Did you experience [Injury] within 24-hours after the fire or explosion? If yes, go to C2 ii. If no, repeat C2 i for next injury. If Yes, where on your body was it located? Repeat C2 i for next injury. Injury Yes No Abrasion/scrape Broken bone/fracture Bruise Cut Dislocation Sprain or strain Burn Crush injury Severe bleeding Ear drum puncture Hearing loss Ringing in ears Whiplash Concussion Bowel perforation Eye injury Any other injuries? If yes, what was it? If applicable, specify where on your body was it located? Record below. 1. 2.
General Survey Module F: Medical History Now I’m going to ask you a few questions about illnesses you may have had and the kinds of medicines you may have used. Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Medical Condition Allergies? Yes (Please specify) ______________________ No Unsure Asthma? Yes No Unsure Diabetes? Yes No Unsure High blood pressure? Yes No Unsure Chronic obstructive pulmonary disease (COPD) or emphysema? Yes No Unsure Heart Disease? Yes No Unsure Physical disability that hinders mobility? Yes (Please specify)_______________________ No Unsure Psychological condition such as anxiety, depression or dependence disorder? Yes (Please specify) ______________________ No Unsure Cancer? Yes (Please specify) _____________________ No Unsure Immune disorders such as lupus, rheumatoid arthritis, or HIV? Yes No Unsure Neurological conditions such as Parkinson’s disease or multiple sclerosis? Yes No Unsure
Fill in the table below. Ask H2 i and only check the box next to the type of information the respondent received first. Then follow-up with H2 ii for the information the respondent received first. Continue to H2 iii and check all boxes that apply and follow-up with H2 iv for each type of follow-up information the respondent received. Source of Information How did you first receive information or instructions about the incident? Check only one box. Was the information you first received timely? Was it accurate? Write yes, no, or DK (for don’t know) in the appropriate box. How did you receive follow-up information or instructions about the incident? Check all that apply. Was the information you received from [source] timely? Was it accurate? Write yes, no, or DK (for don’t know) in the appropriate box. Source of Information Timely Accurate Timely Accurate Directly from person in authority (i.e. police, firefighter, Hazmat official, supervisor) TV Radio Two-way radio Newspaper Relative/friend/neighbor/ coworker Website Reverse 911 call Phone call Text message on a cell phone Email Community Meeting Other, Specify: In the future, what are the best ways for your local authorities or the health department to reach you with information regarding a chemical incident? Check all that apply: TV Radio
To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your child’s medical records for the medical treatment (he/she) received because of the incident? Yes Review the medical records release form with the respondent and collect their signature No Child Survey Module F: Medical History Now I’m going to ask you a few questions about illnesses your child may have had and the kinds of medicines he/she may have used. Prior to the incident, have you ever been told by a doctor or other health care provider that [Child’s name] has any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Medical Condition Allergies? Yes (Please specify)___________________ No Unsure Asthma? Yes No Unsure Diabetes? Yes No Unsure High blood pressure? Yes No Unsure Physical disability that hinders mobility? Yes (Please specify)___________________ No Unsure Psychological condition such as depression? Yes (Please specify) No Unsure Cancer? Yes (Please specify) _________________ No Unsure Neurological conditions such as cerebral palsy? Yes No Unsure Developmental conditions such as ADHD/ADD or autism? Yes No