Form Questionnaire A - Questionnaire A - Premises Level Questionnaire

Form A: Premises Level Questionnaire
This questionnaire consists of questions about the premises at which the EHM index case was
identified. These questions will help identify potential EHM risk factors for both the index case
and subsequent cases of EHM.
Abbreviations for this questionnaire:
EHV-1: Equine herpesvirus-1
EHM: Equine herpesvirus myeloencephalopathy
Y=Yes, N=No, D/K=Don’t know, NA=Not applicable
Definitions for this questionnaire:
Equid: All species of equid such as donkeys, mules, ponies, horses, etc.
Horse: All full-size horse breeds (14 hands or more at withers) including foals on the premises
(does not include donkeys, mules, ponies, and miniatures).
Resident equid: Equids, including foals, which have spent or are expected to spend more time
at this premises than at any other premises, even if not owned by the owner of the premises.
In other words, this premises may be considered the animal’s “home.”
Nonresident equine: Not a resident equid as describe by the definition above.
Isolate: To prevent nose-to-nose contact with other equids from this premises, prevent the
sharing of equipment such as brushes, combs, and buckets between equids, and establish
the practice of hygienic methods for personnel.
In the last 30 days: Includes the past 30 days from the date of this interview. When asked
about a resident equid in the last 30 days, consider equids that may no longer be on the
premises.
Premises identification ________________________________________
Date of data collection: __/__/__

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0579-0376 The time required to complete this
information collection is estimated to average 1 hour 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.

Questionnaire A-F
OMB Approved
0579-0376
EXP Date
XX/201X

SECTION 1: FUNCTION
1. What do you consider the primary function of this premises? (Circle one.)
1–Boarding stable/training
2–Riding stable (lessons, rent equids, etc.)
3–Racetrack
4–Equine breeding farm
5–Farm or ranch
6–Residence with equids for personal use (show, pleasure, etc.)
7–Show grounds (e.g., pleasure, equitation, halter, conformation, showmanship)
8–Western event (e.g., barrel racing, team penning, roping, cutting)
9–Polo match
10–Fairgrounds
11–Rodeo
12–Trail ride
13–Sale or auction
14–Training clinic
15–Draft horse pull/show
16–Horse trials/eventing (including dressage, cross-country, and show jumping)
17–Other (specify: ____________________________________)
2. What do you consider to be the primary use of the equids currently on this premises?
(Circle one.)
1–Pleasure
2–Lessons/school
3–Showing/competition (not betting)
4–Breeding
5–Racing
6–Farm or ranch work
7–Other (specify: ________________)

SECTION 2: POPULATION
1. How many equids have been considered residents at the premises in the last 30 days?
1–Horses (excluding miniature horses)
2–Mules
3–Miniature horses
4–Donkeys or burros
5–Ponies
6–Other equids, (specify: __________________)
7–Total (add items1–6)

#________head
#________head
#________head
#________head
#________head
#________head
#________total

If Total Head=0, skip to Question 5.
2.

a. Did you add any new resident equids to the premises in the last 30 days (excluding
births to resident mares)?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 4.

b. How many new resident equids were added to the premises in the last 30 days?
# _______head
c. How many of the equids added came from:
1–Within State
2–Outside State, within U.S.
3–Canada
4–Mexico
5–Outside North America
6–Unknown location
7–Total items (add items 1–6)

#________head
#________head
#________head
#________head
#________head
#________head
#________total

d. For the majority of these new resident equids, did you (this premises)
always require (1), sometimes require(2), or never require(3):
Always Sometimes Never

1–Official health certificate
2–Veterinary examination other than for
official health certificate
3–Equine herpes vaccination within
the past year
4–Quarantine or isolation prior to contact
with resident equine
3.

1

2

3

1

2

3

1

2

3

1

2

3

a. Did you permanently remove any resident equids from the premises in the last 30
days (including deaths)?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 5.
b. Why were these equids removed from the premises?
1–Died (not euthanized)
2–Euthanized
3–Sold or traded
4–Other (specify)

4.

#________head
#________head
#________head
#________head

a. How many nonresident equids have visited or been stabled at the premises in the
last 30 days?
1–Horses (excluding miniature horses)
2–Mules
3–Miniature horses
4–Donkeys or burros
5–Ponies
6–Other equids (specify: ________________)
7–Total (add items1–6)
If # head=0, skip to Question 6.

#________head
#________head
#________head
#________head
#________head
#________head
#________head

b. For the majority of these nonresident equids, did you (this premises)
always require(1), sometimes require(2), or never require(3):
Always Sometimes Never

1–Official health certificate
2–Veterinary examination other than for
official health certificate
3–Equine herpes virus vaccination within
the past year
4–Quarantine or isolation prior to contact
with resident equine

1

2

3

1

2

3

1

2

3

1

2

3

5. Have there been any dynamic changes for the equids on the premises in the last 30 days?
(Circle all that apply.)
1–No change in dynamics
2–Weaning
3–Fighting
4–Changing of members within groups
5–Construction on premises
6–Other (specify: __________________________________________)

SECTION 3: HEALTH
1. Prior to this outbreak of equine herpesvirus-1, how often did you check the body
temperature on healthy equids (nonsymptomatic of an infectious disease)? (Circle one.)
1–Never
2–Less than once a day
3–Once a day
4–Twice a day
5–Other (specify: ___________________________________)
2. How often did you check the body temperature on an equid with signs of an infectious
disease such as equine herpesvirus-1 prior to this outbreak? (Circle one.)
1–Never
2–Once a day
3–Twice a day
4–Other (specify: ___________________________________)
3. Since this outbreak of equine herpesvirus-1, how often do you check the body temperature
on healthy equids (no clinical signs of an infectious disease)? (Circle one.)
1–Never
2–Once a day
3–Twice a day
4–Other (specify: ____________________________________)

4. Since this outbreak of equine herpesvirus-1, how often are you checking body temperatures
in equids with signs of an infectious disease?
1-Never
2-Once a day
3-Twice a day
4-Other (Specify: ____________________________________)
5. How many pregnant mares were on this premises in the last 30 days?
#________head
6. In the last 30 days, how many mares aborted or had stillborn foals?
#________head
In the next question, signs of acute upper respiratory infection must include a cough and/or
nasal discharge (serous or mucoid) and at least one of the following: fever, malaise, off feed or
decreased appetite, purulent nasal discharge, or enlarged lymph nodes on head or around the
upper neck.
7.

a. In the last 30 days, how many resident equids became ill with acute upper respiratory
infection?
#________head
b. In the last 30 days, how many nonresident equids became ill with acute upper
respiratory infection?
#________head

If # head=0, skip to Section 4.
8. Of these equids that became ill with acute upper respiratory infections, how many were the
following age categories at the time they became ill?

1–Foals less than 6 months old
2–6 months up to 18 months old
3–18 month up to 5 years old
4–5 years up to 20 years old
5–20 years and older
6–Total (add items 1–5)

Resident

Nonresident

#________head
#________head
#________head
#________head
#________head
#________head

#________head
#________head
#________head
#________head
#________head
#________head

SECTION 4: BIOSECURITY
1. Which of the following best describes how far it is from this premises to the nearest premises
with any type of equids? (Circle one.)
1–Adjacent
2–Less than 200 yards
3–200 yards to 1 mile
4–1 mile to 5 miles
5–200 yard to 5 miles
6–More than 5 miles
7–Don’t know
2. Which of the following best describes the premises’ general practice when resident equids
leave the premises, have direct contact with nonresident equids and return? (Circle one.)
1–Resident equids never leave premises or never have contact with nonresident
equids
2–Routinely isolate for at least 14 days after return to home premises
3–Only isolate for a cause such as disease or known exposure to disease
4–Routinely isolate before return to home premises
5–Never isolate returning equids
6–No resident equids on premises (e.g., equine event premises)
3. For infection control, do you ever require people (visitors, veterinarian, farrier, etc.) coming
onto the equine premises to do any of the following? (Circle all that apply.)
1–Use separate or disinfected equipment
2–Change clothes or wear clean coveralls
3–Disinfect or change boots
4–Clean and disinfect their hands
5–Park vehicles away from animal area
6–Other (specify: _____________________________________)
4.

a. Do you have a separate area designated for isolation or infection control?
Y
N

D/K

If “No” or “Don’t know,” skip to Question 5.
b. In the last 30 days have you moved any equids with signs of equine herpesvirus-1 to
this separate isolation area?
Y
N
D/K
c. Where is this separate area located? (Circle one.)
1–Separate building
2–Same building away from other equids but common airspace
3–Same building, away from other equids with separate airspace
4–Other (specify:_________________________)

d. Do you restrict movement of personnel working with the animals in isolation?
Y
N
D/K
If “Yes,” specify how: ____________________________________________________
5. In the last 30 days, have any of the following insect control methods been used?
(Circle all that apply.)
1–Repellents applied to equids
2–Insecticides applied to in or near equine housing area
3–Insecticides applied to pasture areas
4–Sticky tape
5–Bug zapper
6–Fly mask on equid
7–Fly tags attached to equine halters
8–Fly sheets on equids
9–Other (specify: __________________________________)
6. Which of the following best describes how much time the majority of the resident equids
spent confined indoors in the last 30 days? (Circle one.)
1–Never or rarely
2–Half the time or less
3–More than half the time

Form C: EHM Index Case Questionnaire
This questionnaire pertains only to the EHM index case. General background information was
collected on the index case on Form B, but this questionnaire will help identify potential EHM
risk factors for the index case.
Abbreviations for this questionnaire:
EHV-1: Equine herpesvirus-1
EHM: Equine herpesvirus myeloencephalopathy
Y=Yes, N=No, D/K=Don’t know, NA=Not applicable
Definitions for this questionnaire:
Index case: The first equid on the premises with neurological signs consistent with EHM and a
positive biological test for EHV-1.
Equid: All species of equids such as donkeys, mules, ponies, horses, etc.
Horses: All full-size horse breeds (14 hands or more at withers) including foals on the premises.
Does not include donkeys, mules, ponies, and miniatures.
In the last 30 days prior to the onset of EHM: Include the 30 days before the date that the
equid presented with neurological signs of EHM.
The following questions pertain only to the equid identified as the Index Case:
Index Case Name or ID: __________________________
Today’s Date __/__/__

Date of onset of EHM:__/__/__

SECTION 1: HEALTH
This section relates to the clinical health and medical treatments of the index case prior to EHM
diagnosis and after EHM diagnosis. To answer these, please refer to the equid’s medical
records.
1. Use the chart below to describe any clinical signs the equid exhibited within the last 30 days
prior to the onset of EHM. If you answer Yes, please list the date of onset of the clinical sign.
Clinical sign

Answer Y, N, D/K

Date of onset of
clinical sign

Fever (>101.5°F)
Nasal discharge or
cough
Abortion
Lethargy
Leg edema
Decreased appetite
Injury/wounds/trauma
Colic
Lameness (severe
enough to require
treatment)
Other (specify)

2. Use the chart below to describe all neurological signs the equid initially exhibited at the
onset of EHM. Check all that apply and indicate which neurological sign appeared first.
Initial neurological signs

Check all that apply
and circle first sign

Complete recumbency (cannot rise with assistance)
Incomplete recumbency (can rise with assistance)
Hind limb ataxia
Front limb ataxia
Toe dragging
Paresis
Head tilt
Circling
Bladder atony
Reduced tail tone
Reduced anal tone
Other (specify)

3.

a. Has this equid received any type of medication in the last 30 days prior to the onset
of EHM?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 4.

b. Use the chart below to describe the medications administered to the equid in the last
30 days prior to the onset of EHM.

Medication type

4

List name of medication or
NA if not applicable

Date of
treatment
onset

Treatment
duration in
days

Antivirals

_____days

NSAIDS

_____days

Corticosteroids

_____days

Antibiotics

_____days

Lasix/furosemide

_____days

Prerace jug

_____days

Joint injection

_____days

Dewormer

_____days

Vaccination(s)

_____days

Joint supplement(s)

_____days

Nutritional supplement(s)

_____days

Other (specify)

_____days

a. Has this equid received any type of medication after the EHM diagnosis?
Y
N

D/K

If “No” or “Don’t know,” skip to Question 5.
b. Use the chart below to describe the medications administered to the equid after the
EHM diagnosis.
Medication type
Antivirals
NSAIDS
Corticosteroids
Antibiotics
Other (specify)

List name of medication
or NA if not applicable

Date of
treatment onset

5. Use the chart below to list the biological test(s) performed, the result(s) obtained, and the
name of the testing laboratory responsible for processing the sample(s) for the index case.
Biological test

Check all that apply

Results: see code

Laboratory name

Nasal PCR
Blood PCR
*Serologic titers
**Histopathology
Virus isolation
***CSF analysis
Other (specify)
*Positive serologic titer is a 4X rise in titers 2–4 weeks apart with no history of vaccination during that time.
** Abnormal histopathology results include vasculitis and/or thrombosis of CNS blood vessels.
*** Abnormal CSF analysis consistent with EHM is an increase in total protein/albumin without an increase in nucleated
cell count and presence of xanthochromia.

Result codes
1=Positive/abnormal result
2=Negative result
3=Unknown
4=Suspect or inclusive results
6. Use the chart below to characterize the current clinical condition of the equid.
Clinical Status

Check the
appropriate box

Complete recovery
Partial recovery
Stable condition
Condition deteriorating
Died (not euthanized)
Euthanized

SECTION 2: EXPOSURE
The following questions pertain to the index case’s exposure prior to EHM diagnosis.
1. Is the index case a resident of this premises?

Y

N

2. Has the index case been directly exposed to nonresident equids the last 30 days?
(Circle one.)
1–No
2–Yes, one nonresident exposure
3–Yes, more than one nonresident exposure
4–Don’t know

D/K

3. Has the index case been indirectly exposed* to nonresident equids in the last 30 days?
(Circle one.).
[*Indirectly exposed, such as through shared equipment, shared transport, and/or personnel
moving between horses.]
1–No
2–Yes, one nonresident exposure
3–Yes, more than one nonresident exposure
4–Don’t know
4. Has the index case been directly or indirectly exposed to a mule or donkey in the last 30
N
D/K
days?
Y
5. In the 30 days prior to the EHM diagnosis, approximately how many different people on a
daily basis have had direct exposure to this equid (include stall cleaners, groomers, trainers,
caretakers, veterinarians, farriers, etc.)?
#________ or D/K

SECTION 3: BIOSECURITY
This section pertains to biosecurity practices that have taken place since EHV-1 was confirmed
on the premises.
1. Has the index case been isolated from the other equids on the premises since EHM was
diagnosed? If “Yes,” list the date.
Y date __/__/__
N
D/K
2. If “Yes,” has the index case been moved to a different housing area away from the healthy
(nonsymptomatic) equids on the premises since EHM was diagnosed? If “Yes,” list the date.
Y date__/__/__
N
D/K

SECTION 4: NUTRITION
1. Which of the following is the primary grain/concentrate fed to this equid in the 30 days prior
to EHM diagnosis? (Circle one.)
1–Not fed (for example, hay or turned-out only)
2–Unpelleted sweet feed, such as grain mixed with molasses
3–Unpelleted grain, such as whole or rolled oats and corn
4–Geriatric feed
5–Complete feed pellets or cubes, such as a forage/grain mixture
6–Grain mix with pellets
7–Other (specify: ________________________)
2. Which of the following is the primary dried forage fed to this equid in the 30 days prior to the
EHM diagnosis? (Circle one.)
1–Not fed (for example, turned-out only)
2–Alfalfa
3–Grass hay
4–Grass and alfalfa mix hay
5–Other (specify: ________________________)

3. Does this equid typically receive dietary supplements (e.g., folic acid, Vitamin E)?
Y
N

D/K

If “Yes,” please list the dietary supplement(s), the amount, and frequency of
administration:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Form D: Questionnaire for Horses with Fever, Neurologic Signs,
and Exposed to Index EHM Case at Initial Data Collection
This questionnaire pertains only to those equids that have been exposed to the index case and
have developed a fever and/or neurologic signs in the last 30 days. Exposed equids are those
that have shared airspace and/or had direct physical contact with the index case. General
background information was collected on each case on Form B, but this questionnaire will help
identify potential EHM risk factors for new cases of EHM after the exposure to the index case.

Abbreviations for this questionnaire:
EHV-1: Equine herpesvirus-1
EHM: Equine herpesvirus myeloencephalopathy
Y=Yes, N=No, D/K=Don’t know, NA=Not applicable

Definitions for this questionnaire:
Equid: All species of equids such as donkeys, mules, ponies, horses, etc.
Horse: All full-size horse breeds (14 hands or more at withers) including foals on the premises.
Does not include donkeys, mules, ponies, and miniatures.
In the last 30 days: Include the 30 days before the date of this interview.
Resident equid: Equids including foals that have spent or are expected to spend more time at
this premises than at any other premises, even if not owned by the owner of the premises. In
other words, this premises may be considered the animal’s “home.”
Nonresident equid: Not a resident equid as describe by the definition above.
Direct exposure: Physical contact.
Indirect exposure: Cared for by same personnel, shared equipment, or shared airspace.
Index case: The first equid on the premises with neurological signs consistent with EHM, no
epidemiological link to another equid with EHM, and a positive biological test for EHV-1.
Isolate: To prevent nose-to-nose contact with other equids from this premises and the sharing
of equipment, such as brushes, combs, and buckets between equids.

The following questions pertain only to the equine case specified for this questionnaire:
Equid name or ID: __________________________
Today’s date: ____/____/____

SECTION 1: HEALTH
This section relates to the clinical health and medical treatments of this equid in the last 30
days. To answer these, please refer to the equid’s medical records.
1.

a. Has this equid had any of the following signs of EHV-1 disease (neurologic signs,
fever, lethargy, decreased appetite, etc.) in the last 30 days?
Y
N
D/K

If “No” to neurologic signs, skip to Question 2.
b. Use the chart below to characterize EHV-1 disease signs the equid exhibited within
the last 30 days.
Clinical sign

Answer Y, N, D/K

Date of onset of
clinical sign

*Neurologic signs
Fever (>101.5°F)
Nasal discharge
or cough
Abortion
Lethargy
Leg edema
Decreased appetite
Other (specify)

c. Use the chart below to characterize the neurological signs this equid exhibited in the
last 30 days.
Neurological signs
Complete recumbency (cannot
rise with assistance)
Incomplete recumbency (can
rise with assistance)
Hind limb ataxia
Front limb ataxia
Toe dragging
Paresis
Head tilt
Circling
Bladder atony
Reduced tail tone
Reduced anal tone
Other (specify)

Check all that apply

2.

a. Has this equid received any medication in the last 30 days for the treatment or
prevention of EHV-1
Y
N
D/K
If “No” or “Don’t know,” skip to Question 3.
b. Use the chart below to list the medication(s) administered to the equid in the last
30 days for the treatment or prevention of EHV-1.

Medication type

3.

List name of medication
or NA if not applicable

Date of
treatment
onset

Treatment
duration in
days

Antivirals

_____days

NSAIDS

_____days

Corticosteroids

_____days

Antibiotic

_____days

Other (specify)

_____days

a. Has this equid received medications in the last 30 days for reasons other than
treatment or prevention of EHV-1?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 4.
b. Use the chart below to list the medication(s) administered to the equid in the last
30 days for reasons other than treatment or prevention of EHV-1.

Medication type

4.

List name of medication
or NA if not applicable

Date of
treatment
onset

Treatment
duration in
days

Antivirals

_____days

NSAIDS

_____days

Corticosteroids

_____days

Antibiotic

_____days

Lasix/furosemide

_____days

Prerace jug

_____days

Joint injection

_____days

Dewormer

_____days

Vaccination(s)

_____days

Joint supplement(s)

_____days

Nutritional supplement(s)

_____days

Other (specify)

_____days

a. Has any biological testing been performed on this equid to determine
EHV-infectious status?
N
Y
If “No” or “Don’t know,” skip to Question 5.

D/K

b. Use the chart below to describe the biological test(s) and the result(s) that were used
to diagnose the equid with EHM.
Biological test

Check all that apply

Results: see code

Laboratory name

Nasal PCR
Blood PCR
*Serologic titers
**Histopathology
Virus isolation
***CSF analysis
Other (specify)
* Positive serologic titer is a 4X rise in titers 2–4 weeks apart with no history of vaccination during that time.
** Abnormal histopathology results include vasculitis and/or thrombosis of CNS blood vessels.
*** Abnormal CSF analysis consistent with EHM is an increase in total protein/albumin without an increase in nucleated
cell count and presence of xanthochromia.

Result codes
1=Positive result/abnormal
2=Negative result
3=Unknown
4=Suspect or inconclusive results
5. Use the chart below to characterize the current clinical condition of the equid.
Clinical Status

Check the
appropriate box

Complete recovery
Partial recovery
Stable condition
Condition deteriorating
Died (not euthanized)
Euthanized

SECTION 2: EXPOSURE
1. Is this equid a resident of this premises?

Y

N

2. Has this equid been directly exposed to nonresident equids in the last 30 days?
(Circle one.)
1–No
2–Yes, one nonresident exposure
3–Yes, more than one nonresident exposure
4–Don’t know

D/K

3. Has this equid been indirectly exposed to nonresident equids the last 30 days?
(Circle one.)
1–No
2–Yes, one nonresident exposure
3–Yes, more than one nonresident exposure
4–Don’t know
4. Has this equid been directly or indirectly exposed to a mule or donkey in the last 30 days?
Y
N
D/K
5. Prior to the EHV-1 outbreak, approximately how many people on a daily basis had direct
exposure to this equid (include stall cleaners, grooms, trainers, caretakers, veterinarians,
farriers, etc.)?
#__________ or D/K
6. Has this equid had direct exposure to the index case in the last 30 days?
Y
N

D/K

7. Has this equid had indirect exposure to the index case in the last 30 days?
Y
N

D/K

SECTION 3: BIOSECURITY
This section pertains to biosecurity practices that have taken place since EHV-1 was confirmed
on the premises.

1. Has this equid been isolated from the other equids on the premises since EHV-1 was first
confirmed on the premises? If “Yes,” list the date.
Y date __/__/__
N
D/K

SECTION 4: NUTRITION
1. Which of the following was the primary grain/concentrate fed to this equid in the last 30
days?
(Circle one.)
1–Not fed
2–Unpelleted sweet feed, such as grain mixed with molasses
3–Unpelleted grain, such as whole or rolled oats and corn
4–Geriatric feed
5–Complete feed pellets or cubes, such as a forage/grain mixture
6–Grain mix with pellets
7–Other (specify: _________________)

2. Which of the following was the primary dried forage fed to this equid in previous 30 days?
1–Not fed
2–Alfalfa
3–Grass hay
4–Grass and alfalfa mix hay
5–Other (specify: _________________)
3. Does this equid typically receive dietary supplements (e.g., folic acid, vitamin E)?
Y
N

D/K

If “Yes,” please list the dietary supplement(s), the amount, and frequency of
administration.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Form F: Followup Questionnaire for the Index Case,
Subsequent EHV Cases, and Controls
This questionnaire is to be filled out for the index case, subsequent cases/potential subsequent
cases, and randomly selected controls at the end of the EHV-1 outbreak (28 days after the last
EHV-1 case is diagnosed). The subsequent cases and potential subsequent cases are all
equids that have been exposed to the index case and have developed a fever and/or neurologic
signs since the start of the EHV-1 outbreak. There should be three controls per case, which
should be randomly selected at the end of the outbreak. General background information was
collected on each equid on Form B, but this questionnaire will help identify potential EHM risk
factors for the index case and for other equids exposed to the index case.

Abbreviations for this questionnaire:
EHV-1: Equine herpesvirus-1
EHM: Equine herpesvirus myeloencephalopathy
Y=Yes, N=No, D/K=Don’t know, NA=Not applicable
Definitions for this questionnaire:
Equid: All species of equids such as donkeys, mules, ponies, horses, etc.
Exposed equids: Those that have shared airspace and/or had direct physical contact with the
index case.
Horses: All full-size horse breeds (14 hands or more at withers) including foals on the premises.
Does not include donkeys, mules, ponies, and miniatures.
In the last 30 days prior to the onset of EHM: Include the 30 days before the date that the
equid presented with neurological signs of EHM.
Randomly selected controls: Equids that have been exposed to the index case, but have not
developed a fever and/or neurologic signs.

The following questions pertain only to the equid previously specified for this
questionnaire:
Equid name or ID: __________________________
Today’s date: ___/___/___
Indicate status of this equid (circle one):
Index case

Subsequent EHV case in this outbreak

Control

This questionnaire relates to the clinical health and medical treatments of this equid. To answer
these, please refer to the equid’s medical records.
1. Was this equine diagnosed with EHV-1 infection?
Y
If “No,” skip to Question 6.

N

D/K

2. Was this equid diagnosed with EHM?
Y
3.

N

D/K

a. Has this equid shown any signs of EHV-1 disease (neuropathy, fever, lethargy,
decreased appetite, etc.) in the last 30 days?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 6.
b. Use the chart below to characterize the clinical signs of EHV-1 observed in the
equid.
Clinical sign

Answer Y/N

Date of onset of
clinical signs

Fever (>101.5°F)
Respiratory disease
Neurologic disease
Abortion
Lethargy
Leg edema
Other (specify)

If “No” to fever, skip to Question 5.
4.

a. How many days did the elevated body temperature last on the equid? (Circle one.)
1–2 days
3–4 days
5–6 days
7 days
b. What was the date the of the peak body temperature?__/__/__

5.

a. Did this equid have any neurological signs since the start of the EHV-1 outbreak?
(can refer to 3b.)
Y
N
D/K
If “No” or “Don’t know,” skip to Question 7.
b. Use the chart below to characterize the neurological signs observed in this equid.
Neurological signs

Check all that apply

Complete recumbency (cannot rise with assistance)
Incomplete recumbency (can rise with assistance)
Hind limb ataxia
Front limb ataxia
Toe Dragging
Paresis
Head tilt
Circling
Bladder atony
Reduced tail tone
Reduced anal tone
Other (specify)

6.

a. Has this equid received any medication since the date of the first questionnaire for
treatment or prevention of EHV-1?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 7.
b. Use the chart below to list the medication(s) administered to the equid for the
treatment or prevention of EHV-1 since the date of the first questionnaire.
Medication type

List name of medication
or NA if not applicable

Date of treatment
onset

Antivirals
NSAIDS
Corticosteroids
Antibiotic
Other (specify)

7.

a. Has the equid received any medication since the date of the first questionnaire for
reasons other than the treatment of EHV-1?
Y
N
D/K
If “No” or “Don’t know,” skip to Question 8.

b. Use the chart below to describe any type of medication the equiD has received since the
date of the first questionnaire other than the treatment or preventions or EHV-1.

Medication type

8.

List name of medication
or NA if not applicable

Date of initial
treatment

Treatment
duration in
days

Antivirals

_____days

NSAIDS

_____days

Corticosteroids

_____days

Antibiotic

_____days

Lasix/furosemide

_____days

Prerace jug

_____days

Joint injection

_____days

Dewormer

_____days

Vaccination(s)

_____days

Joint supplement(s)

_____days

Nutritional supplement(s)

_____days

Other (specify)

_____days

a. Has this equiD had any biological test to determine EHV-infectious status?
Y
N

D/K

If “No” or “Don’t know,” skip to Question 9.
b. Use the chart below to list the biological test(s) performed, the results obtained, and
the name of the testing laboratory responsible for processing the sample(s) to diagnose
EHM in the equid.
Biological Test

Check all that apply

Results: see code

Laboratory name

Nasal PCR
Blood PCR
*Serologic titers
**Histopathology
Virus isolation
***CSF analysis
Other (specify)
* Positive serologic titer is a 4X rise in titers 2–4 weeks apart with no history of vaccination during that time.
** Abnormal histopathology results include vasculitis and/or thrombosis of CNS blood vessels.
***Abnormal CSF analysis consistent with EHM is an increase in total protein/albumin without an increase in nucleated
cell count and presence of xanthochromia.

Result codes
1=Positive result/abnormal
2=Negative result
3=Unknown
4=Suspect or inconclusive results

9. What was the medical outcome of this equid?

Clinical outcome
No signs of EHV-1 throughout outbreak
Complete recovery
Improved but not completely recovered
Died (not euthanized)
Euthanized
Outcome other than those listed
(specify)______________________________________________

Check the
appropriate
row

Date of
outcome