Initial Questionnaire for Case-Patients

Attachment 1: Initial Questionnaire for Case-Patients

Initial Questionnaire for Case-Patients

[The following questionnaire should be completed for all case-patients that are selected as a basis for household recruitment for this project. If the case-patient is not available to respond, a caregiver who is familiar with the case-patient’s illness may act as a proxy respondent. Each case-patient should be allocated a unique identification number, which should be recorded on every page after the first consent page.]

Informed Consent Script

“Hello, I am (insert name). I am working with the district surveillance officers and contact tracing team here in (insert district name). We are interested in finding out more about what factors might contribute to causing people who live in the same household to become sick with Ebola. We hope that this information will help us stop the virus from spreading. I am asking questions that might help identify risks of become sick with Ebola. We may skip any questions that you do not want to answer.

If you are willing, I will be asking you some questions about [YOUR/NAME OF CASE-PATIENT’S] background, including personal questions about [YOUR/HIS/HER] health. The interview will take about 20 minutes of your time.

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

If some of the questions seem too personal, of course there is no need to answer them. In fact, it is completely your choice whether to answer any of my questions at all, or to answer some but not others, or to answer briefly or at length. You can also refuse or stop at any time without penalty. The information you provide will be kept confidential—it will only be used for project purposes, and it will not be shared with anyone outside of the project. This project is completely separate from any medical care that [YOU/NAME OF CASE-PATIENT] may require, and the medical care of you or your family.

The information you share with me may be used to reduce or prevent Ebola spreading in the future. If you have any questions, please ask me now. If you have questions at a later time, you can contact me at xxxx-xxx-xxxxxx. If you would like to speak with someone besides me, or if you have any questions or concerns about any harm you may have experienced or your rights as a participant, you may contact Dr. James Bangura, National Officer Assigned to Surveillance Pillar, MOH, at 076-803-272.

Please keep this form so that you have this information [HAND RESPONDENT PROJECT INFORMATION SHEET].”

Case name (First/Given): ___________________________ (Last/Family) ______________________

Guardian name if case is a minor (First/Given):

(First/Given): ___________________________ (Last/Family) ______________________

Caregiver/proxy name if case is not available (First/Given):

(First/Given): ___________________________ (Last/Family) ______________________

Interviewer Name: (First/Given): ___________________________ (Last/Family) ___________________

[Q100 For tracking purposes: Indicate if participant (or guardian/caregiver) agrees to participate (check one)]:

YES (1)  Continue with interview.

NO (0)  Do not continue with interview. Thank participant for their time.

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Interviewer: ________________________ Supervisor: _______________________ Keyed by: ______________________

Information provided by: Case Proxy, If proxy, Name:_________________ Relation to contact:_____________________

Date: __ __ / __ __ / __ __

D D M M Y Y

N/A	ID XXX
N/A	Index case-patient name:	First/Given: _________________________

ID XXX number:_______________

Section 1 IndexCase-patient information

Please answer the following questions about [NAME OF CASE-PATIENT]:

101	[Sex of case-patient, circle one]:	Male (0) Female (1)
102	What is [NAME OF CASE-PATIENT’s] age? A B	_______ Years (0) / Months (1) / Weeks (2) / Days (3) (circle one) [If age is unknown: enter approximate age if possible; otherwise, enter 888 and leave B blank].
103	What is [NAME OF CASE-PATIENT’s] date of birth?	__ __ / __ __ / __ __ D D M M Y Y [Enter 88/88/8888 if don’t know].
104	What is [NAME OF CASE-PATIENT’s] religion? A B	Christian (0) Muslim (1) Bahai (2) Traditionalist (3) None (4) Don’t know (8) OTHER: _________________________ (9)
105	What is [NAME OF CASE-PATIENT’s] ethnicity? A B	Creole (0) Fullah (1) Kono (2) Limba (3) Loko (4) Mandingo (5) Mende (6) Sherbro (7) Temne (8) OTHER: _________________________ (9)

Section 2 Case Clinical time course

Instructions:

• Determine the date of onset of the first symptom. Record the date of onset as “Day 0.” Record the dates for all subsequent dates through Day 14.

• Place an “X” in the appropriate boxe(s) for rows A, B, and C (if relevant).

• Discussing one symptom at a time: For each day, mark a line through the box (---) if the case did not experience the symptom or was not in the household on that day; mark an “X” if the case did experience the symptom in the household on that day.

	0	1	2	3	4	5	6	7	8	…
J. Diarrhea				X	X	X	X

EXAMPLE:

201 SYMPTOMS/SIGNS

DAYS AND DATE FOLLOW UP

DATE OF ONSET

DD/MM

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

1

2

3

4

5

6

7

8

9

10

11

12

13

14

A. DATES PRESENT IN HOUSEHOLD

B. REMOVED FROM HOUSEHOLD

C. DIED [IF RELEVANT]

D. Fever

E. Muscle pain

F. Joint pain

G. Neck rigidity

H. Weakness or fatigue

I. Vomiting

J. Diarrhea

K. Abdominal pain

L. Headache

M. Backache

N. Chest pain

O. Sore throat or swallowing

P. Rash

Q. Bruising

R. Red eyes

S. Jaundice

T. Bleeding [indicate site]:

(a)

(b)

U. Other symptoms [list]:

(a)

(b)

Initial Case-Patient Questionnaire, V1.2, 13 Jan 2015