by the law. Your name will never be connected to your answers. We will not share your answers with your parents.
If you have questions or concerns about participating in the study, you may contact ICF International, the independent health research company hired to conduct this survey. They can be reached toll-free at -1-844-604-4399. If you have any questions about your rights as a research participant, please contact Sophia Zanakos at 301-572-0239. This call may be monitored for quality assurance purposes.
May we begin?
01. YES [SKIP TO TRANS1]
02. NO
Ask if adol1=2 or SPST2=02
ADOLCB. We can text [IF SPST2=2 READ “your child”/ IF ADOL1=2 READ “you”] a link to complete the survey online. What is [IF SPST2=2 READ “your child’s”/ IF ADOL1=2 READ “your”] cell phone number?
GIVES NUMBER
NOT INTERESTED
Ask if ADOLCB=01
TEXT
/record number:/
Ask if adolcb=02
ASKEMAIL. I can email [IF SPST2=2 READ “your child”/ IF ADOL1=2 READ “you”] a link to complete the survey online. What is [IF SPST2=2 READ “your child’s”/ IF ADOL1=2 READ “your”] email address?
GIVES EMAIL
02 NOT INTERESTED
Ask if ASKEMAIL=01
/record email/
ask if calltype=1 and two adults in hh selected not available but adult reported as proxy
CBTWOADLT. When would be a good time to reach the other adult in your household?
/schedule CB/
ask if calltype=1 and 3-18 adults in hh
CBTHREEADLT. When would be a good time to reach the adult in your household with the next birthday?
/schedule CB/
//Ask all//
PNCLOSE. That was my last question. Thank you very much for participating in this important research study.
01 CONTINUE
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |