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pdfForm Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
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)
CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
TEAM #: ________________
DATE: ______/_______/_________
Household ID (e.g., SJ-1-A): _______-______-_____
GPS Coordinates: _____.____________°N ______.______________°E
How many people live in this house? _______________people
List all members of household below put yourself first.
Name (First, Paternal, Maternal)
Age
Gender
Participate?
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
Place sticker here
1
2
3
4
5
6
7
8
Head of household contact number to facilitate return of test results:___________________________________________
CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
Household Characteristics
Housing type (check only one):
□Public housing
□ One story house
□ Two story house □
Apartment/condo building
□ Temporary shelter
Has anyone in your immediate household traveled outside of Puerto Rico in the past 3 months?
Has anyone in your household been sick in the past 3 months?
□ Yes
□ Yes
□ No
Does your home have screened windows and doors?
□ All rooms
Do you regularly use air conditioning in your home?
□ Yes, in all rooms □ Yes, but only in some rooms
Do you regularly leave your doors or windows open?
□ Daytime only
Do you use mosquito coils in your house or yard?
□
Notes:
Yes
□ No
□ Some rooms
□ No
□ No
□ No
□ Night-time only □ Always □ Never
File Type | application/pdf |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
File Modified | 2014-06-18 |
File Created | 2014-06-18 |