In-person survey of traveler intercepted at the airport

Form Approved

OMB No. 0920-0932

Expires 05/31/2015

Appendix A: In-person survey of traveler intercepted at the airport

1. General Introduction

Hello, my name is __________ and I am working with the Centers for Disease Control and Prevention. I know you must be tired from your trip but we would like to ask you just a few questions about the Ebola screening process. It should take less than 10 minutes. Would you be willing to talk with me for a few minutes to help us better understand your experience?

Are you over 18 years of age? [If over the age of 18, continue with the interview if they agree to participate. If they are under the age of 18 or do not agree to participate, thank them for their time stop the interview.]

2. Introduction

Great! Thank you for being willing to sharing your opinions with me. Your opinions will help us improve the process. Before I begin I want to go over a couple of items:

• This survey is voluntary. You do not have to answer any question that you don’t want to answer. You can decline to answer any question. You can stop the interview at any time for any reason.

• There are no right or wrong answers. This is not a test. I am interested in your opinion. If you don’t understand the question, let me know and I can ask it another way.

• The information you provide today will be kept confidential, which means we will not link your answers to your name in any written reports.

• With your permission, I would like to record parts of our conversation. I do this simply to make sure that I capture all of the information that you share and so I can listen to what you have to say and not worry about taking notes. The recording helps me in writing my report and is used for that purpose only. Is it okay for me to record parts of our conversation?

C. Survey Questions

First, I want to ask you a few questions about the screening you just went through and the materials you might have received.

1. Is this the first time you’ve been through the screening process for Ebola at an airport in the United States?

1 Yes

2 No

[IF YES, CONTINUE WITH Q2]

[IF NO, ASK…]

1. How many other times have you been screened for Ebola at an airport in the United States? This should not include the screening process you went through today.

1 One other time

2 Two other times

3 Three or more other times

2. When was the last time you were screened for Ebola at an airport in the United States? [PROBE: You can give me your best guess if you don’t know the exact date] [INTERVIEWER WRITE DOWN MONTH AND YEAR]

2. How clear was the purpose of Ebola screening?

1 Very unclear

2 Somewhat unclear

3 Clear

4 Very clear

1. What about the purpose of Ebola screening was [INSERT TRAVELERS RESPONSE}(very unclear/somewhat unclear/clear/very clear)? [INTERVIEWER: RECORD RESPONSE USING AUDIO RECORD TOOL]

3. Do you work in the field of public health or health care?

1 Yes

2 No

4. Did you get a CARE Kit? [PROBE: The CARE Kit would have come in a plain envelope with a card on the front and paper and a thermometer inside.]

1 Yes

2 No

5. Have you opened the CARE Kit yet?

1 Yes

2 No

6. Did you watch a video about checking yourself for symptoms of Ebola at the airport today? The video may or may not have been playing so it is possible you did not see it.

1 Yes

2 No

7. Before today, have you watched a video made by the CDC about checking yourself for symptoms of Ebola?

1 Yes

2 No

8. Before today, how often have you and your family members and friends talked about Ebola in the past month?

1 Not at all

2 Only once or twice

3 Sometimes

4 Often

5 Every day

9. How easy or difficult will it be for you to follow the instructions in the CARE Kit in the next few weeks?

1 Very difficult

2 Difficult

3 Easy

4 Very easy

10. How serious of a health concern is Ebola to you personally?

1 Not serious at all

2 Somewhat serious

3 Serious

4 Very Serious

11. How serious of a health concern is Ebola to the world?

1 Not serious at all

2 Somewhat serious

3 Serious

4 Very serious

12. How would you know whether you had Ebola or not?

[INTERVIEWER: CHECK ALL MENTIONED BY TRAVELER; RECORD ORDER SYMPTOMS MENTIONED]

1 Fever

2 Stomach pain

3 Diarrhea or running stomach

4 Vomiting

5 Bleeding

6 Red eyes

7 Muscle pain

8 Headache

9Feeling weak or tired

10 Runny/Bloody Nose

11 Other [INTERVIEWER: RECORD RESPONSE VERBATIM USING AUDIO RECORD TOOL]

13. In your opinion, how likely do you think it is that you will get sick with Ebola?

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

1. What about your experience makes you think you are [INSERT TRAVELER RESPONSE] (very unlikely/somewhat unlikely/likely/very likely) to get sick with Ebola [INTERVIEWER AUDIO RECORD VERBATIM RESPONSE]

14. Based on what you’ve heard so far, how long do you need to do health checks for Ebola?

1 1 Month

2 21 Days

3 1 Week

4 Unsure

15. How confident are you that you can check yourself for the next few weeks for symptoms of Ebola?

1 Not confident at all

2 Somewhat unconfident

3 Confident

4 Very confident

16. How likely is it that you will report temperature and symptoms to the health department every day for the next few weeks?

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

17. If you have a temperature of 100 degrees Fahrenheit or 38 degrees Celsius, how likely would you be to seek medical care? [Note to interviewer: We are interested in any elevated temperature or “fever”]

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

18. Are there any other symptoms that would make you should seek medical care?

1. Yes

2. No

1. [IF YES] Which symptoms would prompt you to seek medical care?

[INTERVIEWER: CHECK ALL MENTIONED BY TRAVELER]

1 Fever

2 Stomach pain

3 Diarrhea or running stomach

4 Vomiting

5 Bleeding

6 Red eyes

7 Muscle pain

8 Headache

9Feeling weak or tired

10 Runny/bloody Nose

11 Other [INTERVIEWER: RECORD RESPONSE VERBATIM USING AUDIO RECORD TOOL]

19. What would you do to seek medical care? [INTERVIEWER: CHECK ALL MENTIONED BY TRAVELER]

1 Call 911

2 Call the health department

3 Call the number on the CARE Card

4 Call the CDC

5 Go to the doctor

6 Go to the emergency room (ER)

7 Stay where I am

8 Other [INTERVIEWER: RECORD RESPONSE VERBATIM USING AUDIO RECORD TOOL]

20. Other than the thermometer you just received in your CARE Kit, do you have a thermometer where you are going to be staying?

1 Yes

2 No

21. Other than the CARE cell phone you just received during this process, do you have cell phone that works in the United States?

1 Yes

2 No

22. How likely is it that you will use the resources given to you today?

1. Very unlikely

2. Somewhat unlikely

3. Likely

4. Very likely

How likely is it that you will use the…

1. Temperature and Symptom Log

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

5 Unsure

2. CARE Phone

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

5 Unsure

3. Thermometer

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

5 Unsure

4. CARE Card

1 Very unlikely

2 Somewhat unlikely

3 Likely

4 Very likely

5 Unsure

Please tell me how much you agree or disagree with the following statement

23. People who are important to me, like friends or family, will approve of me checking myself for Ebola.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

1. What makes you think your family and friends will disapprove of you checking yourself for Ebola symptoms?

24. The people who wrote the CARE Kit materials care about me as a person.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

25. The CARE Ambassador who talked with me about the actions I must take cares about me as a person.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

26. The CARE Ambassador was knowledgeable as a source of information about Ebola.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

27. I have confidence in the CARE Ambassador as a source of information about Ebola.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

28. I trust the CARE Ambassador as a source of information about Ebola.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

29. The CARE Ambassador is a credible source of information about Ebola.

1 Strongly Disagree

2 Disagree

3 Neither Agree nor Disagree

4 Agree

5 Strongly Agree

I have just a few more questions for you.

30. What is your CARE ID? [INTERVIEWER: Ask to see the front of the CARE Kit envelope to check and write down the CARE ID number]

31. Can I call you on the phone within the next week to ask you a few more questions about your experience coming to the U.S.?

1 Yes

2 No

[IF YES, ASK CONTINUE, OTHERWISE END]

What is your name? [Interviewer write down name provided]

1. Is there a phone number where I can reach you in the next week? [INTERIVEWER Write down phone number]

2. What is the best time to call [Morning, afternoon, evening][INTERVIVEW WRITE DOWN BEST TIME OF DAY TO CALL]

Thank you so much for your participation. We will call you in a few days to hear more about your experience.

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 (0920-0932).