Module E: Medical Care Received Did you or anyone in your family receive medical care or a medical evaluation because of the incident? Yes Go to Question E3 No Why didn’t you or your family members seek medical Ask only if someone had symptoms: care? Record answer, then go to Question F1 Symptoms were not bad enough Don’t like to go to the doctor Didn’t want to take time Worried about who would pay for the medical visit Worried about losing job Other (Please specify): ______________________________________________ Unsure For each person who received medical care, please tell me the person’s name, where they received care, and the date. Please include medical evaluations by emergency medical services or EMTs, hospitals, and doctor’s offices. Name Where Received Care Date Was [name] treated and released from the emergency If a hospital was named, ask: department or hospitalized? How long was [he/she] hospitalized? If hospitalized, ask: Treated and Duration of Name Hospitalized Released Hospitalization
Module E: Medical Care Received Did you or anyone in your family receive medical care or a medical evaluation because of the incident? Yes Go to Question E3 No Ask only if someone had symptoms: Why didn’t you or your family members seek medical care? Record answer, then go to Question F1 Symptoms were not bad enough Don’t like to go to the doctor Didn’t want to take time Worried about who would pay for the medical visit Worried about losing job Other (Please specify): ______________________________________________ Unsure For each person who received medical care, please tell me the person’s name, where they received care, and the date. Please include medical evaluations by emergency medical services or EMTs, hospitals, and doctor’s offices. Name Where Received Care Date If a hospital was named, ask: Was [name] treated and released from the emergency department or hospitalized? If hospitalized, ask: How long was [he/she] hospitalized? Name Treated and Released Hospitalized Duration of Hospitalization