Questionnaire for Passengers and Crew

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Questionnaire for Passengers and Crew, MERS-CoV Aircraft Contact Investigation

Identifying and Residency Information

1. Traveler’s name: _________________________________________________

2. Type of Traveler (circle): passenger crew

3. Home Phone: _________________________ 4. Mobile Phone: ____________________

(circle best number to reach at)

5. E-mail address: _________________________________

6. Home address (or address for next 14 days if nonresident): ____________________

______________________________________________________________________

7. State______________ 8. Zip ____________

9. If non-US resident, country of residence: _________________________________

Attempt(s) to reach traveler:

Date	Time	Outcome	Message left/e-mail sent
		Interview completed / not completed
		Interview completed / not completed
		Interview completed / not completed
		Interview completed / not completed
		Interview completed / not completed

Name of person answering the questions (if not traveler): ____________________________

Relationship of person answering questions to traveler: ____________________________

Name of Interviewer: ___________________________

Agency/Affiliation of Interviewer:______________________________________

Verbal consent/parental permission obtained? Circle: Yes / No

For minors (13-17), assent obtained? Circle: Yes / No

If NO, parent interviewed on child’s behalf? Circle: Yes / No

This section will be filled in with data from eManifest

For each flight: Airline/Flight # : ______________________ Date of Flight (mm/dd/yy): ______________ from Airport Code or Location: ________________ to Airport Code or Location: _______________

For Passengers: Assigned Seat #: ________ Case-patient’s Seat#: _____

-------------------------------------------------------------------------------------------------

Interview date (mm/dd/yy) ___/___/14  Telephone  In-person  E-mail  Other _______

A. Demographic Information

10. Age: ______ years / months (circle one)

11. Sex (circle one): M F

B. Flight History for Passenger (for crew member, skip to Section C)

The airline(s) has/have indicated that you were a passenger on the following flight(s). The next set of questions pertain to that/those specific flight(s).

Questions 12-14 will be repeated for each flight, as applicable

NOTE: If passenger was not on any of the above flights, the interview is completed.

Questions for Flight A [insert flight info]

12a. Confirm passenger traveled [insert date] on [Flight A-airline name,flight number] from [Origin city, state or country] to [destination city, state]  Yes  No  Unsure

If NO or unsure, provide code share info. Check other flights. If not on any of the flights, then the interview is complete.

If YES,

13a: Did you sit in your assigned seat for this entire flight ?

 Yes – Skip to Section D  No  Don’t remember

13a.1. If no, how long did you sit in your assigned seat?

 <30 minutes  30-60 minutes  > 60 minutes  Don’t remember

13a.2. What other seat number did you sit in for all or part of the flight?

Seat Number: _______  Don’t remember

13a.3. If passenger doesn’t remember which seat number, ask to describe which part of the plane she or he sat in. ________________________________________________

13a.4. How long did you sit in this other seat?

 <30 minutes  30-60 minutes  > 60 minutes  Don’t remember

14a. Were you traveling with anyone else on this flight?

 Yes –complete table below  No – Skip to Section D

14.a.1. Who did you travel with? [This information will help make sure we can contact her or him about possible exposure during the flight.]

Name (last, first) Relation* Phone

_______________________ _______________ ______________

_______________________ _______________ ______________

_______________________ ________________ ______________

*A. friend B. colleague C. household member** D. non-household family member

** If household member(s), ask to interview that person when done with this interview

14b. Did you come into contact with anyone who seemed ill with respiratory symptoms (such as cough or difficulty breathing) or appeared feverish?  Yes  No

14c. Did you assist them in any way? If yes, please explain. _______________________________________________________________________

C. Flight History for Crew Member (For passenger, skip to Section D)

15. Confirm that crew member worked on flight #: _______________ on [date of flight]: __________ (mm/dd/yyyy) from [City, country] to [City, state]?  Yes  No  Unsure

If No or unsure, provide code share info. IF still NO, interview is complete. Thank the person for her/his time.

If YES, continue

16. Crew type (circle all that apply)

Flight Deck: Captain

First Officer

Flight engineer/ navigator

Other (such as jumpseater; specify): ________________________

Cabin: First Class

Business Class

Economy Class(specify section if assigned to a specific one): __________

Lead Flight Attendant

17. Did you come into contact with anyone who seemed ill with respiratory symptoms (such as cough or difficulty breathing) or appeared feverish?  Yes  No

18. Did you assist them in any way? If yes, please explain. _______________________________________________________________________

D. Illness and Medical History

19. Have you been ill since the day of your flight on [insert date of flight]?  Yes  No

IF YES, SKIP TO 21. IF NO, continue with question 20.

Follow-up for asymptomatic contacts [if initial telephone contact is < 14 days since flight]

20. Is it OK if I or someone else calls you again in about [insert number of days that will be 14 days after the flight date] to check if you are still well?  Yes  No

If YES,

1. What is the best time to reach you? ___________

2. What is the best number to reach you? ____________

INTERVIEW IS COMPLETE.

• Read end script for asymptomatic contact.

• Send questionnaire to health department for high-risk contact.

21. Have you had any of the following symptoms since [insert date of flight]?

1. Fever (measured temp of > 100.4⁰ F (38⁰ C)  Yes (Temp if known _____°)  No  Don’t Know

2. Coughing  Yes  No  Don’t Know

3. Difficulty breathing or shortness of breath  Yes  No  Don’t Know

4. Wheezing  Yes  No  Don’t Know

5. Pain with coughing or breathing  Yes  No  Don’t Know

6. Other symptom(s):  Yes; List: ____________________  No  Don’t Know

IF NO/DON’T KNOW TO 21 a-e, INTERVIEW IS COMPLETE.

• Read end script for asymptomatic contact.

.

22. What date did you first become ill with these symptoms? (Date : ____/____/14)

If sick on or before date of flight, complete interview, then consult medical officer before giving advice to patient.

23. Are you still sick?  Yes  No

23a. If NO, when did you feel better? Date__/__/14

24. Did you see a doctor for this illness?  Yes  No

If YES,

1. What date were you seen? Date__/__/14

2. Did you receive any treatment for the illness?  Yes  No

   1. If YES, specify: _____________________________________

3. Were you tested by a medical provider for the illness (including, but not limited to, providing a blood sample, or nasal or throat swab) since the day of your flight on [insert date of flight]?  Yes  No

   1. If YES – Specify test or what kind of specimen was tested for you (e.g., blood, nasal swab, throat swab.): _______

      1. Date (mm/dd/yy) ____/____/14

      2. Facility where tested_____________________

4. Were you admitted to the hospital (kept overnight, not just in emergency room)? YES/NO If yes, which hospital? ________________

25. Do you have any medical conditions that you are treated for regularly?

 Yes (Specify: ______________)  No  Don’t Know

26. For women: Are you currently pregnant?  Yes  No  Don’t Know

E. GEOGRAPHIC EXPOSURES

27. Have you visited the Middle East since [insert date that is 14 days before the flight date]*

 Yes  No If NO, skip to Question 29.

1. If YES : Dates of visit (mm/dd/yy) ____/____/14 to ____/____/14

2. List country(ies): ___________________________

3. (Omit for crew) What was the purpose of your trip? (check all that apply)

 Visit family/friends  Personal travel  Business  Study Other, specify_______

28. While you were in the Middle East, did you:

1. Have any close contact with someone who was sick with MERS-Coronavirus?  Yes  No

2. Have any close contact with someone who was sick with a serious respiratory infection, such as pneumonia?  Yes  No

c. Visit a health care facility?  Yes  No

4. (Omit for crew) Work in a health care facility?  Yes  No

F. Household Contacts

29. Has anyone in your household or someone else you have had close contact with had fever, cough, difficulty breathing, or other symptoms similar to what you described?

 Yes ***  No  Don’t Know

1. Name(s): ____________________________________

Relationship: __________________________________

Symptoms: _________________________________________

Date of onset (mm/dd/yy) ____/____/____

Address: ____________________________________________

Phone #: ________________________

2. Name: ____________________________________

Relationship: __________________________________

Symptoms: _________________________________________

Date of onset (mm/dd/yy) ____/____/____

Address: ____________________________________________

Phone #: ________________________

*** Note this person’s name and contact information on the form for follow-up by local health department.

INTERVIEW IS COMPLETE.

IF FEVER PLUS ANY RESPIRATORY SYMPTOMS (21 b-e):

• Read end script for symptomatic contact.

• Send completed questionnaire to health department.

CONSULT MEDICAL OFFICER IF FEVER ALONE OR WITH ONLY “OTHER” SYMPTOMS, OR RESPIRATORY SYMPTOMS WITHOUT FEVER.

THE END

End scripts for passengers and crew interviewed during MERS-CoV flight contact investigation

Note: these scripts will be used at the END of contact investigation interview to provide instructions to contacts on additional steps. The scripts will supplement the written informational notice that will be sent to contacts.

Script for Person who Declined Interview

• Thank you for your time.

• I’d like to send you some information about what to do if you get sick. I will also send you a phone number you can call if you have any questions.

• Would you prefer that I e-mail or fax it? [If select fax, ask for fax number]. Otherwise I can mail it to you. [Document contact information on interview form.] [If the person declines to receive the information sheet, try to provide the dedicated CDC phone number for questions.]

• Do you have a few minutes for me to go over some of the information with you? [If yes, proceed. If no, thank them for their time and send information sheet.]

• The period of risk is 14 days after the flight, so another [days remaining from 14 since flight] days.

• It is important to watch yourself for fever and respiratory illness during this time.

• Fever is a temperature ≥ 38° C or 100.4° F. If you are unable to take your temperature, feeling hot or feverish, can be considered a “fever.”

• Respiratory illness can include cough, difficulty breathing, wheezing, or pain when you cough or breathe deeply.

• If you have any of these symptoms during this time, call your health department.

• There is a phone number for your health department in the information I will send you. [Interviewer: Check location (ZIP Code) to add specific health department contact information.]

• If you can’t reach your health department, see a doctor. There are instructions on what to do in the information sheet.

• Do you have any questions for me?

Asymptomatic Contact Script (will be modified for crew as needed, e.g., replace HD with occupational health) [Interviewer, if exposed traveler is a child and parent/guardian is speaking, replace “you” with “your child” when appropriate]

• Thank you for your time.

• I’d like to send you some information about what to do if you get sick. Would it be better to e-mail or fax it? Otherwise I can mail it to you. [Interviewer: Should already have e-mail address. Ask for fax number if needed.]

• The period of risk is 14 days after the flight, so another [days remaining from 14 since flight] days remain.

• It is important to watch yourself for fever and respiratory illness during this time.

• Fever is a temperature ≥ 38° C or 100.4° F. If you are unable to take your temperature, feeling hot or feverish, can be considered a “fever.”

• Respiratory illness can include cough, difficulty breathing, wheezing, or pain when you cough or breathe deeply.

• If you get sick during this time, call your health department.

• There is a phone number for your health department in the information I will send you.

• If you can’t reach your health department, call your doctor.

  • Tell the doctor you may have been exposed to MERS-CoV on a plane and that you are having flu symptoms.

  • Wear a face mask to the doctor’s office or ask for one as soon as you arrive.

  • Take the information sheet that I send you when you go to the doctor.

  • Ask the doctor to contact your health department.

• While you are sick, you should stay home from work or school and avoid traveling, except to see a doctor. Please look at the information that I send you for other ways to protect others.

• Remember to cover your mouth and nose when you cough and sneeze and wash your hands often.

• [If agreed during interview] We will call you back in a few days to see how you’re doing.

• Do you have any questions for me?

• The information I send also has a phone number you can call if you have questions later. Do you want to also take this down now? [Provide dedicated CDC number over the phone.]

Symptomatic Contact Script (will be modified for crew as needed, e.g., replace HD with occupational health) [Interviewer, if exposed traveler is a child and parent/guardian is speaking, replace “you” with “your child” when appropriate]

• Thank you for your time.

• I’d like to send you some information about getting health care and protecting others from infection. Would it be better to e-mail or fax it? Can you give me your fax number? [should have e-mail address from questionnaire]

• We will tell your local health department about your illness and your possible exposure to MERS-CoV on your flight. Someone from your health department should call you.

  • If you don’t hear from your health department in the next few hours, you can call them.

  • There is a phone number for your health department in the information sheet I will send you. I can also give you this number now. [Provide HD number over the phone.]

• If you can’t reach your health department, call your doctor.

  • Tell the doctor you may have been exposed to MERS-CoV on a plane and that you are having flu symptoms.

  • Wear a face mask to the doctor’s office or ask for one as soon as you arrive.

  • Take the information sheet that I send you when you go to the doctor.

  • Ask the doctor to contact your health department.

• While you are sick, you should stay home from work or school and avoid traveling, except to see a doctor. Please look at our information sheet for other ways to protect others.

• Remember to cover your mouth and nose when you cough and sneeze and wash your hands often.

Public reporting burden of this collection of information is estimated to average 15 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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)