DURING THE PAST THREE MONTHS, that is since {91 days before today date}, {were/was} {you/anyone in the family} injured seriously enough that {you/they} got medical advice or treatment?

(1) Yes (FIJ.020)
(2) No (FIJ.300)
(7) Refused (FIJ.300)
(9) Don't know (FIJ.300)

Who was this? (Anyone else?)

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How many different times in the past three months {were/was} {you/subject's name} injured seriously enough to seek medical advice or treatment?

IJNO3M Times Injured (01-94): _____________

[If FIJ.030 = 1, ask:]
When did {subject's name} injury happen?

IJDATE_M MONTH: _____
IJDATE_D DAY: _____
IJDATE_Y YEAR: _____

[If FIJ.030 greater than 1, ask:]
Now I'm going to ask a few questions about {subject's name} most recent injury. When did that injury happen?

IJDATE_M MONTH: _____
IJDATE_D DAY: _____
IJDATE_Y YEAR: _____

[If FIJ.030 = 2 or more, ask:]
We just talked about {subject's name} injury on {recent injury date}. When did {subject's name} injury BEFORE THAT happen?

IJDATE_M MONTH: _____
IJDATE_D DAY: _____
IJDATE_Y YEAR: _____

[FIJ.050 to FIJ.295 are asked for each injury episode]

At the time of the injury, what part(s) of {subject's name} body was hurt? What kind of injury was it? Anything else?

FR: RECORD THE BODY PART, THEN THE KIND OF INJURY.

BODY PART

IJBODY1 ____________________
IJBODY2 ____________________
IJBODY3 ____________________
IJBODY4 ____________________

KIND OF INURY

IJKIND1 ____________________
IJKIND2 ____________________
IJKIND3 ____________________
IJKIND4 ____________________

How did {subject's name} injury(s) happen? Please describe fully the circumstances or events leading to the injury(s), and any object, substance, or other person involved.

FR: ENTER THE VERBATIM RESPONSE, PROBING FOR AS MUCH DETAIL AS POSSIBLE, INCLUDING SPECIFICALLY WHAT THE INJURED PERSON WAS DOING AT THE TIME AND ALL CIRCUMSTANCES SURROUNDING THE EVENT. RECORD ALL VOLUNTEERED INFORMATION.

IJHOW1 ____________________
IJHOW2 ____________________
IJHOW3 ____________________
IJHOW4 ____________________

FR: ENTER THE FIRST APPROPRIATE BOX WHICH DESCRIBES THE CAUSE OF THE PERSON'S INJURY FROM THE LIST BELOW.

(1) Vehicle as transportation, including motor vehicle/bicycle/motorcycle/pedestrian/train/boat/airplane(FIJ.090)
(2) Gun/being shot (FIJ.190)
(3) Fire/burn/scald related (FIJ.150)
(4) Near drowning/water in lungs (FIJ.160)
(5) Fall (FIJ.170)
(6) Other (FIJ.200)
(7) Refused (FIJ.200)
(9) Don't know (FIJ.200)

FR: THE NEXT SET OF QUESTIONS ARE ASKED TO VERIFY DETAILS OF THE CIRCUMSTANCES SURROUNDING THE INJURY(S). IF YOU ALREADY KNOW THE ANSWER BECAUSE OF THE VERBATIM RESPONSE FOR HOW THE INJURY(S) OCCURRED, VERIFY THE ANSWER WITH THE RESPONDENT. OTHERWISE, ASK THE QUESTION.

{Were/Was} {you/subject's name} injured as the driver of a vehicle, a passenger in a vehicle, a bicycle rider, or as a pedestrian?

(1) Driver of a vehicle (FIJ.100)
(2) Passenger of a vehicle (FIJ.100)
(3) Bicycle rider (FIJ.130)
(4) Pedestrian (FIJ.140)
(7) Refused (FIJ.200)
(9) Don't know (FIJ.200)

What type of vehicle {were/was} {you/subject's name} in?

(01) Passenger car (FIJ.120)
(02) Light truck (including pickups, vans and utility vehicles) (FIJ.120)
(03) Bus (FIJ.200)
(04) Large truck (FIJ.120)
(05) Motorcycles (including mopeds, minibikes) (FIJ.130)
(06) All terrain vehicle or ski/snow-mobile (FIJ.130)
(07) Farm equipment (tractor) (FIJ.200)
(08) Airplane (FIJ.120)
(09) Boat (FIJ.200)
(10) Train (FIJ.200)
(11) Other (FIJ.200)
(97) Refused (FIJ.200)
(99) Don't know (FIJ.200)

[If AGE is greater than or = to 5, ask:]
{Were/Was} {you/subject's name} wearing a safety belt at the time of the accident?

[Else, ask:]
{Were/Was} {you/subject's name} buckled in a car safety seat at the time of the accident?

(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to FIJ.200)

{Were/Was} {you/subject's name} wearing a helmet at the time of the accident?

(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to FIJ.200)

What type of vehicle {were/was} {you/subject's name} struck by?

(01) Passenger car
(02) Light truck (including pickups, vans and utility vehicles)
(03) Bus
(04) Large truck
(05) Motorcycle (including mopeds and minibikes)
(06) All terrain vehicle or ski or snow-mobile
(07) Farm equipment (tractor)
(08) Bicycle
(09) Train
(10) Boat (includes all on) water vehicles
(11) Other
(97) Refused
(99) Don't know

(Go to FIJ.200)

What was it that burned/scalded {you/subject's name}?

FR: IF RESPONSE IS FIRE OR SMOKE ASK:

What caused the fire/smoke?

(01) Cigarette, cigar, pipe
(02) Cooking unit
(03) Heater
(04) Wiring
(05) Motor vehicle battery caps, radiator caps
(06) Fireworks
(07) Other explosive
(08) Water or steam
(09) Food
(10) Chemicals
(11) Other
(97) Refused
(99) Don't know

(Go to FIJ.200)

What body of water was involved?

(1) Bathtub
(2) Swimming pool
(3) Lake, pond
(4) Bay, ocean, sea
(5) River, creek
(6) Other
(7) Refused
(9) Don't know

(Go to FIJ.200)

How did {you/subject's name} fall? Anything else?

FR: SHOW CARD F3. RECORD UP TO 2 RESPONSES. ENTER 'N' FOR NO MORE.

On or down or from:

On or down from or into:

1. Escalator
2. Stairs or steps
3. Floor/Level ground
4. Curb, including sidewalk
5. Ladder or scaffolding
6. Playground equipment
7. Building or other structure
8. Chair, bed, sofa, or other furniture
9. Tree
10. Toilet, commode
11. Bathtub, shower

Into:

12. Swimming pool
13. Hole or other opening
14. Other

(1) Escalator
(2) Stairs or steps
(3) Floor/level ground
(4) Curb, including sidewalk
(5) Ladder or scaffolding
(6) Playground equipment
(7) Building or other structure
(8) Chair, bed, sofa or other furniture
(9) Tree
(10) Toilet, commode
(11) Bathtub, shower

Into:

(12) Swimming pool
(13) Hole or other opening
(14) Other
(97) Refused
(99) Don't know

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What caused {you/subject's name} to fall? Was it due to:

(1) Slipping, tripping or stumbling
(2) Jumping or diving
(3) Collision with/pushing, shoving by another person
(4) Loss of balance/dizziness/becoming faint/seizure
(5) Or something else
(7) Refused
(9) Don't know

(Go to FIJ.200)

What kind of gun was it?

(1) Firearm (handgun, shotgun, rifle)
(2) BB or pellet gun
(3) Dart gun
(4) Other
(7) Refused
(9) Don't know

What {were/was} {you/subject's name} doing when the injury(s) happened?

FR: SHOW CARD F4. RECORD UP TO 2 RESPONSES. ENTER 'N' FOR NO MORE.

1. Driving or riding in a motor vehicle
2. Working at a paid job
3. Working around the house or yard
4. Attending school
5. Unpaid work (including housework, shopping, volunteer work)
6. Sports (organized team or individual sport such as running, biking, skating)
7. Leisure activity (excluding sports)
8. Sleeping, resting, eating, drinking
9. Cooking
10. Being cared for (hands-on care from other person)
11. Other

(1) Driving or riding in a motor vehicle
(2) Working at paid job
(3) Working around the house or yard
(4) Attending school
(5) Unpaid work (incl. housework, shopping, volunteer work)
(6) Sports (organized team or individual sport such as running, biking, skating)
(7) Leisure activity (excluding sports)
(8) Sleeping, resting, eating, drinking
(9) Cooking
(10) Being cared for (hands on care from other person)
(11) Other
(97) Refused
(99) Don't know

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Where (were/was} {you/subject's name} when the injury(s) happened?

FR: SHOW CARD F5. RECORD UP TO 2 RESPONSES. ENTER 'N' FOR NO MORE.

1. Home (inside)
2. Home (outside)
3. School (not residential)
4. Child care center or Preschool
5. Residential institution (excluding hospital)
6. Health care facility (including hospital)
7. Street/highway
8. Parking lot
9. Sport facility, athletic field or playground
10. Trade and service areas (shopping center, restaurant, store, bank, gas station)
11. Farm
12. Park/recreation area (fields, bike or jog path)
13. River/lake/stream/ocean
14. Swimming pool
15. Industrial or construction area
16. Mine/quarry
17. Other public building
18. Other

(1) Home (inside)
(2) Home (outside)
(3) School (not residential)
(4) Child care center or Preschool
(5) Residential institution (excl. hosp.)
(6) Health care facility (incl. hospital)
(7) Street/highway
(8) Parking lot
(9) Sport facility, ath. field or playground
(10) Trade and service areas (Shopping Center restaurant, store, bank, gas station)
(11) Farm
(12) Park/recreation area (fields, bike or jog path),
(13) River/lake/stream/ocean
(14) Swimming pool
(15) Industrial or construction area
(16) Mine/quarry
(17) Other public building
(18) Other
(97) Refused
(99) Don't know

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{Were/Was} {you/subject's name} hospitalized for at least one night as a result of this injury/these injuries?

(1) Yes (FIJ.250)
(2) No (Check Item FIJCCI1)
(7) Refused (Check Item FIJCCI1)
(9) Don't know (Check Item FIJCCI1)

How many nights {were/was} {you/subject's name} in the hospital?

FR: IF "STILL IN HOSPITAL," ASK HOW MANY NIGHTS UP TO TODAY.

(01-94) 1-94 nights
(95)95+ nights
(97) Refused
(99) Don't know

Check item FIJCCI1 : If AGE is greater than 13 then go to FIJ.260; Else
If AGE is greater than 4 and less than 14 then go to FIJ.270; Else
If AGE is less than 5 then return to FIJ.040 for next injury episode or next person.
If there are no more persons and no more injury episodes, go to FIJ.300.

As a result of this injury/these injuries, how much work did{you/subject's name} miss?

FR: SHOW CARD F6.

None
Less than 1 day
1 to 5 days
6 or more days
Not employed at the time of the injury/poisoning

(0) None
(1) Less than 1 day
(2) 1 to 5 days
(3) Six or more days
(6) Not employed at the time of the injury
(7) Refused
(9) Don't know

As a result of this injury/these injuries, how much school did {you/subject's name} miss?

FR: SHOW CARD F7.

None
Less than 1 day
1 to 5 days
6 or more days
Not in school at the time of the injury/poisoning

(0) None
(1) Less than 1 day
(2) One to five days
(3) Six or more days
(6) Not in school at the time of the injury
(7) Refused
(9) Don't know

As a result of this injury/theses injuries {do/does}{you/subject's name} now need the help of other persons with {your/his/her} personal care needs, such as eating, bathing, dressing or getting around this home?

(1) Yes (FIJ.285)
(2) No (FIJ.290)
(7) Refused (FIJ.290)
(9) Don't know (FIJ.290)

Do you expect {you/subject's name} will need this help for a total of 6 months or longer?

(1) Yes
(2) No
(7) Refused
(9) Don't know

As a result of this injury/these injuries {do/does} {you/subject's name} now need the help of other persons in handling routine needs such as everyday household chores, doing necessary business, shopping or getting around for other purposes?

(1) Yes (FIJ.295)
(2) No (Check Item FIJCCI1A)
(7) Refused (Check Item FIJCCI1A)
(9) Don't know (Check Item FIJCCI1A)

Do you expect {you/subject's name} will need this help for a total of 6 months or longer?

(1) Yes
(2) No
(7) Refused
(9) Don't know

(Go to Check Item FIJCCI1A)

Check item FIJCCI1A: Return to FIJ.040 for next injury episode or next person.
If there are no more persons and no more injury episodes, go to FIJ.300.