MERS-CoV Aircraft Contact Investigation

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Questionnaire for Passengers and Crew

MERS-CoV Aircraft Contact Investigation

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 serology? Yes / No

For minors (13-17): Assent obtained? Circle: Yes / No If NO, parent interviewed on child’s behalf? Circle: Yes / No Assent for serology? Yes / No

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 should 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(s)

12a. Confirm passenger traveled on [check flight(s) below]

• Flight Leg A, May 1^st, 2014  Yes  No  Unsure

• Flight Leg B, May 1^st, 2014  Yes  No  Unsure

• Flight Leg C, May 1^st, 2014  Yes  No  Unsure

• Flight Leg D, May 1^st, 2014  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 Question 14a  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 Question 14b

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 Leg A, May 1^st, 2014  Yes  No  Unsure

• Flight Leg B, May 1^st, 2014  Yes  No  Unsure

• Flight Leg C, May 1^st, 2014  Yes  No  Unsure

• Flight Leg D, May 1^st, 2014  Yes  No  Unsure

IF NO, interview is complete. Thank the person for her/his time.

If YES, continue

16. Crew type (circle all that apply) or Cabin for passenger

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 the flight?  Yes  No

IF YES, GO TO 20. IF NO, GO TO APPENDIX I (SEROLOGY). THEN…

• Read end script for asymptomatic contact.

• Send Information Notice to traveler by e-mail or fax.

20. Have you had any of the following symptoms since your 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 20 a-e, GO TO APPENDIX I (SEROLOGY). THEN…

• Read end script for asymptomatic contact.

• Send Informational Notice for MERS-CoV Exposure on Airplane to traveler by e-mail or fax.

21. 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.

22. Are you still sick?  Yes  No

22a. If NO, when did you feel better? Date__/__/14

23. 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?  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? ________________

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

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

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

E. GEOGRAPHIC EXPOSURES

26. Have you visited the Middle East since April 17^th?

 Yes  No If NO, skip to Question 28.

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_______

27. 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

5. Have any animal exposures?  Yes  No

If yes: name animals

1: ______________ (describe) ___________________, date:____/____/____

2: ______________ (describe) ___________________,  date:____/____/___

3: ______________ (describe) ___________________, date:____/____/____

F. Household Contacts

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

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 #: ________________________

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)