Form assigned Appendix 2_CATI screener script

Survey of Residential Fire Injury Incidents

Page 1
Form Approved: xx-xx-xxxx
OMB No: 0920-xxxx
Expiration Date: xx-xx-xxxx

Screener Call Script
CASE ID................................................
START TIME...........................................

:

AM
PM

May I speak with (NAME FROM FIRE REPORT) or another adult in the (LAST NAME) household? IF NONE FROM FIRE
HOUSEHOLD AVAILABLE, ASK: When would be a good time to reach someone from the (LAST NAME) household?
RECORD DAYS/TIMES.

Good (morning/afternoon/evening), my name is ___________________. I was referred to your household from the
fire department’s report about the fire that occurred in your home. I am calling from Battelle on behalf of the Centers
for Disease Control and Prevention and the National Center for Injury Prevention and Control. Battelle is working with
CDC to conduct a study to learn more about ways to reduce the risk of injury in fires. I would like to ask you a few
questions to determine if any members of your household are eligible to participate in the study. This will only take
about 5 minutes. You will not have to answer any question you do not wish to answer. Participation in the study is
voluntary and all of your responses are confidential. For quality assurance purposes, my supervisor may monitor this
call.
1.

I want to confirm that the date of the fire was (DATE).
Is this correct?

A.

What is the correct date?

YES ................................. (SKIP TO 2) .................................... 1
NO.......................................(ASK A) ....................................... 2
DK ................................... (SKIP TO 2) .................................... 7
RF ................................... (SKIP TO 2) .................................... 8

DATE .................................

MM

DD

YY

IF DATE IS > 1 MONTH AGO, SKIP TO Q13

2.

I also need to confirm that your home is a (single family
dwelling/low rise multi-family dwelling). Is that right?

YES ................................. (SKIP TO 3) .................................... 1
NO......................................(ASK 2A) ...................................... 2
DK ......................................(ASK 2A) ...................................... 7
RF ................................... (SKIP TO 3) .................................... 8

A. What type of dwelling did the fire occur in?

SINGLE FAMILY DETACHED ................................................. 1
LOW-RISE MULTI-FAMILY ..................................................... 2
OTHER TYP OF BUILDING ................(SKIP TO 13).............. 3

Public Reporting burden of this collection of information is estimated at 15 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 many 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 NW, MS D-74,
Atlanta, GA 30333; Attn: PRA (0920-XXXX).

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Survey of Residential Fire Injury Incidents

3.

Page 2

Would you tell me who normally lives in your household starting with yourself, and then the rest of the
household, beginning with the youngest and going to the oldest person? I’d like to know their first name, how
they are related to you, their age, and gender. The names you tell me are just to help us keep track of which
person we are discussing in the rest of the questions, so nicknames or first names are fine. Let’s start with you.
I.
What is the first
name? FOR R,

II.
What is (NAME)’s
relationship to you?

RECORD W/O
ASKING.

FOR R, RECORD 0
W/O ASKING.

III.
What is
your/
(NAME)’s
age?
(IF <1,

IV.
What is
(NAME)’s
gender? FOR R,
RECORD W/O
ASKING.

RECORD
MOS.)

YRS/MOS

1.

YRS

_____________________
____________________

2.

____________________

3.

____________________

4.

____________________

5.

____________________

6.

____________________

7.

____________________

8.

____________________

9.

____________________

10.

____________________

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

MOS
YRS

_____________________

NO

MOS
YRS

_____________________

YES

MOS
YRS

_____________________

NO

MOS
YRS

_____________________

YES

MOS
YRS

_____________________

FEMALE

MOS
YRS

_____________________

MALE

MOS
YRS

_____________________

ONLY ASK
OF 18 AND
OLDER.

MOS
YR

_____________________

VI.
Were
you/Was
(NAME)
treated for
an injury in
the fire?

MOS
YRS

_____________________

V.
Were
you/Was
(NAME)
home at the
time of the
fire?

MOS

RELATIONSHIP CODES:
0= SELF
1 = SPOUSE
2 = CHILD
3 = PARENT
4 = GRANDPARENT

5 = OTHER RELATIVE
6 = SIGNIFICANT OTHER
7 = FRIEND
8 = ROOMMATE/ BOARDER
9 = OTHER (SPECIFY

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Survey of Residential Fire Injury Incidents
A.

RECORD THE LINE NUMBER OF THE DESIGNATED
CASE (18 AND OLDER AND INJURED). IF MORE THAN
ONE ADULT WAS INJURED IN THE FIRE, PROBE: Who

Page 3
LINE NUMBER OF CASE ...................................................

was the most seriously injured adult in the fire?
IF EQUALLY INJURED, PROBE: Which of the injured
had their birthday most recently?
IF ONLY 1 ADULT PRESENT DURING FIRE AND NOT
INJURED, RECORD LINE NUMBER. IF MORE THAN 1
ADULT PRESENT, PROBE: Which of the adults present

in the household during the fire had the most recent
birthday?
RECORD LINE NUMBER. THIS IS THE RESPONDENT.

4.

Were there visitors staying at the house at the time of the
fire? That is, someone who doesn’t normally live in the
home?

YES .......................................................................................... 1
NO .................................. (SKIP TO 5)...................................... 2
DK................................... (SKIP TO 5)...................................... 7
RF................................... (SKIP TO 5)...................................... 8

A.

YES .......................................................................................... 1
NO ............................................................................................ 2

Were any of the visitors injured in the fire?

PROGRAMMER NOTE: If eligible R is person the interviewer is speaking with, skip to 9. (3A=1.)

5.

I have determined that (NAME) is eligible to participate in
the study. (Is he/she) available to schedule a time for
the survey?

YES............................... (SKIP TO 10) .....................................1
NO...................................... (ASK 6) .........................................2

INTERVIEWER NOTE: If (NAME) is hospitalized or too ill for interview, select next most injured person.

6.

When would be a good time to reach (NAME)?

DATE: .............................................................
MONTH
-

TIME: .......................................................

DAY
AM
PM

7.

Is there a better phone number to use to contact
(NAME)?

YES.................................... (ASK 8) .........................................1
NO................................. (SKIP TO 12) .....................................2

8.

What is that number?

PHONE # ..............

-

-

SKIP TO 12.

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Survey of Residential Fire Injury Incidents

9.

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I have determined that you are eligible to participate in the study. We are currently conducting a study to learn
more about ways to reduce the risk of injury in fires that occur in people’s homes. The study consists of a
survey that is administered in person by a trained interviewer who will travel to your home to do the survey.
The survey itself takes about 60 minutes. Your answers to these few questions will provide vital information on
the actions of people in household fires, and help to develop public health programs to reduce injuries that
occur in home fires. Participation in the study is voluntary and all of your responses are confidential. We will
provide a $25.00 money order upon completion of the interview to thank you for your time, and for participation
in the study. I will arrange an interview with you at a time and place that is convenient for you. Since our
interviewer will have to arrange to travel to your home to conduct the interview, I would like to arrange for a
time when it would be convenient for her to call you to set up the interview. When would be a convenient time
for the interviewer to give you a call to set up an appointment? RECORD BELOW.
DATE ..............................................................
MONTH
TIME ........................................................

-

DAY
AM
PM

NOTES: __________________________________________
_________________________________________________
_________________________________________________
SKIP TO 14.

IF UNABLE TO SPEAK WITH R DURING THE INITIAL SCREENING, THEN #10 WILL BE COMPLETED BY THE
INTERVIEWER HIM/HERSELF, WHEN CALLING TO SET UP APPOINTMENT.

10.

Hello. I was were referred to your household by a report compiled by the fire department after the fire in your
home. Earlier, I spoke with (NAME OF R), and I determined that you are the member of your household who is
eligible to participate in this study. I am calling on behalf of the National Center for Injury Prevention and Control
at the Centers for Disease Control and Prevention. We are currently conducting a study to learn more about ways
to reduce the risk of injury in fires that occur in people’s homes. The study consists of a survey that is
administered in person by a trained interviewer who will travel to your home to do the survey. The survey itself
takes about 60 minutes. Your answers to these few questions will provide vital information on the actions of
people in household fires, and help to develop public health programs to reduce injuries that occur in home fires.
Participation in the study is voluntary and all of your responses are confidential. I will provide a $25.00 money
order upon completion of the interview to thank you for your time and participation in the study. We will arrange
an interview with you at a time and place that is convenient for you. When would be a convenient time for the
interviewer to give you a call to set up an appointment? RECORD BELOW.
DATE ..............................................................
MONTH
TIME ........................................................

-

DAY
AM
PM

LOCATION: _______________________________________
_________________________________________________
_________________________________________________

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Survey of Residential Fire Injury Incidents

Page 5

11.

Thank you for your help with this very important project We will send you a letter reminding you about your
appointment. Someone will also call you a couple of days before the interview to confirm the time and place. In
the meantime if you have any questions about this project, you can call Kathy Tiefenwerth, Study Leader for
the project at 410-377-5660 or 1-800-777-6115. If you have any questions about your rights as a study
subject, please call Dr. Margaret Pennybacker at 1-877-810-9530, ext. 500. If you need to change your
appointment date or time, please call us back at 1-800-777-6115, and ask for Ms. Fields. END CALL.

12.

Thank you for your time and help. We will get in touch with (NAME) to discuss (his/her) participation in the
study. END CALL.

13.

Thank you for your time and help. No one in your household is eligible to participate in this study. We
appreciate your cooperation. Goodbye. END CALL.

14.

Thank you for your time and help. The interviewer will get in touch with you to set up a specific time to conduct
the interview. In the meantime if you have any questions about this project, you can call Kathy Tiefenwerth,
Study Leader for the project at 410-377-5660 or 1-800-777-6115. If you have any questions about your rights
as a study subject, please call Dr. Margaret Pennybacker at 1-877-810-9530, ext. 500. END CALL.

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