Form No Number No Number Attachment 7- Aim 2 Health Questionnaire

Form Approved:

OMB No. 0920-XXX

Exp. Date: ________

Health Questionnaire for study “Aerosol Generation by Cough”

Record Number:

Job description (circle one):

Physician Nurse Receptionist Security guard Respiratory Therapist

Do you have any symptoms of the flu? These typically include: fever (usually high), headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose, muscle aches, and sometimes stomach symptoms, such as nausea, vomiting, and diarrhea.

YES NO

Oral temperature:

Results from influenza test: Positive Negative Invalid

(Note: If a worker reports flu-like symptoms, has an oral temperature in excess of 100°F (37.8°C), or has a positive result from the rapid influenza test, they should not participate in the study).

Public reporting burden of this collection of information is estimated to average 5 minutes per response. 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; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX).