Post-exposure Questionnaire

Attachment 5

Post-exposure Questionnaire

Form Approved

OMB No. 0920-0527

Exp. Date

POST WATER ACTIVITY SURVEY

Thank you for coming back for the second part of our study for today.

Now I’m going to ask what kinds of activities you have been doing here today.

Total time in water (min)	Swim	Water ski	Jet ski	Fish	Did you put your head under the water?	Did you swallow any water?	Other: Describe
	 Y  N  DK  R	 Y  N  DK  R	 Y  N  DK  R	 Y  N  DK  R	 Y  N  DK  R	 Y  N  DK  R

Public reporting burden for this collection of information is estimated to average 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 may 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; Paperwork Reduction Project (0920-0527); M.S. D-24; 1600 Clifton Road NE, Atlanta, Ga. 30333

Great and thanks. Now, I’d like to go over the symptom questions with you again and I’d like to tell me what symptoms you have now.

Interviewer Initials:_______

Symptom or Problem	When did it start?	When did it end?	Do you still have the symptom or problem?
First I have some general health questions.
Fever  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Chills  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Headache  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Sore throat  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Ear ache  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Discharge or fluid running from ear  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Abdominal pain  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Nausea  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Vomiting  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Diarrea  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Diarrhea with blood  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Other (specify)_______________  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Now, I have a few questions about eye symptoms
Blurred Vision  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Irritation or pain  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Redness or discharge from eyes  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Conjunctivitis  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Other eye problems (specify)___________  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Now I have a few questions about breathing-related symptoms
Cough or choke  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Shortness of breath  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Nasal congestion or runny nose  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Throat irritation  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Other (specify) ___________________  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Thank you. Now, I have some questions about problems you might have with your nerves
Agitation  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Confusion  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Dizziness  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Lethargy  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Loss of consciousness  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Weakness  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Seizures  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Numbness  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Tremor  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Great. Now, just a few questions about skin problems.
Itchy skin  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Red skin  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Hives or welts  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Skin irritation/pain  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Rash (describe) ____________________  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Infected cuts or scrapes  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R
Other (specify) ____________________  Y  N  DK  R	 DK  R ____/____/____ DD MM YY	 DK  R ____/____/____ DD MM YY	 Y  N  DK  R

Thank you.

END OF ON-SITE SURVEY!

OMB Application_ Microcystins in Drinking Water.wpd Page 9