Burkholderia Pseudomallei Release

National Animal Health Monitoring System

2150 Centre Ave Bldg B

Fort Collins, CO 80526

Form Approved

OMB Number 0579-0376

Approval expires: 09/30/2017

Animal and Plant Health

Inspection Service

Veterinary Services

TNPRC Employee

Domestic Animal

Questionnaire

Purpose: This questionnaire is being administered in response to the finding of Burkholderia pseudomallei (Bpm) at the Tulane National Primate Research Center (TNPRC). The intent is to collect data on the potential exposure of domestic animals outside of the TNPRC from employees in contact with non-human primates at the TNPRC. Participation in this data collection activity is voluntary. Data collected by the Data Collector is not being collected for regulatory purposes. However, information on an employee’s animals may be disclosed as a result of disease containment or response efforts.

Employee Instructions: Please complete the attached survey and return to the contact person listed below. It is important that all questions be answered as completely as possible for the study to meet its goals. If you have any questions or need assistance please see the contact person. The deadline for completing the surveys is March 20, 2015.

Contact Person Instructions: Please separate this cover page from the completed survey questions. Utilize cover sheets to track response rates. Prepaid UPS shipping labels are available for returning the completed questionnaires to NAHMS. Upon receipt of the surveys, NAHMS will assign each respondent a unique number for data entry. Return completed questionnaires to:

National Animal Health Monitoring System

C/O Abby Zehr

2150 Centre Ave. Building B MS 2E7

Fort Collins, CO 80526

Employee Name:

Date questionnaire completed:

Contact Person Name:

This Page Intentionally Left Blank

Animal and Plant Health

Inspection Service

Veterinary Services

National Animal Health Monitoring System

2150 Centre Ave Bldg B

Fort Collins, CO 80526

Form Approved

OMB Number 0579-0376

Approval expires: 09/30/2017

TNPRC Employee

Domestic Animal

Questionnaire

1. Do you own any animals? ₁ Yes ₃ No

[If question 1 = No, SKIP to question 5.]

2. If you own any pets or livestock, please indicate the number of each:

a. Dog/cat _____ #

b. Horse _____ #

c. Poultry _____ #

d. Sheep/goat _____ #

e. Cattle _____ #

f. Pigs _____ #

g. Other (specify: ______________________________) _____ #

3. Since August 2014, have you noticed any unusual illness or death

in animals you own? ₁ Yes ₃ No

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
0.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected.

0579-0376

Exp.: 9/30/2017

If Yes, please complete the table below describing the type of animal, illness and dates:

Species / type of animal affected	Symptoms or signs of illness	Date of onset

4. What is the name of the veterinarian you most often use for your owned animals?

_______________________________________________

5. Other than animals you own, have you had regular

contact with other pets or livestock since August 2014? ₁ Yes ₃ No

[If question 5 = No, SKIP to question 9.]

6. Where do you have regular contact with animals that you don’t own since August 2014?

[Check all that apply.]

₁ Farm

₂ Stable

₃ Livestock show

₄ Nonfarm residence

₅ Work for veterinarian (Name: ______________________________)

₆ Other (________________________________________________)

7. What pets or livestock have you had regular contact with that you don’t own?

a. Dog/cat _____

b. Horse _____

c. Poultry _____

d. Sheep/goat _____

e. Cattle _____

f. Pigs _____

g. Other (specify: ______________________________) _____

8. Have you noticed any unusual illness or death

in animals with which you have contact? ₁ Yes ₃ No

If Yes, please complete the table below describing the type of animal, illness and dates:

Species / type of animal affected	Symptoms or signs of illness	Date of onset

9. Do you have direct contact (via animal handling) with primates at the Center? …………… ₁ Yes ₃ No

10. Do you have indirect contact with primates at the Center? Indirect contact is contact with environmental surfaces, such as soil, water and enclosures; contact with clothing or feeding and cleaning equipment that would also have been in contact with primates. ………………………………………………………..… ₁ Yes ₃ No

11. Is there anything you would like to share with epidemiologic investigators regarding the potential exposure of domestic animal health? If yes, please describe:

____________________________________________________________________________________