Chikungunya Household Interview

CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

TEAM #:

DATE: / _/

Household ID (e.g., SJ-1-A): - -

GPS Coordinates: . , . SANID of lab-positive case:

How many people live in this house? people

List all members of household below put yourself first.

Head of household contact number to facilitate return of test results:_

	Name (First, Paternal, Maternal)	Age	Gender	Participate?	Place sticker here
1			M / F	Yes / No
2			M / F	Yes / No
3			M / F	Yes / No
4			M / F	Yes / No
5			M / F	Yes / No
6			M / F	Yes / No
7			M / F	Yes / No
8			M / F	Yes / No

Household Characteristics

Housing type (check only one): □ One story house □ Two story house □ Apartment/condo building

□Public housing □ Temporary shelter

Has anyone in your immediate household traveled outside of Puerto Rico in the past 3 months? □ Yes □ No

Has anyone in your household been sick in the past 3 months? □ Yes □ No

Does your home have screened windows and doors? □ All rooms □ Some rooms □ No

Do you regularly use air conditioning in your home? □ Yes, in all rooms □ Yes, but only in some rooms □ No Do you regularly leave your doors or windows open? □ Daytime only □ Night-time only □ Always □ Never Do you use mosquito coils in your house or patio? □ Yes □ No

Do you use citronela in your house or patio to keep mosquitoes away? □ Yes □ No

Notes:

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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)