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

(1) Yes (FIJ.020)
(2) No (FAU.010)
(7) Refused (FAU.010)
(9) Don't know (FAU.010)

FR: ASK OR VERIFY. ENTER APPLICABLE LINE NUMBER(S).
ENTER (N) FOR NO MORE AFTER THE LAST NUMBER.

Who was this? (Anyone else?)

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How many different times in the PAST THREE MONTHS (were/was) (you/subject name) injured or poisoned seriously enough to seek medical advice or treatment?

IJNO3M_T Times Injured (01-94): _________

[If IJNO3M_T/FIJ.030 = 1]

Now I'm going to ask a few questions about (your/subject name)'s most recent injury/poisoning. When did it happen?

FR: SHOW CALENDAR CARD - PROBE FOR SPECIFIC DATE

IJDATE_M MONTH: _________
IJDATE_D DAY: _________
IJDATE_Y YEAR: _________

[If IJNO3M_T/FIJ.030 gt 1 and the other injuries are asked]

We just talked about (your/subject name)'s injury/poisoning on (recent injury date). When did (your/subject name)'s injury BEFORE THAT happen?

FR: SHOW CALENDAR CARD - PROBE FOR SPECIFIC DATE

IJDATE_M MONTH: _________
IJDATE_D DAY: _________
IJDATE_Y YEAR: _________

Where did (you/subject name) receive MEDICAL ADVICE OR TREATMENT for this injury/poisoning? Anywhere else?

FR: MARK ALL THAT APPLY. ENTER (N) FOR NO MORE.

(1) Did not receive medical treatment or advice (FIJ.046)
(2) Phone call to doctor or health care professional
(3) Phone call to Poison Control Center
(4) Visit to Doctor's Office
(5) Visit to Clinic or Outpatient department
(6) Visit to Emergency department
(7) Visit to Hospital (stayed at least one night) (FIJ.047)
(97) Refused
(99) Don't Know

[If IJMED not equal to 01 or 07, skip to FIJ.050]

FR: PLEASE VERIFY:

(You/subject name) DID NOT receive any medical treatment or advice for this injury/poisoning - even a phone call to a doctor's office for advice. Is that correct?

(1) Make correction
(2) Proceed

How many nights (were/was) (you/subject name) in the hospital?

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

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

[FIJ.050 to FIJ.295 are asked for each injury/poisoning episode as appropriate]

At the time, what part(s) of (your/subject name)'s body was/were hurt? What kind of injury/poisoning was it? Anything else?

FR: RECORD THE BODY PART, THEN THE KIND OF INJURY. RECORD UP TO FOUR PART/KIND COMBINATIONS. FOR POISONINGS AFFECTING THE WHOLE BODY, INDICATED "WHOLE BODY" UNDER BODY PART AND SUBSTANCE CAUSING THE POISONING UNDER KIND OF POISONING. ENTER (N) WHEN ALL ENTRIES HAVE BEEN MADE.

BODY PART

IJBODY1 _________________________
IJBODY2 _________________________
IJBODY3 _________________________
IJBODY4 _________________________

KIND OF INJURY OR POISONING

IJKIND1 _________________________
IJKIND2 _________________________
IJKIND3 _________________________
IJKIND4 _________________________

FR: VERIFY OR ASK:

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

FR: ENTER THE VERBATIM RESPONSE, PROBING FOR AS MUCH DETAIL AS POSSIBLE, INCLUDING SPECIFICALLY WHAT THE PERSON WAS DOING AT THE TIME AND ALL CIRCUMSTANCES SURROUNDING THE EVENT. RECORD ALL VOLUNTEERED INFORMATION. ENTER (N) FOR NO MORE.

IJHOW1 _________________________
IJHOW2 _________________________
IJHOW3 _________________________
IJHOW4 _________________________

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

(01) Transportation, including motor vehicle/bicycle/
motorcycle/pedestrian/train/boat/airplane (FIJ.090)
(02) Fire/burn/scald related (FIJ.150)
(03) Fall (FIJ.171)
(04) Poisoning (FIJ.195)
(05) Overexertion/strenuous movements (FIJ.200)
(06) Struck by object or person (FIJ.200)
(07) Animal or insect bite (FIJ.191)
(08) Cut/pierce (FIJ.200)
(09) Machinery (FIJ.200)
(10) Other(FIJ.200)
(97) Refused (FIJ.200)
(99) 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 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 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) Motorcycle (including mopeds, minibikes) (FIJ.130)
(06) All terrain vehicle or ski/snow mobile (FIJ.130)
(07) Farm equipment (tractor) (FIJ.200)
(08) Airplane (FIJ.200)
(09) Boat (FIJ.200)
(10) Train (FIJ.200)
(11) Other (FIJ.200)
(97) Refused (FIJ.200)
(99) Don't know (FIJ.200)

FR: VERIFY OR ASK

[If AGE is ge 5]
(Were/Was) (you/subject name) wearing a safety belt at the time of the accident?

[Else]
(Were/Was) (you/subject 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)

FR: VERIFY OR ASK:

(Were/Was) (you/subject 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 name) struck by?

(01) Passenger car
(02) Light truck (including pickups, vans, and utility vehicles)
(03) Bus
(04) Large truck
(05) Motorcycle (including mopeds, 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 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)

FR: VERIFY OR ASK. SHOW CARD F3. RECORD UP TO 2 RESPONSES:
ENTER (N) FOR NO MORE.

How did (you/subject name) fall? Anything else?

On, down, from, or into:

On or down from or into:
1. Stairs, steps or escalator
2. Floor/Level ground
3. Curb, including sidewalk
4. Ladder or scaffolding
5. Playground equipment
6. Building or other structure
7. Chair, bed, sofa or other furniture
8. Bathtub, shower, toilet or commode
9. Hole or other opening
10. Other

(01) Stairs, steps, or escalator
(02) Floor/level ground
(03) Curb, including sidewalk
(04) Ladder or scaffolding
(05) Playground equipment
(06) Building or other structure
(07) Chair, bed, sofa or other furniture
(08) Bathtub, shower, toilet, or commode
(09) Hole or other opening
(10) Other
(97) Refused
(99) Don't know
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What caused (you/subject 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 type of animal or insect bit (you/subject name)?

(01) Dog
(02) Cat
(03) Poisonous snake/reptile
(04) Nonpoisonous snake/reptile
(05) Unknown snake/reptile
(06) Poisonous insect
(07) Nonpoisonous insect
(08) Unknown insect
(09) Rodent
(10) Other
(97) Refused
(99) Don't know

(Go to FIJ.200)

FR: SHOW CARD F4.

Did (your/subject name) poisoning result from:

1. A drug or medical substance used
mistakenly or in overdose
2. A harmful or toxic solid or liquid substance
3. Inhaling gases or vapors
4. Eating a poisonous plant or other substance mistaken for food
5. A venomous animal or plant
6. Food poisoning
7. Allergic reaction
8. Something else

(01) a drug or medicinal substance used mistakenly or in overdose
(02) a harmful or toxic solid or liquid substance
(03) inhaling gases or vapors
(04) eating a poisonous plant or other substance mistaken for food
(05) a venomous animal or plant
(06) Food poisoning
(07) Allergic Reaction
(08) Something else
(97) Refused
(99) Don't know

FR: VERIFY OR ASK. SHOW CARD F5. RECORD UP TO 2 RESPONSES:
ENTER (N) FOR NO MORE.

What (were/was) (you/subject name) doing when the injury/poisoning happened?

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

(01) Driving or riding in a motor vehicle
(02) Working at a paid job
(03) Working around the house or yard
(04) Attending school
(05) Unpaid work (including housework, shopping, volunteer work)
(06) Sports (organized team or individual sport such as running, biking, skating)
(07) Leisure activity (excluding sports)
(08) Sleeping, resting, eating, drinking
(09) Cooking
(10) Being cared for (hands on care from other person)
(11) Other
(97) Refused
(99) Don't know
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[ ]

(Go to FIJ.221)

FR: VERIFY OR ASK. SHOW CARD F6. RECORD UP TO 2
RESPONSES. ENTER (N) FOR NO MORE.

Where (were/was) (you/subject name) when the injury/poisoning happened?

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. Industrial or construction area
15. Other public building
16. Other

(01) Home (inside)
(02) Home (outside)
(03) School (not residential)
(04) Child care center or Preschool
(05) Residential institution (excluding hospital)
(06) Health care facility (including hospital)
(07) Street/highway
(08) Parking lot
(09) 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) Industrial or construction area
(15) Other public building
(16) Other
(97) Refused
(99) Don't know
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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/poisoning event or next person.
If there are no more persons and no more injury/poisoning events, go to FAU.010.

FR: SHOW CARD F8.

As a result of this injury/poisoning, how much school did (you/subject name) miss?

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

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

As a result of this injury/poisoning (do/does)(you/subject 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 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/poisoning (do/does) (you/subject 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 name) will need this help for a total of 6 months or longer?

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

Check item FIJCCI1A:Return to FIJ.040 for next injury/poisoning episode or next person.
If there are no more persons and no more injury episodes, go to FAU.010.
(Go to next section--Health Care Access and Utilization.)