Telephone Survey 2 Days before Last Scheduled Day To Rep

Form Approved

OMB No. 0920-0932

Expires 05/31/2015

Appendix C: Telephone Survey 2 Days before Last Scheduled Day To Report to Health Department

1. General Introduction

Hello, is [name] available? I wanted to follow-up on a survey we did with them a few weeks ago.

IF correct person: CONTINUE

IF not correct person: Is [name] available to talk now?

• IF YES, continue

• IF NO, Is there a good time to call back? [RECORD TIME]

Hello [respondent name]. My name is _________ and I am working with the Centers for Disease Control and Prevention. Someone working with CDC spoke with you about your experience with the Ebola screening process at the [insert name] airport on [insert day]. At the end of your survey on [day of follow-up survey] you said you would be willing to be called again. Are you still willing to do this?

Is now a good time to talk? This will take about 5 minutes. [INTERVIEWER: IF YES, GO TO SECTION B. IF NO, ASK…]

1. When would be a good time to call you back?[INTERVIEW RECORD TIME FOR CALL BACK]

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 survey 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.

• Whether you take part in the survey or not and anything you say will not affect your monitoring for Ebola.

Survey Questions

1. Are you currently being asked by the health department to check and report your temperature and symptoms to them?

1 Yes

2 No [SKIP TO QUESTION 9]

2. Did you check your temperature twice yesterday?

1 Yes

2 No

3. Yesterday did you check yourself for any other symptoms that were mentioned in the CARE Kit?

1 Yes

2 No

4. Yesterday did you record or write down your temperature and any symptoms mentioned in the CARE Kit?

1 Yes

2 No

5. Did you report your temperature and symptoms to the health department yesterday?

1 Yes

2 No

6. Did you carry your CARE Card with you everywhere you went yesterday?

1 Yes

2 No

7. Since the last time we called you, how often have you and your family members talked about Ebola?

1 Not at all

2 Only once or twice

3 Sometimes

4 Often

5 Every day

8. 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

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

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

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

10. 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

11. The people at the health department care about me as a person.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

12. The people at the health department are knowledgeable as a source of information about Ebola.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

13. I have confidence in the people at the health department as a source of information about Ebola.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

14. I trust the people at the health department as a source of information about Ebola.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

15. The people at the health department are a credible source of information about Ebola.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

16. The actions that I have taken have protected me and those around me.

1 Strongly disagree

2 Disagree

3 Neither agree nor disagree

4 Agree

5 Strongly agree

17. How have you usually reported your temperature and any symptoms to the health department? (PROBE:

[INTERVIEWER: RECORD ONLY ONE. IF NEEDED, EXPLAIN THAT WE ARE LOOKING FOR HOW THEY USUALLY COMMUNICATED THEIR TEMPERATURE AND SYMPTOMS TO THE HEALTH DEPARTMENT]

1 CARE Phone

2 Personal phone

3 Other phone

4 Online (including video conference such as Skype or Facetime)

5 In person

6 Other [INTERVIEWER: RECORD RESPONSE VERBATIM]

18. Have you reported your temperature and symptoms to more than one health department?

1 Yes

2 No

19. If you had to report your temperature and symptoms to the health department in the future of the following list of methods, which would you prefer? Pick your top three choices. [INTERVIEWER NOTE 1^ST , 2^ND, AND 3^RD CHOICE]

1. Speaking to a person live on the phone

2. Using an automated system on the phone

3. Using an app on my phone

4. Going to a website

5. Sending a text message

6. Going to visit the health department

7. Having someone from the health department visit me

8. Other [INTERVIEWER: RECORD RESPONSE VERBATIM]

20. Do you believe that you have done what is expected of you by your health department?

1 Yes

2 No

2. Why or Why not? [INTERVIEWER: RECORD RESPONSE VERBATIM]

Thank you so much for your participation in all of our surveys. The information you have provided will be useful in helping design ways to get important information to travelers in the future. This is our final call.

Public reporting burden of this collection of information is estimated to average 5 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).