Suspected Chikungunya Case

Form Approved

OMB No. 0920-1011

Expiration 03/31/2017

Suspected Chikungunya Case Questionnaire August 16, 2014

Interviewer:______________ Date of Interview: ___/___/_____

Name of person/parent giving consent:_____________________ □ Refused Interview

If case-patient is not available, ask for an alternate contact number or time to call back to speak with case patient. Alternate number _______________ Alternate day/time _________________

1.) We have your age (your child’s age) as ______, is this correct? [If no] What is the correct age? ____

a. [For parents <17 year old child] Can I ask what is your age and sex?

Age in years____ Sex: □ Male □ Female

2.) Per our records, a sample was taken for chikungunya testing on __ __ /__ __ /2014 , does this sound correct?

□ Yes □ No

[If this is not correct] Can you recall which date the sample was drawn? __ __ /__ __ /2014

3.) Besides yourself (or your child), has anyone else in your household had similar symptoms?

□ Yes (go to question 4)

□ No (go to question 5)

□ Don’t know (go to question 5)

4.) How many of these household members with similar symptoms sought medical care? _______

5.) How long did the initial joint pain last when you were tested for Chikungunya? _________ days after symptoms started.

6.) Do you have any joint pain (i.e., pain in your wrists, ankles, hands or feet) or joint swelling today that you think might be related to your recent illness? □ Yes (go to question 8)

□ No (go to question 7)

□ Don’t know (go to question 7)

7.) Have you (or your child) had any joint pain or swelling in the last week that you think might be related to your recent illness? □ Yes (go to question 8)

□ No (go to question 9)

□ Don’t know

8.) How often do you (your child) experience joint pain or swelling that you think might be related to your recent illness? □ Daily

□ Two to three times per week

□ Once per week

□ Less than once per week

□ Don’t know

9.) What is your current employment status? □ Working (go to question 10)

□ Retired (go to question 13)

□ Not Working (go to question 13)

□ Child (go to question 15)

□ Refused

10.) In the time since you have visited the doctor for suspected chikungunya, have you missed time from work because of your illness? □ Yes (go to question 11)

□ No (go to question 16)

11.) Have you (your parent) returned to work? □ Yes (go to question 12)

□ No (go to question 16)

12.) How many days of work did you miss? ______ (go to question 16)

13.) In the time since you visited the doctor for suspected chikungunya, have you been unable to do your normal chores and activities?

□ Yes (go to question 14)

□ No (go to question 16)

14.) How many days of chores/activities have you missed? ______ (go to question 16)

15.) Have you (or has your parent) had to miss work to care for your sick child (or you)?

□ Yes (go to question 11)

□ No (go to question 16)

16.) Were you been hospitalized due to your illness for which you were tested for chikungunya?

□ Yes (go to question 17)

□ No (go to question 18)

17.) How many days were you hospitalized? ________

18.) Did you seek additional medical attention following the date your sample was drawn for suspected chikungunya? □ Yes (go to question 19)

□ No (go to question 20)

19.) How many times did you seek medical attention? ________ healthcare visits

20.) Do you have a history of chronic joint pain prior to being diagnosed with chikungunya?

□ Yes

□ No

Thank you for answering our additional question. The information you have provide will let us learn more about chikungunya and how the disease is affecting you and other people in your community.

Would you be willing for the health department to contact you again related to your illness? □ Yes

□ No

Finally, do you have any questions for me?

Public reporting burden of this collection of information is estimated to average 10 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)