June
11,
2014
Form
Approved OMB
No.
0920-1011 Exp.
Date
03/31/2017
Hypothesis Generating Questionnaire Gastroenteritis
Hi! My name is . We are working with the Health department to try and figure out what caused the outbreak of diarrhea. Could we please ask you a few questions? Your answers will help prevent diarrhea in the future.
Your answers will be completely confidential. That means we will not share your personal information with anybody else.
Thank you!!!
Interviewer name:
Date:
DEMOGRAPHIC INFORMATION: Patient name:
Name (if not the patient):
Relationship to child (if patient is <18 years of age):
Sex: M F
Nationality: American Samoan Western Samoan
Other Pacific Islander Asian
White, non-Hispanic Black, non-Hispanic Unknown
Number of people in household:
Number of adults: Number of children:
CLINICAL SYMPTOMS:
According to our records, you came to the Emergency room for diarrhea on (DATE). Please think back to the week before you got sick.
When did you first get sick (mm/dd/yyyy)?
On what day did diarrhea begin (mm /dd /yyyy)?
For how many days did you experience diarrhea? :
When at its worst, what was the total number of episodes of diarrhea you experienced in a 24 hour period?
1-3 per day
4-6 per day
5-10 per day
10+ per day
What symptoms did you have? : Circle all that apply.
Fever
Vomiting
Poor feeding
Irritable
Bloody diarrhea
Non-bloody diarrhea
Watery diarrhea
Fatigue/Weakness
Chills
Headache
Abdominal cramps
Nausea
Bodyaches
What was the first place you went to seek treatment?
Emergency room
Local clinic
Village healer
Other:
Did you take any medications for the diarrhea?
Over the counter: Yes No /Name:
From the hospital: Yes No /Name:
Do you use any at-home remedies for diarrhea? Yes No /Name:
Did you hear about diarrhea from family/friends recently? Yes No
Did you hear about diarrhea from on TV/in the newspaper recently? Yes No How long after you first got sick did you seek medical treatment?
Less than 1 day
1 – 2 days
3 – 4 days
5 – 6 days
7 days or more
What prompted you to go to the emergency room? Circle all that apply.
Diarrhea
Dehydration
Fever
Stomach / gut pain
Unable to eat
To get medicine
Worried about ameba
Friend or family member suggested going
Other:
Did you attend flag day? Yes No
In the week before illness, did you travel anywhere outside the village? Yes No If yes, where?
Other village(s): (Village name(s):
Off-island (Name of location):
In the week before illness, did you have contact with anyone who traveled: Outside the village: Yes No
Off-island: Yes No
In the week before illness, were you exposed to a school or child-care facility? Yes In the week before illness, were you exposed to any flies? Yes No
Is your home screened? Yes No
Do you have a refrigerator? Yes No
In the week before illness, did you attend any special events where food was served or catered (weddings, community meetings, church events, etc.)? Yes No
If yes:
#1 Type of event:
#1 Was there a sink with soap and water to wash your hands? Yes No
#2 Type of event:
#2 Was there a sink with soap and water to wash your hands? Yes No
In the week before illness, did you go swimming or have other recreational water exposures (fishing, etc.)? Yes No
If yes, please describe:
What is the water supply source for your home or residence? Circle all that apply.
ASPA water
Village water
Rain water
Vending machines
Bottled water
Other:
If multiple sources, what source is usually used for each?
Drinking: Cooking: Bathing: Washing clothing: Cleaning: Hand washing:
Where do you typically wash your hands at home?
When do you typically wash your hands at home?
When you don’t wash your hands at home, what are some reasons why?
Does the household usually boil or filter water before use for cooking?
Boiling
Filtering
No treatment
Does the household usually boil or filter water before use for drinking?
Boiling
Filtering
No treatment
What type of sewage disposal does your house have?
ASPA sewage
Septic Tank
Cesspool
Nothing
Other :
How do you dispose of trash?
ASPA
Self-disposal
Other:
IF ASPA:
How many days per week is trash collected by ASPA?
days per week
IF SELF DISPOSAL:
How many days per week is trash taken outside the house?
days per week
How many days per week is trash taken off the property?
days per week
Where do you take the trash to:
What do you eat on a typical day?
Breakfast
What do you eat?
Where do you eat?
Lunch
What do you eat?
Where do you eat?
Dinner
What do you eat?
Where do you eat?
Snacks
What do you eat?
Where do you eat?
Drinks
What do you drink?
Where do you usually shop for groceries?
What restaurants do you usually go to?
Do you know anyone else who is ill? Yes No
#1 Relation to you:
#1 Does this person live with you?:
#1 Village:
#2 Relation to you:_
#2 Does this person live with you?:
#2 Village:
#3 Relation to you:_
#3 Does this person live with you?:
#3 Village:
#4 Relation to you:
#4 Does this person live with you?:
#4 Village:
#5 Relation to you:
#5 Does this person live with you?:
#5 Village:
How do you think you got sick?
Is there anything else you would like to share with us, relating to the diarrhea outbreak?
We truly appreciate your talking to us today.
| File Type | application/zip |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |