Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Community-associated Clostridium difficile Infection (CDI) Surveillance Health Interview
Call Log
Telephone number:__________________________________
Date Time 1 Time 2
(mm/dd/yy) (circle am or pm)
Day 1: _________ ________ am/pm ________ am/pm
Day 2: _________ ________ am/pm ________ am/pm
Day 3: _________ ________ am/pm ________ am/pm
Day 4: _________ ________ am/pm ________ am/pm
Day 5: _________ ________ am/pm ________ am/pm
Call no more than 10 times with 2 attempts per day for 5 days over a two week period: at least one weekday between 5-8pm; and one weekend day (Sat: 9am-6pm or Sun: 1pm-8pm).
Call back at _____________(day) ________________(time)
Call back at _____________(day) ________________(time)
Call back at _____________(day) ________________(time)
Public reporting burden of this collection of information is estimated to average 40 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).
Enrollee Interview – This portion will be Transferred to CDC
Section 1: Identifiers (to be filled out by EIP staff)
Patient ID: _________________________________
State ID: __________________________________
Provider ID: ________________________________
Lab ID: ___________________________________
Specimen ID (accession number): ___________________________________
Specimen Collection Date _____/_____/______
(mm/dd/yyyy)
Age
Sex Male Female
HAVE A CALENDAR IN FRONT OF YOU.
I will ask you questions about [your/your child’s] illness, healthcare contacts, household contacts, other exposures and medical history. It may be difficult to remember, but I would like your best guess for each question. Because I will be asking about specific dates around the time [your/your child’s] diarrhea began (initial specimen collection date), it may be helpful for you to have a calendar or datebook in front of you. Do you need a minute to go get any of these items?
If interviewees gravitate toward answering that they don’t know/are unsure how to answer questions, encourage them to try to remember one way or another. [See Interviewer Manual]
Specimen
collection date:
_____/_____/______
(mm/dd/yyyy) 8
weeks before specimen collection _____/_____/______ 12
weeks before specimen collection _____/_____/______ Date
diarrhea began:
_____/_____/______
(mm/dd/yyyy) 1
week before diarrhea began _____/_____/______ 2
weeks before diarrhea began_____/_____/______ 12
weeks before diarrhea began _____/_____/______
Section 2: Screening Questions (Please Refer to the screening Form. if patient eligible please proceed)
Section 3: Illness Questions
Now I will ask you questions about [your/your child’s] illness.
11. Did [you/your child] have diarrhea at the time [your/your child’s] stool specimen was collected on [specimen collection date_____/_____/______]? We define diarrhea as 3 or more loose stools in a 24 hour period.
Yes 1 (Go to Q. 11A)
No 2 (Go to Q. 11D)
Don’t know/Not sure 7 (Go to Q.12 and use initial date of specimen collection as reference date.)
Refused 9 (Go to Q.12 and use initial date of specimen collection as reference date.)
11A. If yes, Do [you/your child] remember when [your/your child’s] diarrhea began?
Yes 1 (If Yes –fill in date diarrhea began)
No 2 (fill in date diarrhea began with date of specimen collection.)
Don’t know/Not sure 7 (fill in date diarrhea began with date of specimen collection.)
Refused 9 (fill in date diarrhea began with date of specimen collection.)
Date
diarrhea began: _____/_____/______
(mm/dd/yyyy) 1
week before _____/_____/______ 2
weeks before _____/_____/______ 12
weeks before _____/_____/______
11B. How many days did [your/your child’s] diarrhea last?
11C. On the worst day of [your/your child’s] diarrhea, what was the approximate number of stools [you/your child] had in a 24-hour period? (Go to Q.12)
≥3-<5 stools 1
5-10 stools 2
>10 stools 3
Don’t know/Not sure 7
Refused 9
11D. If no to Q.11, why was [your/your child’s] stool tested? (Go to Q.12) ____________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________
12. Did [you/your child] have any of the following symptoms associated with [your/your child’s] C. difficile illness?
[READ LIST] Yes No DK/NS Refused
Bloody stools 1 2 7 9
Fever 1 2 7 9
Nausea 1 2 7 9
Vomiting 1 2 7 9
Abdominal pain 1 2 7 9
Other 1 2
Specify:_______________________________________________________________
13. Were [you/your child] hospitalized overnight for [your/your child’s] C. difficile illness?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
14. At the time of [your/your child’s] C. difficile diagnosis, were [you/your child] told by a doctor or healthcare provider that [you/your child] had any other stomach [enteric, gastrointestinal] infection?
Yes 1
No 2 (Go to Q.15)
Don’t know/Not sure 7 (Go to Q.15)
Refused 9 (Go to Q.15)
14A. If yes, what was the name of the infection?
[Read list if necessary] Yes No DK/NS Refused
Campylobacter 1 2 7 9
E. coli 1 2 7 9
Listeria 1 2 7 9
Salmonella 1 2 7 9
Shigella 1 2 7 9
Vibrio 1 2 7 9
Yersinia 1 2 7 9
Cryptosporidium 1 2 7 9
Giardia 1 2 7 9
Other 1 2
Specify:____________________________________________________________________________
Section 4: Healthcare contacts
Now I will ask you questions about [you/your child] healthcare contacts in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), which would be from [12 weeks before date] to [date diarrhea began], and ALSO in the 1 week before [your/your child’s] diarrhea began (initial specimen collection date), which would be from [1 week before date] to [date diarrhea began].
15. Did [you/your child] receive care in any doctor’s office, dentist, hospital, nursing home, or any other medical facility in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2 (Go to Q.16)
Don’t know/Not sure 7 (Go to Q.16)
Refused 9 (Go to Q.16)
15A. If yes, was it in the 1 week before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
15B. What type of facility did [you/your child] visit in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
If yes, in the
1 week before
[READ LIST] Yes No DK/NS Refused Yes No
Emergency department 1 2 7 9 1 2
Doctor’s office 1 2 7 9 1 2
Dentist 1 2 7 9 1 2
Long term care (skilled nursing facility) 1 2 7 9 1 2
Hemodialysis facility 1 2 7 9 1 2
Other facility 1 2 1 2
Specify:________________________________________________________
15C. During those visits in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date) did [you/your child] have any of the following procedures performed?
If yes, in the
1 week before
[READ LIST] Yes No DK/NS Refused Yes No
Upper Endoscopy 1 2 7 9 1 2
(Did the doctors pass a tube through
your mouth or nose into your stomach?)
Colonoscopy or Sigmoidoscopy 1 2 7 9 1 2
(Did the doctors pass a tube into your
rectum to look into your colon/bowel?)
X-ray that required GI Prep 1 2 7 9 1 2
(Did you have an X-ray performed where
you had to swallow something first?)
Chemotherapy 1 2 7 9 1 2
Surgery in an operating room 1 2 7 9 1 2
If yes, did [you/your child] take an
antibiotic before surgery? 1 2 7 9 1 2
Oral Surgery 1 2 7 9 1 2
If yes, did [you/your child] take an
antibiotic before surgery? 1 2 7 9 1 2
Other procedures 1 2 1 2
Specify:________________________________________________________________________
16. Did [you/your child] visit or accompany anyone to a doctor’s office, dentist, hospital, nursing home, or any other medical facility in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2 (Go to Q.17)
Don’t know/Not sure 7 (Go to Q.17)
Refused 9 (Go to Q.17)
16A. If yes, was it in the 1 week before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
16B. What type of facility did [you/your child] visit or accompany someone to in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
If yes, in the
1 week before
[READ LIST] Yes No DK/NS Refused Yes No
Hospital 1 2 7 9 1 2
Emergency department 1 2 7 9 1 2
Doctor’s office 1 2 7 9 1 2
Dentist 1 2 7 9 1 2
Long term care (skilled nursing facility) 1 2 7 9 1 2
Hemodialysis facility 1 2 7 9 1 2
Other facility 1 2 1 2
Specify:___________________________________________________________________
Section 5: Household contacts
The next few questions are about [you/your child] and persons who lived with [you/your child].
17. Including [yourself/your child], how many persons were spending at least 50% of their nights in [your/your child’s]
home in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
(If patient lived alone, only one person in the household, go to Q.22)
18. How many household members were in each of these age groups? [List number of people in each group]
Ages <1 1 to 3 4 to 10 11 to 18 19 to 34 35 to 59 60+
If children <4 years of age are present in household go to Q.18A; if no children <4 years of age, go to Q.19
18A. Were any of the children in diapers?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
18B. Did any of the children attend a group childcare setting or daycare?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
18B1. If yes, what type of childcare setting? [Read list if necessary]
Home 1
Center 2
Other 3
Specify:__________________________________________________
Don’t know/Not sure 7
Refused 9
19. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did any household member stay overnight in a hospital?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
20. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did any household member stay overnight in another healthcare institution (long-term care facility, nursing home, chronic care, or rehab unit)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
21. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did anyone else in [your/your child’s] household have diarrhea?
Yes 1
No 2 (Go to Q.22)
Don’t know/Not sure 7 (Go to Q.22)
Refused 9 (Go to Q.22)
21A. If yes, did [you/your child] assist this person with toileting (including diaper changes)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
21B. Was this person diagnosed with C. difficile?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
22. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [your/your child’s] household have any pets?
Yes 1
No 2 (Go to Q.23)
Don’t know/Not sure 7 (Go to Q.23)
Refused 9 (Go to Q.23)
22A. If yes, which of the following pets:
[READ LIST] Yes No DK/NS Refused
Dog 1 2 7 9
Cat 1 2 7 9
Other pet 1 2
Specify: _____________________________________________________________________
22B. Did [your/your child’s] pet have diarrhea in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
23. Did [you/your child] work or volunteer, in any capacity, at a hospital, other medical facility, or in any facility where patient care is provided in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2 (Go to Q.24)
Don’t know/Not sure 7 (Go to Q.24)
Refused 9 (Go to Q.24)
23A. If yes, what type of healthcare setting?
[READ LIST] Yes No DK/NS Refused
Hospital 1 2 7 9
Emergency department 1 2 7 9
Doctor’s office 1 2 7 9
Dentist 1 2 7 9
Long term care (skilled nursing facility) 1 2 7 9
Hemodialysis facility 1 2 7 9
Other facility 1 2
Specify:____________________________________________________________________________
23B. Did [your/your child’s] job involve direct patient care?
Yes 1
No 2 (Go to Q.24)
Don’t know/Not sure 7 (Go to Q.24)
Refused 9 (Go to Q.24)
23B1. If yes, what was [your/your child’s] main job?
____________________________________________________________________________________
Job Code- (Fill in job code after interview is finished)
(If patient lived alone, only one person in the household, go to Q.25)
24. Did any of [your/your child’s] household members work at or volunteer, in any capacity, at a hospital, other medical facility, or in any facility where patient care is provided in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2 (Go to Q.25)
Don’t know/Not sure 7 (Go to Q.25)
Refused 9 (Go to Q.25)
24A. If yes, what type of healthcare setting?
(READ LIST) Yes No DK/NS Refused
Hospital 1 2 7 9
Emergency department 1 2 7 9
Doctor’s office 1 2 7 9
Dentist 1 2 7 9
Long term care (skilled nursing facility) 1 2 7 9
Hemodialysis facility 1 2 7 9
Other facility 1 2
Specify:__________________________________________________________________________
24B. Did their job involve direct patient care?
Yes 1
No 2 (Go to Q.25)
Don’t know/Not sure 7 (Go to Q.25)
Refused 9 (Go to Q.25)
24B1. If yes, what was their main job?
____________________________________________________________________________________
Job Code- (Fill in job code after interview is finished)
25. Did [you/your child] work or volunteer in a veterinary clinic, on a farm, or in other profession caring for animals in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
(If patient lived alone, only one person in the household, go to Q.27)
26. Did any of [your/your child’s] household members work or volunteer in a veterinary clinic, on a farm, or in other profession caring for animals in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
Section 6: Other Exposures
I’d like to change direction now and ask you about some other exposures [you/your child] may have had.
27. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] travel outside of the US?
Yes 1
No 2 (Go to Q.28)
Don’t know/Not sure 7 (Go to Q.28)
Refused 9 (Go to Q.28)
27A. If yes, where did [you/your child] travel to and when did [you/your child] travel?
Country: ____________________ Date: ____/____/_____ to Date: ____/____/_____
Country: _____________________ Date: ____/____/_____ to Date: ____/____/_____
Country: _____________________ Date: ____/____/_____ to Date: ____/____/_____
28. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] visit a farm, petting zoo, state, county, or local fair, or other events at which animals were present?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
29. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] have any contact with any of the following live animals?
[READ LIST] Yes No DK/NS Refused
Chicken/baby chick/turkey 1 2 7 9
Cow/bull/steer/calf 1 2 7 9
Goat/sheep/lamb 1 2 7 9
Pig 1 2 7 9
Horse 1 2 7 9
30. In a typical week how frequently do [you/your child] consume the following foods?
[READ LIST] Often Sometimes Rarely Never DK/NS Refused
Beef 1 2 3 4 7 9
Pork 1 2 3 4 7 9
Lamb 1 2 3 4 7 9
Chicken 1 2 3 4 7 9
Turkey 1 2 3 4 7 9
Deli meats 1 2 3 4 7 9
(pre-sliced or sliced at meat counter)
Eggs 1 2 3 4 7 9
Milk 1 2 3 4 7 9
Section 7: Medical History
The next set of questions are about medications [you/your child] may have been taking in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date). Medicine bottles or records may help you remember about specific medications. Would you like to gather this information before we go on?
31. Did [you/your child] take any antibiotics in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?
Yes 1
No 2 (Go to Q.32)
Don’t know/Not sure 7 (Go to Q.32)
Refused 9 (Go to Q.32)
31A. If yes, how was this antibiotic obtained? [Read list if necessary]
Prescribed for the problem that [you/ your child] had 1
Borrowed from a friend or relative 2
Prescribed in the past for another problem 3
Other 4
Specify: ______________________________________________________
Don’t know/Not sure 7
Refused 9
31B. Why did [you/your child] take this antibiotic?
[DO NOT READ LIST] Yes No DK/NS Refused
Ear, sinus, upper respiratory infection 1 2 7 9
Bronchitis/ pneumonia 1 2 7 9
Urinary tract infection 1 2 7 9
Skin infection 1 2 7 9
Acne 1 2 7 9
Dental cleaning/oral surgery 1 2 7 9
Surgery 1 2 7 9
Other 1 2
Specify:____________________________________________
31C. Which antibiotic(s) did [you/your child] take in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)? [DO NOT READ LIST]
If yes, in the If yes, in the
2 weeks before 2 weeks before
Yes Yes No Yes Yes No
Amoxicillin 1 1 2 Floxin 1 1 2
Amoxicillin/Clavulanate 1 1 2 Keflex 1 1 2
Ampicillin 1 1 2 Keftab 1 1 2
Augmentin 1 1 2 Levofloxacin 1 1 2
Azithromycin 1 1 2 Levoquin 1 1 2
Bactrim 1 1 2 Monurol 1 1 2
Biaxin 1 1 2 Metronidazole 1 1 2
Ceclor 1 1 2 Norfloxacin or Norflox 1 1 2
Cefaclor 1 1 2 Ofloxacin or Oflox 1 1 2
Cefadroxil 1 1 2 Omnicef 1 1 2
Cefdinir 1 1 2 Penicillin or Pen VK 1 1 2 Ceftin 1 1 2 Pediazole 1 1 2
Cefixime 1 1 2 Septra 1 1 2
Cefuorixime 1 1 2 Suprax 1 1 2
Cefzil 1 1 2 Tetracycline 1 1 2
Cefprozil 1 1 2 Tequin 1 1 2
Cephalexin 1 1 2 Trimox 1 1 2
Cephradine 1 1 2 Trimethoprim/Sulfa 1 1 2
Ciprofloxacin or Cipro 1 1 2 Vancomycin 1 1 2
Clarithromyc 1 1 2 Zagam 1 1 2
Cleocin 1 1 2 Zithromax or Z-Pak 1 1 2
Clindamycin 1 1 2
Dapsone 1 1 2 Other antibiotic 1 1 1 2
Doxycycline 1 1 2 Specify: _______________________________
Duricef 1 1 2 Other antibiotic 2 1 1 2
Erythromycin 1 1 2 Specify: _______________________________
Erythromycin/sulfa 1 1 2 Don’t know/Not sure 1
Flagyl 1 1 2 Refused 1
32. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any acid-reducing medications to treat excessive stomach acid, heartburn, or gastroesophageal reflux disease (GERD)? We define regular use as use of the product at least 3 days per week. Such medications might include Tums, Maalox, Mylanta, Tagamet, Zantac, Prilosec, or Nexium.
Yes 1
No 2 (Go to Q.33)
Don’t know/Not sure 7 (Go to Q.33)
Refused 9 (Go to Q.33)
32A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date).
If yes, in the
2 weeks before
[Read list if necessary] Yes No DK/NS Refused Yes No
Aciphex/rabeprazole 1 2 7 9 1 2
Alka-Seltzer 1 2 7 9 1 2
Maalox 1 2 7 9 1 2
Mylanta 1 2 7 9 1 2
Nexium/esomeprazole 1 2 7 9 1 2
Pepcid/famotidine 1 2 7 9 1 2
Prevacid/lansoprazole 1 2 7 9 1 2
Prilosec/omeprazole 1 2 7 9 1 2
Protonix/pantoprazole 1 2 7 9 1 2
Rolaids 1 2 7 9 1 2
Tums 1 2 7 9 1 2
Tagamet/cimetidine 1 2 7 9 1 2
Zantac/ranitidine 1 2 7 9 1 2
Other 1 2 1 2
Specify:_______________________________________________________
33. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any laxatives? We define regular use as use of the product at least 3 days per week
Yes 1
No 2 (Go to Q.34)
Don’t know/Not sure 7 (Go to Q.34)
Refused 9 (Go to Q.34)
33A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date). This does not include the use of supplemental fiber or Metamucil.
If yes, in the
2 weeks before
[Read list if necessary] Yes No DK/NS Refused Yes No
Alophen 1 2 7 9 1 2
Aqualax 1 2 7 9 1 2
Bisacodyl 1 2 7 9 1 2
Calube 1 2 7 9 1 2
Colace 1 2 7 9 1 2
Correctol 1 2 7 9 1 2
Docusate 1 2 7 9 1 2
Dulcolax 1 2 7 9 1 2
Other 1 2 1 2
Specify:______________________________________________________________
34. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any anti-diarrheal drugs such as Imodium or Pepto-Bismol? We define regular use as use of the product at least 3 days per week
Yes 1
No 2 (Go to Q.35)
Don’t know/Not sure 7 (Go to Q.35)
Refused 9 (Go to Q.35)
34A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date).
If yes, in the
2 weeks before
[Read list if necessary] Yes No DK/NS Refused Yes No
Antispas 1 2 7 9 1 2
Bentylol 1 2 7 9 1 2
Dimor 1 2 7 9 1 2
Imodium 1 2 7 9 1 2
Kaopectate 1 2 7 9 1 2
Levsin 1 2 7 9 1 2
Loperamide 1 2 7 9 1 2
Lopex 1 2 7 9 1 2
Lomotil 1 2 7 9 1 2
Other 1 2 1 2
Specify:______________________________________________________________
35. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any non-steroidal anti-inflammatory drugs, or NSAIDS, for fever or pain? We define regular use as use of the product at least 3 days per week. This would include drugs such as aspirin, naproxen, or ibuprofen but does not include Tylenol, or acetaminophen.
Yes 1
No 2 (Go to Q.36)
Don’t know/Not sure 7 (Go to Q.36)
Refused 9 (Go to Q.36)
35A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date).
If yes, in the
2 weeks before
[Read list if necessary] Yes No DK/NS Refused Yes No
Advil or ibuprofen 1 2 7 9 1 2
Aspirin 1 2 7 9 1 2
Naproxen or Aleve 1 2 7 9 1 2
Other 1 2 1 2
Specify:______________________________________________________________
Now I am going to ask you about medical conditions [you/your child] may have had in the past 2 years.
36. In the 2 years before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] have any of the following medical conditions? [READ LIST – including information in parentheses]
Yes No DK/NS Refused Year of diagnosis
Diabetes 1 2 7 9 _______
High blood pressure 1 2 7 9 _______
Chronic renal (kidney) failure 1 2 7 9 _______
If yes, are [you/your child] on dialysis or
awaiting dialysis? 1 2 7 9 _______
Chronic pulmonary disease 1 2 7 9 _______
(COPD, emphysema, asthma)
Organ transplant 1 2 7 9 _______
Bone marrow transplant 1 2 7 9 _______
Stomach ulcer (peptic/gastric ulcer disease) 1 2 7 9 _______
Stomach surgery 1 2 7 9 _______
Chronic Hepatitis C infection 1 2 7 9 _______
Chronic Hepatitis B infection 1 2 7 9 _______
Sickle cell disease (not sickle cell trait) 1 2 7 9 _______
Lupus 1 2 7 9 _______
Rheumatoid arthritis 1 2 7 9 _______
Inflammatory bowel disease 1 2 7 9 _______
(Crohn’s disease, Ulcerative colitis)
Heart attack 1 2 7 9 _______
Congestive heart failure 1 2 7 9 _______
Stroke 1 2 7 9 _______
Peripheral vascular disease 1 2 7 9 _______
(intermittent claudication, gangrene, peripheral
arterial bypass)
Leukemia or lymphoma 1 2 7 9 _______
Cancer (e.g. breast, prostate, lung cancer) 1 2 7 9 _______
Other 1 2 _______
Specify:__________________________________________________________________________
Section 8: Demographics
Now I would like to ask you a few final questions.
37. How would you describe [your/your child’s] race? [Read list if necessary]
Respondent may choose more than one race
American Indian or Alaskan native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other, Specify: _________________________________________
Unknown
Refused
38. Are [you/your child] of Hispanic or Latino origin?
Yes
No
Don’t know
Refused
That was my last interview question. Thank you very much for your time and participation!
39. Comments: ______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
40. Interview Completed? Yes No
41. Date of interview: ____/____/______
(mm/dd/yyyy)
42. Interviewer initials: ______________
Health Interview Appendix—Job Codes
OFFICE OF MANAGEMENT AND BUDGET - 1998 Standard Occupational Classification
29-0000 Healthcare Practitioners and Technical Occupations
29-1000 Health Diagnosing and Treating Practitioners
29-1010 Chiropractors
29-1020 Dentists
29-1021 Dentists, General
29-1022 Oral and Maxillofacial Surgeons
29-1023 Orthodontists
29-1024 Prosthodontists
29-1029 Dentists, All Other Specialists
29-1030 Dietitians and Nutritionists
29-1040 Optometrists
29-1050 Pharmacists
29-1060 Physicians and Surgeons
29-1061 Anesthesiologists
29-1062 Family and General Practitioners
29-1063 Internists, General
29-1064 Obstetricians and Gynecologists
29-1065 Pediatricians, General
29-1066 Psychiatrists
29-1067 Surgeons
29-1069 Physicians and Surgeons, All Other
29-1070 Physician Assistants
29-1080 Podiatrists
29-1110 Registered Nurses
29-1120 Therapists
29-1121 Audiologists
29-1122 Occupational Therapists
29-1123 Physical Therapists
29-1124 Radiation Therapists
29-1125 Recreational Therapists
29-1126 Respiratory Therapists
29-1127 Speech-Language Pathologists
29-1129 Therapists, All Other
29-1130 Veterinarians
29-1190 Miscellaneous Health Diagnosing and Treating Practitioners
29-1199 Health Diagnosing and Treating Practitioners, All Other
29-2000 Health Technologists and Technicians
29-2010 Clinical Laboratory Technologists and Technicians
29-2011 Medical and Clinical Laboratory Technologists
29-2012 Medical and Clinical Laboratory Technicians
29-2020 Dental Hygienists
29-2030 Diagnostic Related Technologists and Technicians
29-2031 Cardiovascular Technologists and Technicians
29-2032 Diagnostic Medical Sonographers
29-2033 Nuclear Medicine Technologists
29-2034 Radiologic Technologists and Technicians
29-2040 Emergency Medical Technicians and Paramedics
29-2050 Health Diagnosing and Treating Practitioner Support Technicians
29-2051 Dietetic Technicians
29-2052 Pharmacy Technicians
29-2053 Psychiatric Technicians
29-2054 Respiratory Therapy Technicians
29-2055 Surgical Technologists
29-2056 Veterinary Technologists and Technicians
29-2060 Licensed Practical and Licensed Vocational Nurses
29-2070 Medical Records and Health Information Technicians
29-2080 Opticians, Dispensing
29-2090 Miscellaneous Health Technologists and Technicians
29-2091 Orthotists and Prosthetists
29-2099 Health Technologists and Technicians, All Other
29-9000 Other Healthcare Practitioners and Technical Occupations
29-9010 Occupational Health and Safety Specialists and Technicians
29-9011 Occupational Health and Safety Specialists
29-9012 Occupational Health and Safety Technicians
29-9090 Miscellaneous Health Practitioners and Technical Workers
29-9091 Athletic Trainers
29-9099 Healthcare Practitioners and Technical Workers, All Other
31-0000 Healthcare Support Occupations
31-1000 Nursing, Psychiatric, and Home Health Aides
31-1010 Nursing, Psychiatric, and Home Health Aides
31-1011 Home Health Aides
31-1012 Nursing Aides, Orderlies, and Attendants
31-1013 Psychiatric Aides
31-2000 Occupational and Physical Therapist Assistants and Aides
31-2010 Occupational Therapist Assistants and Aides
31-2011 Occupational Therapist Assistants
31-2012 Occupational Therapist Aides
31-2020 Physical Therapist Assistants and Aides
31-2021 Physical Therapist Assistants
31-2022 Physical Therapist Aides
31-9000 Other Healthcare Support Occupations
31-9010 Massage Therapists
31-9090 Miscellaneous Healthcare Support Occupations
31-9091 Dental Assistants
31-9092 Medical Assistants
31-9093 Medical Equipment Preparers
31-9094 Medical Transcriptionists
31-9095 Pharmacy Aides
31-9096 Veterinary Assistants and Laboratory Animal Caretakers
31-9099 Healthcare Support Workers, All Other
Public reporting burden of this collection of information is estimated to average 45 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 current 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 (0920-xxxx).
Health
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| File Type | application/msword |
| File Title | Background and Justification |
| Author | fwu4 |
| Last Modified By | ziy6 |
| File Modified | 2011-03-01 |
| File Created | 2011-03-01 |