Name *

First Name

Last Name

Date

Please provide the date of your call to us.

MM

DD

YYYY

Time

Please note the time you called us.

Hour

Minute

Second

AM PM

Phone

Please note the phone number you called us from.

(###)

###

####

Was this the first time you have contacted the MiPDC? *

Yes

No

How did you find the National Poison Help Hotline phone number 1-800-222-1222? *

Internet

Health Care Provider

Emergency Services

Family/Friend

Billboard/Advertising

Michigan Poison & Drug Information Center webpage

Other

Did you call on behalf of yourself or for someone else? *

Self

Child

Other

If you called on behalf of someone else, what was your relationship to the patient(s)? *

Parent

Grandparent

Babysitter

Other Caregiver

Other

If your call was regarding a child, what age was the child? *

0-24 months

2 to 4 years

5 to 8 years

9 to 12 years

13 to 18 years

Unknown

Did the adult or child experiencing a poisoning emergency have any impairments that may have contributed to the poison related exposure? *

Yes

No

Unknown

Decline to answer

How long did it take before a poison center specialist answered your call? *

0-30 seconds

Less than 3 minutes

More than 3 minutes

More than 5 minutes

Did the poison center specialist provide their name when answering your call? *

Yes

No

Unknown

After speaking with the poison center specialist, was the patient referred to an emergency department? *

Yes

No

Would you call your MiPDC again if you have a poisoning emergency or need poison-related information? *

Yes

No

Unsure