Form 1 Survey Instrument

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

APPENDIX 2: SURVEY INSTRUMENTS

Enumerator Initials ______ Household ID#______ Participant ID# ______

Serologic Survey ENGLISH Questionnaire

(NOTE: Questionnaire will be translated into Haitian Creole for use in the field)

Elicit answers from [name of case].

• IF ADULT—Read the consent form and proceed to Q.1 if the person agrees to participate.

• IF 7-17 YEARS OLD—Ask to speak with the parent or guardian, read the parent/guardian the parental consent form, read the child the assent form, and proceed to Q1if they agree to participate.

• IF 2-6 YEARS OLD— Ask to speak with the parent or guardian, read the parent/guardian the parental consent form, and proceed to Q1if they agree to participate.

**Note to Enumerators**

If the participant is a child between the ages of twelve and seventeen, please ask the parent or guardian if they will permit the child to answer questions for themselves. If the parent or guardian does not give permission, the parent or guardian will answer the questions. The parent or guardian will answer questions for children under twelve years old.

VAR
	Who is answering the questions? Participant Parent/Guardian (If the participant’s parent or guardian is answering questions, please insert “your child” into questions when appropriate.)
	Sex of the participant 1. Male 2. Female
	How old are you (is your child)? ______(years) 77. Refused 99. Don’t Know
	How many people live in this household? ______ 77. Refused 99. Don’t Know
	In the last four months (since the start of the cholera outbreak), have you (has your child) been sick with watery diarrhea? 1. Yes 0. No  skip to Q15 77. Refused 99. Don’t know
	On the day you were most ill, how many stools did you (your child) have in a 24 hour period? (Do not read, circle one) Less than 3 stools/day 3–6 stools/day 7–12 stools/day More than 12 stools/day 77. Refused Don’t know
	Did you (your child) drink ORS rehydrating solution at home? 1. Yes 0. No 77. Refused 99. Don’t know

Public reporting burden of this collection of information is estimated to average 20 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

8. Did your (your child’s) stool appear like rice water?

1. Yes 0. No 77. Refused 99. Don’t know

9. Did your (your child’s) stool appear bloody?

1. Yes 0. No 77. Refused 99. Don’t know

10. Date of first watery diarrhea: ____(day)/____(month)/2010

77. Refused 99. Don’t know

11. In the last four months (since the start of the cholera outbreak) did you (or your child) visit a health center or hospital because of watery diarrhea?

1. Yes

0. No  skip to Q15

77. Refused

99. Don’t know

12. Date Admitted to Hospital (if admitted): ____(day)/____(month)/2010

77. Refused 99. Don’t know

13. Did you (your child) receive ORS rehydrating solution at the treatment center?

1. Yes 0. No 77. Refused 99. Don’t know

14. Did you (your child) receive intravenous fluids at the treatment center?

1. Yes 0. No 77. Refused 99. Don’t know

15. In the last four months (since the start of the cholera outbreak), have you (your child) taken antibiotics)?

1. Yes 0. No 77. Refused 99. Don’t know

16. If you took antibiotics, when did you (your child) take them? ____(day)/____(month)/2010

77. Refused 99. Don’t know (approximate date)

17. In the last four months (since the start of the cholera outbreak), have you (has your child) taken medicines for heartburn or to decrease stomach acid?

1. Yes 0. No 77. Refused 99. Don’t know

18. In the last four months (since the start of the cholera outbreak), have you (or your child) been told by a health care worker that you had cholera (i.e. diarrhea)?

1. Yes

0. No

77. Refused

99. Don’t know

19. (If a woman), Are you pregnant?

1. Yes 0. No 77. Refused 99. Don’t know

20. Have you (your child) ever been told that you have HIV or AIDS?

1. Yes 0. No 77. Refused 99. Don’t know

21. Have you (your child) ever been told that you have a condition that weakens your immune system?

1. Yes 0. No 77. Refused 99. Don’t know

22. Has anyone in the house died of cholera in the last four months (since the start of the cholera outbreak)?

1. Yes  next question

0. No  skip to Q24

77. Refused

99. Don’t Know

I’m very sorry to hear that…

23. What was his/her age? ______(years)

77. Refused 99. Don’t know

24. What is your (your child’s) relationship to the person who died from cholera (i.e., diarrhea) (circle one)

1. Spouse

2. Parent

3. Child

4. Sibling

88. Other (specify) ________________

77. Refused

99. Don’t know

25. What was the last year of school you (your child) completed? (circle one)

1. None

2. Some primary school

3. Completed primary school

4. Some secondary school

5. Completed secondary school

6. Any trade school/university

77. Refused

88. Other (specify) ______________

99. Don’t know

26. Can you (your child) read?

1. Yes 0. No 77. Refused

27. Do you (Does your child) speak French?

1. Yes 0. No 77. Refused

28. What is your (your child’s) occupation? (circle one)Student

1. Student

2. Child (not in school)

3. Gardener/farmer (not in rice field)

4. Work in rice field

5. Fisherman

6. Teacher

7. Health Care Worker

88. Other (specify) ______________________

77. Refused

99. Don’t know

29. Does your household own any of the following items? (ANSWER EACH QUESTION)

	1. Yes	0. No	77. Refused	99. Don’t know
Working Radio				
Working Motorcycle/Moped				
Working Electricity				
Working Mobile telephone				
Cow				
Donkey/Mule				
Goat				
Horse				

Thank you very much for your participation.

House GPS Coordinates [TO BE USED ONLY IN PROSPECTIVE SURVEY FOR FOLLOW-UP]

N:_____________________________________ W:______________________________________________

Enumerator Initials ______ Household ID#______ Participant ID# ______

Follow Up Serologic Survey ENGLISH Questionnaire

(NOTE: Questionnaire will be translated into Haitian Creole for use in the field)

Thank you again for your participation in this study. We have a few last questions. All questions in this survey today will ask about things that happened since our last visit with you.

**Note to Enumerators**

If the participant is a child between the ages of twelve and seventeen, please ask the parent or guardian if they will permit the child to answer questions for themselves. If the parent or guardian does not give permission, the parent or guardian will answer the questions. The parent or guardian will answer questions for children under twelve years old.

VAR
	Who is answering the questions? Participant Parent/Guardian (If the participant’s parent or guardian is answering questions, please insert “your child” into questions when appropriate.)
	Since our visit two weeks ago, have you (has your child) been sick with watery diarrhea? 1. Yes 0. No  skip to Q12 77. Refused 99. Don’t know
	On the day you were most ill since our visit two weeks ago, how many stools did you (your child) have in a 24 hour period? (Do not read, circle one) Less than 3 stools/day 3–6 stools/day 7–12 stools/day More than 12 stools/day 77. Refused Don’t know
	Did you (your child) drink ORS rehydrating solution at home? 1. Yes 0. No 77. Refused 99. Don’t know
	Did your (your child’s) stool appear like rice water? 1. Yes 0. No 77. Refused 99. Don’t know
	Did your (your child’s) stool appear bloody? 1. Yes 0. No 77. Refused 99. Don’t know
	Date of first watery diarrhea: ____(day)/____(month)/2010 77. Refused 99. Don’t know

Public reporting burden of 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

	Since our visit two weeks ago, did you (or your child) visit a health center or hospital because of watery diarrhea? 1. Yes 0. No  skip to Q12 77. Refused 99. Don’t know
	Date Admitted to Hospital (if admitted): ____(day)/____(month)/2010 77. Refused 99. Don’t know
	Did you (your child) receive ORS rehydrating solution at the treatment center? 1. Yes 0. No 77. Refused 99. Don’t know
	Did you (your child) receive intravenous fluids at the treatment center? 1. Yes 0. No 77. Refused 99. Don’t know
	Have you (your child) taken antibiotics since our visit two weeks ago? 1. Yes 0. No 77. Refused 99. Don’t know
	If you took antibiotics, when did you (your child) take them? ____(day)/____(month)/2010 77. Refused 99. Don’t know (approximate date)
	Have you (has your child) taken medicines for heartburn or to decrease stomach acid since our visit two weeks ago? 1. Yes 0. No 77. Refused 99. Don’t know
	Since our visit two weeks ago, have you (or your child) been told by a health care worker that you had cholera (i.e. diarrhea)? 1. Yes 0. No 77. Refused 99. Don’t know
	Has anyone in the house died of cholera since our visit two weeks ago? Yes  next question 0. No  go to end 77. Refused 99. Don’t Know
	I’m very sorry to hear that… What was his/her age? ______ (years) 77. Refused 99. Don’t know
	What is your (your child’s) relationship to the person who died from cholera (i.e., diarrhea) (circle one) Spouse Parent Child Sibling 77. Refused 88. Other (specify) ________________ 99. Don’t know

Thank you very much for your participation.