E-Scooter Survey_Updated Demographics

E-Scooter - Copy
Survey Flow
Standard: Start Block (1 Question)
Authenticator: Single Sign On - Token
EmbeddedData
hospnameValue will be set from Panel or URL.
injurydateValue will be set from Panel or URL.
passwordValue will be set from Panel or URL.
tknoValue will be set from Panel or URL.
Standard: Introductory Block (5 Questions)
Standard: Item Verification Block (11 Questions)
Standard: Incident Block (12 Questions)
Standard: Scooter Characteristics Block (11 Questions)
Standard: Closing Block (5 Questions)
Standard: Updated Demographics (2 Questions)
Standard: Submit Message Block (1 Question)
Standard: submit block (0 Questions)
Page Break

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Start of Block: Start Block
start
Note: The OMB Control Number for this collection is 3041-0029
Interviewer instructions: In this questionnaire, please read the response categories unless
indicated otherwise, or unless necessary for prompting the respondent to answer the question.
Italicized words are meant to serve as a guide to emphasis.

Hello, I'm_______________[interviewer's name] from ______________________
[interviewer's company]. We are working with the U.S. Consumer Product Safety Commission
(CPSC). CPSC collects data through the National Electronic Injury Surveillance System
(NEISS) on injuries treated in hospital emergency departments. CPSC conducts follow-up
investigations with a small number of people to learn more about how the injury occured. The
results of these investigations will be used to determine if similar injuries can be prevented in
the future.
Your participation in this survey is completely voluntary and your identity and answers will be
strictly confidential. This survey will take between 10-15 minutes and data are used for
statistical purposes only. The following information is needed to continue: 1. Investigation
Task Number 2. Randomly generated password To continue, you will have to enter the task
number correctly on the next page:

End of Block: Start Block
Start of Block: Introductory Block
I1
CPSC would prefer that the person who answers this questionnaire is the actual person injured
and treated in the hospital emergency department. If the injured person is under the age of 16,
CPSC would prefer that a parent or guardian completes the questionnaire.
Was the injured person 16 years old or older? Interviewer instruction: If the respondent
answers that they are the injured person and they are under 16, please ask to speak to a parent
or guardian. If no one is available, it is okay to interview the under 16 year old.

o Yes (1)
o No (2)
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I2 According to our records from the National Electronic Injury Surveillance System the injured
person was seen on ${e://Field/injurydate} in the emergency department
at ${e://Field/hospname} for an injury that involved a scooter. Is that correct?

o Yes (1)
o No (2)
o Don't know (3)
Skip To: End of Block If According to our records from the National Electronic Injury Surveillance System
the injured pers... = Don't know
Skip To: End of Block If According to our records from the National Electronic Injury Surveillance System
the injured pers... = Yes

I3 What information is incorrect from the statement above?

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Different date (1)
Different hospital (2)

⊗

(I/the victim) did not receive treatment in a hospital emergency department
for a scooter injury (3)
Skip To: End of Survey If What information is incorrect from the statement above? = (I/the victim) did not
receive treatment in a hospital emergency department for a scooter injury
Display this question:
If What information is incorrect from the statement above? = Different date

I4 What is the correct date?
________________________________________________________________

Display this question:
If What information is incorrect from the statement above? = Different hospital

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I5 Where did (you / the victim) receive treatment for (your / their) injury?
________________________________________________________________
End of Block: Introductory Block
Start of Block: Item Verification Block
V1 Are you the:

o Injured person (1)
o Parent or guardian of injured person (2)
o Other (specify in next window) (3)
Skip To: V3 If Are you the: = Injured person
Skip To: V3 If Are you the: = Parent or guardian of injured person
Display this question:
If Are you the: = Other (specify in next window)

V2 Specify relationship:
________________________________________________________________

Display this question:
If Are you the: = Injured person
Or Are you the: = Parent or guardian of injured person
Or Or Specify relationship: Text Response Is Not Empty

V3 Was the scooter unpowered (e.g., a kick scooter or push scooter)?
Interviewer instruction: Powered scooters have a power source like electric or gas.

o Yes (1)
o No (2)
o Don't know (4)
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Skip To: V10 If Was the scooter unpowered (e.g., a kick scooter or push scooter)? Interviewer instruction:
Powere... = Yes
Display this question:
If Was the scooter unpowered (e.g., a kick scooter or push scooter)? Interviewer instruction:
Powere... = No
Or Was the scooter unpowered (e.g., a kick scooter or push scooter)? Interviewer instruction:
Powere... = Don't know

V4 Was the scooter an assisted mobility scooter to help people with physical limitations?

o Yes (1)
o No (2)
Skip To: End of Block If Was the scooter an assisted mobility scooter to help people with physical
limitations? = Yes

V5 Was the scooter a moped, motorcycle, or scooter that requires a registration or license?

o Yes (1)
o No (2)
Skip To: End of Block If Was the scooter a moped, motorcycle, or scooter that requires a registration or
license? = Yes

V6 Did the scooter have handles for steering?
Interviewer instruction: Handles for steering are distinct from handles used for balancing
purposes.

o Yes (8)
o No (9)
Skip To: End of Block If Did the scooter have handles for steering? Interviewer instruction: Handles for
steering are dist... = No

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V7 If your scooter had only two wheels, were those wheels side-by-side? Interviewer
instruction: side-by-side wheels are distinct from wheels that are one in front of the other.

o Yes (1)
o No (2)
Skip To: End of Block If If your scooter had only two wheels, were those wheels side-by-side?Interviewer
instruction: side... = Yes

V8 What kind of power did the scooter run on?

o Gas (1)
o Electric (2)
o Other (specify in next window) (3)
Skip To: V10 If What kind of power did the scooter run on? = Gas
Skip To: V10 If What kind of power did the scooter run on? = Electric
Display this question:
If What kind of power did the scooter run on? = Other (specify in next window)

V9 Specify.
________________________________________________________________

V10 You/the victim were/was:
Interviewer instruction: If two scooters collided select "Riding the scooter."

o Riding the scooter (1)
o Struck by scooter (2)
o Other (specify) (3)
Page 6 of 17

Skip To: End of Block If You/the victim were/was: Interviewer instruction: If two scooters collided select
"Riding the sco... = Riding the scooter
Skip To: End of Block If You/the victim were/was: Interviewer instruction: If two scooters collided select
"Riding the sco... = Struck by scooter

V11 Specify.
________________________________________________________________
Skip To: End of Block If Condition: Specify. Is Not Empty. Skip To: End of Block.

End of Block: Item Verification Block
Start of Block: Incident Block
A1 Please describe how the accident happened. That is, what were you/the victim doing just
before, during, and just after the injury occurred? Please specify the location of the accident and
any environmental factors; such as weather, temperature, and anything else that may have
contributed to the accident.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Display this question:
If If Please describe how the accident happened. That is, what were you/the victim doing just before,
d... Text Response Is Not Empty
And If
Was the scooter an assisted mobility scooter to help people with physical limitations? = No
And Was the scooter a moped, motorcycle, or scooter that requires a registration or license? = No
And Did the scooter have handles for steering? Interviewer instruction: Handles for steering are dist...
= Yes
And If your scooter had only two wheels, were those wheels side-by-side?Interviewer instruction:
side... = No

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A2 Next, I am going to ask some specific questions about the incident that you may have
already described. Please bear with me as I collect this information from you.

Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

A3 What type of surface were you/the victim on?

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Paved Road (1)
Paved Sidewalk (2)
Gravel (3)
Grass (4)
Driveway (5)
Other (specify in next window) (6)

⊗Don't know

(7)

Display this question:

If What type of surface were you/the victim on? = Other (specify in next window)

A4 Specify.
________________________________________________________________

Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

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A5 Was it dark or difficult to see?

o Yes (1)
o No (2)
o Don't know (3)
Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

A6 Was there anything else occurring at the time of the accident such as music, cell phone
interference, or loud music?

o Yes (1)
o No (2)
o Don't know (3)
Display this question:
If Was there anything else occurring at the time of the accident such as music, cell phone interfere...
= Yes

A7 Please specify the additional factors.
________________________________________________________________

Display this question:
If You/the victim were/was: Interviewer instruction: If two scooters collided select "Riding the sco... =
Riding the scooter
And And Next, I am going to ask some specific questions about the incident that you may have
already desc... Displayed

Page 9 of 17

A8 Were/was you/the victim carrying or holding something such as a bag, purse, or backpack?

o Yes (1)
o No (2)
o Don't know (3)
Display this question:
If Were/was you/the victim carrying or holding something such as a bag, purse, or backpack? = Yes

A9 What were/was you/the victim carrying?
________________________________________________________________

Display this question:
If You/the victim were/was: Interviewer instruction: If two scooters collided select "Riding the sco... =
Struck by scooter
And And Next, I am going to ask some specific questions about the incident that you may have
already desc... Displayed

A10 Which of the following best describes how you were injured?

o Hit from the front (1)
o Hit from the side (2)
o Hit from behind (3)
o Other (specify in next window) (4)
o Don't know (5)
Display this question:
If Which of the following best describes how you were injured? = Other (specify in next window)

A11 Specify.
________________________________________________________________

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Display this question:
If You/the victim were/was: Interviewer instruction: If two scooters collided select "Riding the sco... =
Struck by scooter
And And Next, I am going to ask some specific questions about the incident that you may have
already desc... Displayed

A12 Was there any warning before you/the victim were/was hit? (ex. bell, shouting, or other
noise)

o Yes (1)
o No (2)
o Don't know (3)
End of Block: Incident Block
Start of Block: Scooter Characteristics Block
Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

S1 Which of the following best describes the scooter?

o Rental (1)
o Owned by victim (2)
o Borrowed (3)
o Other (specify in next window) (4)
o Don't know (5)
Display this question:
If Which of the following best describes the scooter? = Other (specify in next window)

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S2 Specify.
________________________________________________________________

Display this question:
If Which of the following best describes the scooter? = Rental

S3 Who was the scooter rented from?
________________________________________________________________

Display this question:
If Which of the following best describes the scooter? = Borrowed
Or Which of the following best describes the scooter? = Owned by victim
Or Or Specify. Text Response Is Not Empty
Or Or Who was the scooter rented from? Text Response Is Not Empty
Or Which of the following best describes the scooter? = Don't know

S4 Do you know the brand and model names of the scooter involved in the injury?

o Yes (1)
o No (2)
Skip To: S7 If Do you know the brand and model names of the scooter involved in the injury? = No
Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

S5 Specify brand
________________________________________________________________

Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

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S6 Specify model (if brand is known but model is not, enter unknown below)
________________________________________________________________
Skip To: S10 If Condition: Specify model (if brand is ... Is Not Empty. Skip To: I'm going to read a list of
safety eq....
Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

S7 It is very important for us to know what brands are involved in these injuries. If I hold on,
would you be willing to go look at the scooter and tell me what the brand and model names are?

o Yes (1)
o No (2)
Skip To: S10 If It is very important for us to know what brands are involved in these injuries. If I hold on,
wou... = No
Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

S8 Specify brand
________________________________________________________________

Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

S9 Specify model (if brand is known but model is not, enter unknown below)
________________________________________________________________

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Display this question:
If If Specify model (if brand is known but model is not, enter unknown below) Text Response Is Not
Empty
Or Do you know the brand and model names of the scooter involved in the injury? = Yes
No

Or It is very important for us to know what brands are involved in these injuries. If I hold on, wou... =

S10 I'm going to read a list of safety equipment that riders might wear. Please tell me if the rider
was wearing any of these at the time of the incident.
Interviewer instruction: Select all that apply

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Helmet (1)
Knee pads (2)
Elbow pads (3)
Wrist pads (4)
Reflective vest (5)
Blinking lights/Head lamp (6)
Other (specify in next window) (7)

⊗None of the above

(8)

Display this question:

If I'm going to read a list of safety equipment that riders might wear. Please tell me if the rider... =
Other (specify in next window)

S11 Specify.
________________________________________________________________
End of Block: Scooter Characteristics Block
Start of Block: Closing Block

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Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

C1 Is there anything else about this accident or the scooter involved that you would like me to
know?

o Yes (1)
o No (2)
Display this question:
Yes

If Is there anything else about this accident or the scooter involved that you would like me to know? =

C2 Explain.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Display this question:
If Next, I am going to ask some specific questions about the incident that you may have already
desc... Displayed

C7 We may be interested in sending a CPSC investigator to your home to gather more
information about how the accident occurred and take pictures of the scooter. This investigation
would be set up at your convenience. May we have an investigator contact you by phone to
setup a visit?

o Yes (1)
o No (2)
Skip To: End of Block If We may be interested in sending a CPSC investigator to your home to gather
more information about... = No

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Display this question:
If We may be interested in sending a CPSC investigator to your home to gather more information
about... = Yes

C8 Please supply your phone number.
________________________________________________________________

Display this question:
If We may be interested in sending a CPSC investigator to your home to gather more information
about... = Yes

C9 When is a good time to call? (Check all that apply.)

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Morning (1)
Afternoon (2)
Evening (3)

End of Block: Closing Block
Start of Block: Updated Demographics
Q1 The following race and ethnicity questions will help the U.S. Consumer Product Safety
Commission better focus outreach and education efforts related to product safety.

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Q2 What is your race and/or ethnicity? select all that apply and enter additional details in the
spaces below.

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American Indian or Alaska Native For example: Navajo Nation, Blackfeet Tribe
of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional
Government, Nome Eskimo Community, Aztec, Maya, etc. (1)

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Asian For example: Chinese, Asian Indian, Filipino, Vietnamese, Korean,
Japanese, etc. (2)

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Black or African American For example: African American, Jamaican, Hatian,
Nigerian, Ethiopian, Somali, etc. (3)

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Hispanic or Latino For example: Mexican, Puerto Rican, Salvadoran, Cuban,
Dominican,Guatemalan, etc. (4)

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Middle Eastern or North African For example: Lebanese, Iranian, Egyptian,
Syrian, Iraqi, Israeli, etc. (5)

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Native Hawaiian or Pacific Islander For example: Native Hawaiian, Samoan,
Chamorro, Tongan, Fijian, Marshallese, etc. (6)

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White For example: English, German, Irish, Italian, Polish, Scottish, etc. (7)
Refused/Prefer not to answer (9)

End of Block: Updated Demographics
Start of Block: Submit Message Block
Q57 Interviewer Instructions: You have reached the end of the survey. If you wish to come
back and edit later, exit the survey by closing the browser window. Click 'Submit' to complete
the survey. Once you click submit, you will no longer be able edit responses.
End of Block: Submit Message Block
Start of Block: submit block

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