10-Day Post-exposure Questionnaire

Attachment 6

10-day Post-exposure Questionnaire

Form Approved

OMB No. 0920-0527

Exp. Date

TELEPHONE INTERVIEW 10-14 DAYS FOLLOWING INITIAL INTERVIEW

Hello, this is _________________ calling from (name of institution). May I speak with (Name of Contact Person from initial interview)?

About ___ days ago we spoke with you at (name of recreational area) and asked if you (your child/children) had been in the water on that day. We told you we’d be calling back to ask about your (your child/children) health. Is this a good time to talk?

I’ll be reading a list of symptoms or health problems and want to know if you or anyone else in the family who was in the water that day has experienced them. If you’ve had any of the symptoms, I’ll also ask about when they started and ended and if you’ve taken any medicine or seen a doctor about them.

Interviewer Initials:_______

Date:_______________

Since your visit to (Recreational area), have you experienced any of the following symptoms or problems?

Public reporting burden for this collection of information is estimated to average 10 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

Symptom or Problem	When did it start?	When did it end?	Do you still have the symptom or problem?
First I have a list of some general health symptoms.
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
Diarrhea  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, that’s all. We appreciate you being a part of the study.

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