Family Interview Questionnaire
Emergency Epidemic Investigation Data Collections - Expedited Reviews
2014018-XXX_Appendix 2
Pediatric cluster of neurologic symptoms - Colorado
OMB: 0920-1011
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Appendix II: Questionnaire for Family Interview
Please note that this questionnaire has 17 pages and contains 8 parts:
Part A: Demographic information about the patient
Part B: Summary of patient’s neurological admission, including history of preceding respiratory symptoms
Part C: Review of child’s general health
Part D: Child’s surroundings and household contacts in the week before illness
Part E: Family and friend visits in the week before illness
Part F: Childcare or healthcare worker visits in the week before illness
Part G: Other information
Interview form for ___________________________________________ (please insert infant’s name)
Date of interview: ________________ (MM/DD/YYYY)
Name of interviewer: _________________________________________________________
Interviewer’s institution: ______________________________________________________
Primary interviewee (eg mother): ________________________________________________
Phone number to call: ________________________________________ Home
________________________________________ Cell
________________________________________ Work
________________________________________ Other
Secondary interviewee (eg father): _______________________________________________
Phone number to call: ________________________________________ Home
________________________________________ Cell
________________________________________ Work
________________________________________ Other
When initiating the interview, please use the following paragraph:
Hello, my name is ____________________________, and I am a _____________________________ at the________________________________________.
Along with the Colorado Children’s Hospital, Colorado state health departments, and Centers for Disease Control and Prevention, we are investigating recent cases of patients admitted with neurological symptoms after experiencing respiratory symptoms. I understand that your son/daughter _____________________ was recently hospitalized. Is that correct?
I’m calling today to ask if you would be willing to answer a few questions regarding your son’s/daughter’s recent illness. It should take about 15 minutes. We are hoping to understand more about what happened around the time of the illness. We hope that this will help us to understand their symptoms better and the potential causes. Are you willing to speak with me today about this?
Yes: That’s great, thank you very much.
No: Is there a more convenient time for me to call you back?
Call back time: Day: _______________ Time: _______________
No: Is there anyone else in the house that is able to talk with me today?
Was consent given? Yes No
Final interview was conducted with: _____________________________________________
Relationship to infant (case patient): ____________________________________________
Part A: Case-patient demographic information |
Patient’s First Name: _______________________ ____ Patient’s Last (Family) Name: __________________________ Date of Birth: __________________ (MM/DD/YYYY) Sex: Female Male Unknown
First name of first parent/guardian: _____________________________________ Last (Family) name of first parent/guardian: ______________________________ Email address: ___________________________________________________ Residence address: __________________________________________________________________ __________________________________________________________________________________
First name of second parent/guardian: _____________________________________ Last (Family) name of second parent/guardian: ______________________________ Email address: ___________________________________________________ Residence address: __________________________________________________________________ __________________________________________________________________________________
|
Part B: Summary of patient’s illness |
I will now ask a few questions about your son’s/daughter’s illness. Date of first symptoms: ______________________ (MM/DD/YYYY)
Please describe any other symptoms that followed and when they occurred:
Was he/she at home when the illness began? Yes No Unknown If no, where was he/she? ____________________________________________________________ Did you seek medical care for any of these symptoms at a doctor’s office, clinic or urgent care center before your son/daughter was admitted to hospital? Yes No If yes, please give details (where, when, name of physician etc): _____________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
When did you take him/her to hospital? _____________________ (MM/DD/YYYY) Hospital name: _____________________________________________________________________ Hospital floor and room number: ________________________________________________________ Admitting physician’s name: ____________________________________________________________ Were they transferred to another hospital? Yes No Unknown If yes, transfer date: _____________________ (MM/DD/YYYY) If yes, receiving hospital name: ________________________________________________________ If yes, doctor’s name: ________________________________________________________________ |
Part C: Review of patient’s general health |
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Before your son/daughter became ill and required admission, was he/she on any medications?
Before this illness, did you take your son/daughter to the hospital for any reason? Yes No Before this illness, did you take your son/daughter to an outpatient clinic? Yes No
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Part D: Patient’s surroundings and household contacts in the week before illness |
I would now like to ask you some questions about who your son/daughter might have had close contact with in the week before their illness. Does your child (who was ill) attend day care? Yes No Unknown Does your child (who was ill) attend after school programs? Yes No Unknown
If speaking to the mother, please skip to Person 2, under household contacts Now I would like to ask you about the people who may have had contact with your child, starting with yourself: Person 1 Name: ____________________________________________________________________________ Age: ________________ Relationship to infant: ____________________________________ Occupation: ________________________________________________________________________ Were you ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms)
If yes, what kind of symptoms did you have? _____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ If yes, did you receive any treatment? ___________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Household contacts Could you now please describe the other members of your household, including both adults and children:
Person 2 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ___________________________________ Occupation or school/preschool: ________________________________________________________ Were they ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms) If yes, what kind of symptoms did they have? _____________________________________________ __________________________________________________________________________________ If yes, did they seek medical care and where? _____________________________________________ __________________________________________________________________________________ If yes, did they receive any treatment? __________________________________________________ __________________________________________________________________________________
Person 3 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Occupation or school/preschool: ________________________________________________________ Were they ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms) If yes, what kind of symptoms did they have? _____________________________________________ __________________________________________________________________________________ If yes, did they seek medical care and where? _____________________________________________ __________________________________________________________________________________ If yes, did they receive any treatment? __________________________________________________ __________________________________________________________________________________
Person 4 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Occupation or school/preschool/day care: _______________________________________________ Were they ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms) If yes, what kind of symptoms did they have? _____________________________________________ __________________________________________________________________________________ If yes, did they seek medical care and where? _____________________________________________ __________________________________________________________________________________ If yes, did they receive any treatment? __________________________________________________ __________________________________________________________________________________
Person 5 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Occupation or school/preschool/day care: _______________________________________________ Were they ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms) If yes, what kind of symptoms did they have? _____________________________________________ __________________________________________________________________________________ If yes, did they seek medical care and where? _____________________________________________ __________________________________________________________________________________ If yes, did they receive any treatment? __________________________________________________ __________________________________________________________________________________
Person 6 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Occupation or school/preschool/day care: _______________________________________________ Were they ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms) If yes, what kind of symptoms did they have? _____________________________________________ __________________________________________________________________________________ If yes, did they seek medical care and where? _____________________________________________ __________________________________________________________________________________ If yes, did they receive any treatment? __________________________________________________ __________________________________________________________________________________
Person 7 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Occupation or school/preschool/day care: _______________________________________________ Were they ill in the week before your son/daughter became ill? Yes No Unknown (please ask specifically about respiratory and diarrheal symptoms) If yes, what kind of symptoms did they have? _____________________________________________ __________________________________________________________________________________ If yes, did they seek medical care and where? _____________________________________________ __________________________________________________________________________________ If yes, did they receive any treatment? __________________________________________________ __________________________________________________________________________________
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Part E: Family and friend visits in the week before illness |
Were there any other family members or close friends who appeared unwell and who visited the patient in the week prior to onset of illness? Or that you went to visit? Please include children too. Person 8 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Occupation or school/preschool/day care: _______________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below Person 9 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Occupation or school/preschool/day care: _______________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below
Person 10 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Occupation or school/preschool/day care: _______________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below
Person 11 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Occupation or school/preschool/day care: _______________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below
Person 12 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Occupation or school/preschool/day care: _______________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below
Person 13 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Occupation or school/preschool/day care: _______________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please continue overleaf |
Part F: Childcare or healthcare worker visits in the week before illness |
Were there any childcare or healthcare worker contacts who appeared unwell,in the week before illness? (e.g. babysitter, pediatric provider) Person 14 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Reason for visit:_____________________________________________________________________ What kind of symptoms did the visitor have? _____________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below Person 15 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Reason for visit:_____________________________________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below
Person 16 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Reason for visit:_____________________________________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please include details in the next person below
Person 17 Name: ____________________________________________________________________________ Age: ________________ Relationship to patient: ____________________________________ Where did you see them? _____________________________________________________________ Reason for visit:_____________________________________________________________________ What kind of symptoms did they have? _________________________________________________ __________________________________________________________________________________ Did they seek medical care and where? __________________________________________________ __________________________________________________________________________________ Did they receive any treatment? _______________________________________________________ __________________________________________________________________________________ Do you know if they had any ill family members or friends? Yes No Unknown If yes, please continue overleaf |
Part G: Other information |
Is there any other information that you feel may be important or unusual, with regard to your son’s/daughter’s illness or stay in hospital:
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Thank you very much for taking the time to speak with me today. Your interview has been extremely useful and we hope it will help us to better understand the current situation.
We might need to contact you again in the future to ask some more questions about this. Would it be OK if I (or my colleagues) contacted you? Yes No
Thanks again, good bye.
End of interview form
Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
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| Author | ydk5 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |
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