Questionnaire for Ebola-affected Households

Attachment 2. Questionnaire for Ebola-affected Households

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Questionnaire for Ebola-affected Households

[The following questionnaire should be administered to the head of household of the Ebola-affected patient.]

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. If you do not wish to answer my questions, that is perfectly fine.

If you are willing, I will be asking you some questions about your background including questions about your household. The interview about the household will take about 20 minutes of your time. We would also like to talk with household contacts of [NAME OF CASE-PATIENT] about their background, health, and exposures.

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 may require, and the medical care of your child or 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].”

Head of Household Name: (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: ______________________

Section 1 household identification

Information provided by: Contact Proxy, If proxy, Name:_________________ Relation to case:___________________

[Please answer the following questions about the household]:

101 A B C D	Household address Chiefdom/ward [see list for codes]: District [see list for codes]: Location: Urban/Peri-Urban/Rural:	________________________ (Code: _____) ________________________ (Code: _____) ____________________________________ Rural (0) Urban (1)
102	At the time of this report, what is the lab status of [NAME OF CASE PATIENT]? [based on lab results]	Confirmed case (positive lab results) (0) [Continue interview] Suspected case (pending lab results) (1) [Continue interview] Not a case (negative lab results) (2) [Household not eligible; end interview]
102	GPS Coordinates	A) Latitude: _________ B) Longitude: _______
N/A	Head of household name [respondent]	First/Given: _________________________
N/A	Case-patient name [this is the case-patient to which the contact has been exposed]	First/Given: _________________________

Section 2 management of index case-patient

201	In the past three months, has anyone else had Ebola or died of an unexplained illness in this household?	[GO TO 202] No (0) [Not eligible; answer201A and end interview] Yes (1)
A	Please give the approximate date that the person had Ebola or died of an unexplained illness.	__ __ / __ __ / __ __ D D M M Y Y
202	At the time of this report, has [NAME OF CASE PATIENT] been removed from the house?		[GO TO 203] No (0) [GO TO 202A] Yes (1) [GO TO 203] Don’t know (8)
A	When was [NAME OF CASE PATIENT] removed from the house? [Enter 88/88/8888 if unknown].		__ __ / __ __ / __ __ D D M M Y Y
203	After [NAME OF CASE PATIENT] became ill, was he/she separated from other people in the household in any way?		[GO TO 205] No (0) [GO TO204] Yes (1) [GO TO 205] Don’t know (8)
204	[IF YEST TO 203]: How was [NAME OF CASE PATIENT] separated? [Please circle all that apply]. CODE = 0 if not circled = 1 if circled		Moved to a room by him/herself (A) Slept in a room by him/herself (B) Slept on a separate mat by him/herself (C) Used a toilet that was not used by others (D) Handled and washed clothing, bed clothing (E) separate from other clothing and people Ate food or drank using bowls, cups, utensils (F) that were not used by other people OTHER: _________________________________ (G) Don’t Know (I)

Section 3 household Linelist

Line NO	Household Member	Relationship to Head of Household	Relationship to Case-Patient	Sex	Age
	Please give me the names of the persons who usually live in your household—all those who share a joint cooking fire or stove.	What is the relationship of [NAME] to the head of household? SEE CODES BELOW	What is the relationship of [NAME] to [NAME OF CASE-PATIENT]? SEE CODES BELOW	IS [NAME] male or female?	How old is [NAME]?
301	302	303	304	305	306
01		__ __	__ __
02		__ __	__ __
03		__ __	__ __
04		__ __	__ __
05		__ __	__ __
06		__ __	__ __
07		__ __	__ __
08		__ __	__ __
09		__ __	__ __
10		__ __	__ __
11		__ __	__ __
12		__ __	__ __
13		__ __	__ __
14		__ __	__ __
15		__ __	__ __
16		__ __	__ __
17		__ __	__ __
18		__ __	__ __
19		__ __	__ __
20		__ __	__ __

CODES FOR 203 & 204: RELATIONSHIP TO HEAD OF HOUSEHOLD AND CASE-PATIENT

00 = Parent 01 = Husband/wife 02 = Son/daughter 03 = Brother/sister 04 = Niece/nephew 05 = Uncle, aunt 06 = Cousin

07 = Grandparent08 = Grandchild 09 = Tenant 10 = Landlord 11 = Other non-relative resident in same household as case-patient 12 = Self 99 = Other

Section 4 Household information

The following questions are about your personal living situation. We will ask about your household, which includes those sharing a single cooking fire or kitchen.

401	What type of dwelling do you live in? A	Apartment (0) Detached house (1) Make-shift (2) OTHER: _______________________ (9)
402	What is the number of rooms inside your dwelling (including sleeping, living, and cooking quarters)?	Number of rooms: ________
403	What is the main source of drinking water for members of your household? A	Piped water (0) Tube well or borehole (1) Dug well (2) Water from spring (3) Rainwater (4) Cart with small tank (5) Surface water (6) Bottled/packet water (7) Don’t know (8) OTHER: _______________________ (9)
404	In this household, is the food cooked on an open fire, an open stove or a closed stove? A	[Circle one]. Open fire (0) Open stove (1) Closed stove with chimney (2) OTHER: _______________________ (9)
405	What kind of toilet facility do members of your household usually use? A	Flush or pour flush toilet (0) Pit latrine (1) Composting toilet (2) Bucket toilet (3) Hanging toilet/hanging latrine (4) No facility/bush/field (5) Stream/river (6) OTHER: _______________________ (9)
406	Was this household quarantined?	No (0) Yes (1) Don’t know (8)
A	[IF YES TO 406]: How many times?	______
407	Did someone in the household call 117?	[CONCLUDE INTERVIEW] No (0) [GO TO 407A] Yes (1) [CONCLUDE INTERVIEW] Don’t know (8)
	How long did it take for the DSO and/or response team to respond? A B	_____ Days (0) / Hours (1) / Minutes (2) [Circle one] [Enter 88/88/8888 if unknown].

END OF INTERVIEW

[CONCLUDE INTERVIEW. REVIEW QUESTIONNAIRE TO BE SURE ALL QUESTIONS HAVE BEEN ANSWERED. MAKE ANY CORRECTIONS THAT ARE NEEDED. THANK THE PARTICIPANT FOR THEIR TIME.]

Household Questionnaire, V1.2, 13 Jan 2015