20140006XXX Measles FSM

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Measles Case Control Study Questionnaire

MEASLES CASE CONTROL STUDY Questionnaire (last revised 5/30/14)

UNIQUE STUDY ID # (lab #?)# _ _ _ _ _ _ -_

[LAB #] [CASE CONTROL #] Case –control # [ CASE = 0 ; CONTROL 1 =1; CONTROL 2 =2; CONTROL 3 = 3]

REPORTING DATE (CASE ONLY ) (DAY/MONTH/YEAR) ______/________/_________

DATE OF INTERVIEW/INVESTIGATION (DAY/MONTH/YEAR ) ___/____/_____

NAME OF INTERVIEWER:

Written consent

obtained

INTERVIEW WITH: CASE

CONTROL

AGE: ______ years OR

_______ months

(if less than 12 months old)

DATE OF BIRTH

_____/______/_____

(DAY/MONTH/

YEAR)

SEX : MALE

FEMALE

START HERE: THANK YOU FOR AGREEING TO PARTICIPATE IN THE STUDY.

1. WHO IS THE RESPONDENT

 1 – CASE/CONTROL THEMSELF

 99 – OTHER (SPECIFY)__________

1. EXPOSURE HISTORY

2. HAVE YOU (CASE) HAD CONTACT WITH A PERSON WITH RASH AND FEVER IN THE 1 TO 3 WEEKS BEFORE THE BEGINNING OF YOUR RASH ILLNESS?

 1 – YES GO TO QUESTION 4

 2 – NO GO TO QUESTION 5

 99 – UNKNOWN GO TO QUESTION 5

3. HAVE YOU (CONTROL) HAD CONTACT WITH A PERSON WITH RASH AND FEVER IN THE PREVIOUS 1- 3 WEEKS?

 1 – YES GO TO QUESTION 4

 2 – NO GO TO QUESTION 6

 99– UNKNOWN GO TO QUESTION 6

4. WHERE DID YOU (CASE OR CONTROL) HAVE CONTACT WITH THIS PERSON?

Choose all that apply

 1 – AT HOME

 2 – AT WORK

 3 – AT SCHOOL

 4– HEALTH CENTER/HOSPITAL (SPECIFY) __________

 5 – CHURCH/MOSQUE/TEMPLE

 6 – PLAYING OUTSIDE

 7– ON PUBLIC TRANSPORT

 8 – OTHER __________

 99 – UNKNOWN

5. DID YOU (CASE) GO TO A HOSPITAL OR CLINIC 7 TO 21 DAYS BEFORE THE ONSET OF RASH ILLNESS ?

 1 – YES GO TO QUESTION 7

 2 – NO GO TO QUESTION 12

 99 – UNKNOWN GO TO QUESTION 12

6. DID YOU (CONTROL) GO TO A HOSPITAL OR CLINIC IN THE LAST 7 TO 21 DAYS?

(THE 7-21 DAYS PRIOR TO THIS INTERVIEW)

 1 – YES GO TO QUESTION 7

 2 – NO GO TO QUESTION 12

 99 – UNKNOWN GO TO QUESTION 12

7. HOW MANY TIMES DID YOU GO TO A HOSPITAL OR CLINIC?

 1 – ONCE GO TO QUESTION 8

 2 – MORE THAN ONCE GO TO QUESTION 11

8. NAME OF THE HOSPITAL/CLINIC?

9. WERE YOU ADMITTED TO THE HOSPITAL?

 1 – YES

 2 – NO

10. DATE OF VISIT

_____/________/_______

IF THE EXACT DATE IS NOT KNOWN, WRITE THE INFORMATION GIVEN BY THE INTERVIEWEE

11. LIST THE DATES AND LOCATIONS OF ALL HOSPITAL/CLINIC VISITS IN THE LAST 7-21 DAYS?

DATE

HOSPITAL/CLINIC NAME

ADMITTED TO HOSPITAL ON THIS VISIT?

____/________/_______

 1 – YES  2 – NO

____/________/_______

 1 – YES  2 – NO

____/________/_______

 1 – YES  2 – NO

____/________/_______

 1 – YES  2 – NO

12. HAVE YOU BEEN IN ANY DENSELY POPULATED INDOOR (CONGREGATED) SETTINGS IN THE LAST THREE WEEKS (SUCH AS KINDERGARTEN, SCHOOL, FACTORY OR DORMITORY)

 1 – YES GO TO QUESTION 13

 2 – NO GO TO QUESTION 15

 99 – UNKNOWN GO TO QUESTION 15

13. WHAT WAS THE CONGREGATED SETTING? Choose all that apply

 1 - KINDERGARTEN

 2 – SCHOOL

 3- FACTORY

 4 – RELIGIOUS SERVICE

 5 -PUBLIC TRANSPORTATION (SPECIFY __________________)

 6 – JAIL/PRISON

 7- HOSPITAL

 8 – GOVERNMENT BUILDING

 9– DORMITORY

 10 – WEDDING

 11 – WORK PLACE

 12– OTHER (SPECIFY ____________)

ADDRESS OF CONGREGATED SETTING:

______________________

ADDRESS: _______COUNTRY/DISTRICT

_______ TOWNSHIP/STREET

________ VILLAGE/NEIGHBORHOOD

2. VACCINATION STATUS

NOW I AM GOING TO ASK YOU SOME QUESTIONS RELATED TO VACCINATION

14. WERE YOU VACCINATED AGAINST MEASLES AS A CHILD?

 1 – YES GO TO QUESTION 16

 2 – NO GO TO QUESTION 17

 99 – UNKNOWN GO TO QUESTION 17

15. HOW MANY DOSES OF MEASLE VACCINE DID YOU RECEIVE AS A CHILD?

 1 – ONE

 2- TWO OR MORE

 99– UNKNOWN

3. INFORMATION ABOUT PLACE OF RESIDENCE AND TRAVEL HISTORY

I AM GOING TO ASK YOU (CASE OR CONTROL) SOME QUESTIONS ABOUT YOUR TRAVEL HISTORY

16. IN THE LAST 2 MONTHS HAVE YOU TRAVELED OUTSIDE OF KOSRAE (FOR ANY REASON)?

17. HOW MANY TIMES IN THE LAST 2 MONTHS HAVE YOU TRAVELED OUSIDE OF KOSRAE?

18. WHERE DID YOU TRAVEL TO?

19. IN THE LAST 2 MONTHS HAS A MEMBER OF THE HOUSEHOLD TRAVELED OUTSIDE OF “X”?

20. WHICH HOUSEHOLD MEMBER AND WHERE DID THEY GO TO?

21. IN THE LAST 2 MONTHS HAVE YOU HAD CONTACT WITH ANYBODY FROM A FOREIGN COUNTRY?

22. WHERE WAS THIS PERSON OR PEOPLE FROM?

23. (LIST ALL APPOPRIATE RESPONSES)

24. WHERE DID YOU HAVE CONTACT WITH THIS PERSON?

25. (LIST ALL APPOPRIATE RESPONSES)

SOCIODEMOGRAPHIC INFORMATION

MY LAST QUESTIONS DEAL WITH YOUR HOUSEHOLD

26. PLEASE LIST NAMES AND AGES OF ALL HOUSEHOLD MEMBERS

HH MEMBER	NAME	AGE	FEVER AND RASH IN LAST 3 MONTHS? (yes/no)	DATE OF ILLNESS
 1
 2
 3
 4
 5
 6
 7
 8
 9
 10

27. HOW MANY PEOPLE SLEEP IN THE SAME ROOM AS YOU?

28. DO YOU HAVE ANY CHILDREN?

29. HOW MANY CHILDREN DO YOU HAVE?

HOW OLD IS THIS CHILD/CHILDREN?

DOES THIS CHILD/ CHILDREN LIVE WITH YOU?

WHICH ETHNIC GROUP DO YOU BELONG TO?

WHAT RELIGION DO YOU PRACTICE?

30. WHAT IS YOUR LEVEL OF SCHOOLING

31. WHAT IS THE LEVEL OF SCHOOLING OF YOUR MOTHER?

WHAT IS THE LEVEL OF SCHOOLING OF YOUR FATHER?

32. WHAT IS YOUR OCCUPATION?

SIGNATURE OF SUPERVISOR _________________ DATE OF VERIFICATION BY SUPERVISOR___/___/___

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)