Questionnaire for Investigation of Household Contacts of

Attachment 3. Questionnaire for Investigation of Contacts of Ebola-infected Case-Patients

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Questionnaire for Investigation of Household Contacts of Ebola-infected Case-patients

[The following questionnaire should be used for all household contacts of the case-patient that agree to participate in this project. Any persons who slept in the same household or used the same kitchen/cooking stove from 7 days before symptom onset until the index case-patient was removed from the household should be included as a contact. Each participant 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 background including personal questions about your health, your family, and your household. The interview will take about 30 minutes of your time. At the end of the 21-day monitoring period, or if/when any symptoms are observed, we will also conduct a brief (5 minute) exit interview to document any additional potential exposures since the index patient was removed from the household.

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 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].”

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

Guardian name if contact is a minor (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 30 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: Contact Proxy, If proxy, Name:_________________ Relation to contact:___________________

SECTION 1 GENERAL QUESTIONS

[Please answer the following questions about the case-patient]:

N/A	Case-patient name [this is the case-patient to which the contact has been exposed]	First/Given: _______________________________
101	Case-patient identification number [this is the number of the case-patient to which the contact is linked]
102	Household Line NO. [Q301 of HH Questionnaire]	____ ____

Project ID number:_______________

Please answer the following questions about yourself (the contact):

103	[Sex of contact, circle one]:	Male (0) Female (1)
104	Is this your primary residence?	[GO TO 104A ] No (0) [GO TO 105] Yes (1)
A	Did you sleep here at least one night between [list date: 7 days before onset of symptoms of case-patient] and [list date: when case-patient was removed from household]?	[Ineligible; end interview] No (0) [GO TO 105] Yes (1)
105	What is your date of birth?	__ __ / __ __ / __ __ D D M M Y Y
106	What is your occupation [circle all that apply]? CODE = 0 if not circled = 1 if circled	Health care worker (A) Laboratory worker (B) Environmental decontamination/cleaning (C) Traditional/spiritual healer (D) Ambulance driver (E) Burial attendant/corpse removal (F) [IF YES, GO TO 106H] Trader (G) Teacher (H) Student (I) Housewife (J) OTHER: ________________________________ (K)
H	In the last month, have you had contact or interaction with individuals sick with Ebola while working?	No (0) Yes (1) Don’t know (8)

107	What is your relationship to the case-patient? [circle one.] A	Parent (0) Husband/wife (1) Son/daughter (2) Brother/sister (3) Niece/nephew (4) Uncle/aunt (5) Cousin (6) Grandparent (7) Grandchild (8) Tenant (9) Landlord (10) Other non-relative resident in household (11) OTHER: ____________________________ (99)
108	What is your religion? A	Christian (0) Muslim (1) Bahai (2) Traditionalist (3) None (4) OTHER: ________________________________ (9)
109	What is your ethnicity? A	Creole (0) Fullah (1) Kono (2) Limba (3) Loko (4) Mandingo (5) Mende (6) Sherbro (7) Temne (8) OTHER: ________________________________ (9)
110	Are you currently being followed as a contact of another case outside the household?	[GO TO SECTION 2] No (0) [GO TO 110A] Yes (1) [GO TO SECTION 2] Don’t know (8)

Section 2 Background Medical History A B C

[IF YES TO 110]: What is the name and location of the case? First/Given: Chiefdom/ward [see list for codes]: District [see list for codes]: Location:

__________________________________________ ______________________________ (Code: _____) ______________________________ (Code: _____) __________________________________________

The following questions are addressing your background medical history.

201	Do you have any known medical conditions?	[GO TO 202 ] No (0) [GO TO 201A] Yes (1)
A-J	Please list your known medical conditions. [Please circle all that apply]. CODE = 0 if not circled = 1 if circled	Diabetes (A) Sickle cell disease (B) Asthma (C) Kidney failure (D) Chronic liver disease (E) Hypertension (F) Heart disease (G) History of cancer treatment in last year (H) HIV or AIDS (I) Tuberculosis (J) Hematological disorder (chronic anemia) (K) OTHER: ____________________________ (L)

202	Are you on any medications?	[GO TO 203 ] No (0) [GO TO 202A] Yes (1)
A-D	Please list the medications you take. A B [Continue on additional page if necessary] C	_______________________________ (Code: _____) _______________________________ (Code: _____) _______________________________ (Code: _____)
203	[For females age 14 years and over]: Are you currently pregnant?	No (0) Yes (1) [male or child under 13 years] Not applicable (7) Don’t know (8)

Section 3 Exposure Questions

household exposures and protective behaviors

N/A	[Date when [NAME OF CASE-PATIENT] first started having symptoms of Ebola—Date of Onset, from Household Questionnaire]:	__ __ / __ __ / __ __ D D M M Y Y
N/A	[Date when [NAME OF CASE-PATIENT] was removed from the household—from Household Questionnaire]:	__ __ / __ __ / __ __ D D M M Y Y

Please tell me on which of the following days you slept or ate at the household:

• Insert appropriate dates into “DATE” row in table below; circle the date that the case-patient was removed from the household.

• For each day in rows A and B, mark a line through the box (---) if the case did not sleep or eat in the household on that day; mark an “X” if the case did sleep or eat in the household on that day.

DAY	I1	I2	I3	I4	I5	I6	I7	…
SLEPT			X	X			X	…

EXAMPLE: CODE: = 0 if “---“

= 1 if “X”

301

INCUBATION PERIOD

Date of Onset

[CIRCLE DATE CASE-PATIENT WAS REMOVED FROM HOUSEHOLD]

DATE DD/MM

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

DAY

I1

I2

I3

I4

I5

I6

I7

D0

D1

D2

D3

D4

D5

D6

D7

D8

D9

D10

D11

D12

D13

D14

D15

D16

D17

D18

D19

D20

D21

SLEPT

B. ATE

The following questions will ask about your contact with [NAME OF CASE-PATIENT] while he/she was sick. Please answer the questions about the following time periods:

Phase 1- In the 7 days before [CASE-PATIENT] became sick.

Phase 2- When [CASE-PATIENT] first became sick with “dry symptoms” like fever, muscle pain, or weakness.

Phase 3- When [CASE-PATIENT] became sick with “wet symptoms” like vomiting, diarrhea, or bleeding.

[IF RELEVANT] Phase 4- After [CASE-PATIENT] died, but before removed from household.

Also, please indicate if the contact took place: Never; Once; Sometimes; or Always or nearly always.

	[Reference Case Clinical Time Course and visual aids to help contacts answer the following items. For each exposure and time period, indicate if the contact took place: Never (0); Once (1); Sometimes (2); or nearly always/always (3).]	Phase 1 (A)	Phase 2 (B)	Phase 3 (C)	Phase 4 (D)
302	Did you sleep in the same room as [NAME]? [IF YES, GO TO 303; IF NO, GO TO 304]
303	[IFYES to 302] Did you sleep in the same mat/bed as [NAME]

	For each exposure and time period, indicate if the contact took place: Never (0); Once (1); Sometimes (2); or Always or nearly always (3).]	Phase 1 (A)	Phase 2 (B)	Phase 3 (C)	Phase 4 (D)
304	Did you use a blanket that [NAME] had used without washing it first?
305	Did you travel in the same vehicle as [NAME]?
306	Did you use the same pit latrine/toilet as [NAME]?
307	Did you eat meals with [NAME]? [IF YES, GO TO 308; IF NO, GO TO 311]
308	[If YES to 307] Did you share food from the same plate or dish as [NAME]?
309	Did you share the same eating utensils with [NAME]?
310	Did you drink from the same cup or container as [NAME]?
311	Did you touch or wash bed linens used by [NAME]?
312	Did you wash clothing worn by [NAME]?
313	Did you wear clothing that [NAME] had worn without washing it first?
314	Did you have contact with any body fluids from [NAME]?	[GO TO 326] No (0) [GO TO 315] Yes (1)
315	[IF YES TO 314] Did you have contact with [NAME’s] ………
316	……….Urine?
317	……….Stool/feces?
318	……….Sweat?
319	……….Tears?
320	……….Saliva?
321	……….Vomit?
322	……….Respiratory secretions (e.g., sputum, nasal mucus)?
323	……….Blood?
324	………Semen or vaginal fluids
325	………[IF CASE IS FEMALE] Vaginal bleeding?
326	Did you have physical contact of any kind with [NAME] during or just prior to his/her illness?	[GO TO 334] No (0) [GO TO 327] Yes (1)
327	[If YES to 326] Did you………
	……….Have minor skin to skin contact with [NAME], for example shaking hands or touching extremeties?
328	………Hug, hold, or cuddle with [NAME]?
329	………Kiss [NAME] on the lips?
330	………Have sexual intercourse with [NAME]?
331	………Wash, clean, or bathe [NAME]?
332	[If the contact is an infant and the case-patient is a lactating woman]………Nurse/suckle?
333	[If the contact is a lactating woman and the case-patient is an infant]………Breastfeed?
334	Did you provide care for [NAME]?	[GO TO 345] No (0) [GO TO 335] Yes (1)
335	Did you use plastic gloves when caring for [NAME]?
336	Did you use plastic bags on your hands when caring for [NAME]?
337	Did you use a protective gown or apron when caring for [NAME]?
338	Did you cover your face with a mask when caring for [NAME]?
339	Did you wear eye glasses or other eye protection when caring for [NAME]?
340	Did you clean up vomit, blood, diarrhea or a diaper when caring for [NAME]?	[GO TO 345] No (0) [GO TO 341] Yes (1)
341	Did you cover your hands with gloves or plastic bags?

342	Did you wash your hands after having direct contact with [NAME OF CASE-PATIENT]		[GO TO 343] No (0) [GO TO 342A] Yes (1) [GO TO 343] Don’t know (8)
A-D	[IF YES TO 342] Did you wash your hands with……? [Circle all that apply]. CODE = 0 if not circled = 1 if circled		Water only (A) Soap and water (B) Bleach and water (C) Salt water (D) Hand sanitizer (E) All of the above (F) None of the above (G)
343	Did you use any of these cleaning solutions? [Circle all that apply]. CODE = 0 if not circled = 1 if circled		Water only (A) Soap and water (B) Bleach and water (C) Salt water (D) Hand sanitizer (E) All of the above (F) None of the above (G)
344	What did you do with cloths or mops used for cleaning body fluids from [NAME]? [Circle all that apply]. CODE = 0 if not circled = 1 if circled		Thrown away with household trash (A) Buried or burned (B) Washed with household laundry (C) Washed separate from household laundry (D) Put in plastic bags for disposal (E) Other (F)
345	After [NAME OF CASE-PATIENT] became ill, did you do any of the following? [Circle all that apply]. CODE = 0 if not circled = 1 if circled		Stay at least 1 meter from him/her (A) Stop sleeping with or near him/her (B) Stop talking to him/her (C) Stop eating with him/her (D) Avoid touching him/her (E) Other (F)
[IF CASE-PATIENT IS STILL ALIVE, SKIP TO NEXT SECTION; IF CASE-PATIENT HAS DIED, CONTINUE TO 346.]
346	[IF CASE-PATIENT HAS DIED]: Did you eat a communal meal at the funeral	No (0) Yes (1) Don’t know (8)
347	Did you have any contact with [NAME OF CASE-PATIENT] after he/she died?	[GO TO NEXT SECTION] No (0) [GO TO 348] Yes (1) [GO TO NEXT SECTION] Don’t know (8)
348	[IF YES TO 347] Did you………? [Circle all that apply]. CODE = 0 if not circled = 1 if circled	Wash or clean the body (A) Dress or wrap the body (B) Carry the body (C) Clean the bowels of the body (D) Touch any of the washing solution or mud (E) [IF YES, GO TO 349] [IF NONE APPLY, GO TO NEXT SECTION]
349	[IF YES TO any of Q348A-E] Did you wear any gloves or plastic bags on your hands before touching the body?	No (0) Yes (1) Don’t know (8)

350	Did you wash your hands after touching the body or the washing solution/mud?	[GO TO NEXT SECTION] No (0) [GO TO 350A] Yes (1) [GO TO NEXT SECTION] Don’t know (8)
350 A-D	[IF YES TO 350] Did you wash your hands with……? [Circle all that apply]. CODE = 0 if not circled = 1 if circled	Water only (A) Soap and water (B) Bleach and water (C) Salt water (D) Hand sanitizer (E)

non-household exposures

The following questions relate to events within the last month [use a calendar or recent events to provide a point of reference for the respondent].

351	Have you travelled outside of this town/district within the past month?	[GO TO 352 ] No (0) [GO TO 351A] Yes (1)
A-D	List the areas to which you have travelled and dates of travel. Trip 1 (A) Chiefdom/ward [see list for codes]: (B) District [see list for codes]: (C-D) Dates travelled: [Continue on additional page if necessary]	_______________________________ (Code: _____) _______________________________ (Code: _____) __ __ /__ __ / __ __ to __ __ /__ __ / __ __ D D M M Y Y D D M M Y Y
352	Have you been a patient in a hospital, CHC, or holding center in the last one month?	[GO TO 353 ] No (0) [GO TO 352A] Yes (1)
	[IF YES TO 352] How long were you in the hospital, CHC, or holding center? A	________
	B	Years (0) / Months (1) / Weeks (2) / Days (3) (circle one) [Enter 88 if unknown].
353	Have you been treated in an outpatient facility for any illness in the last one month?	[GO TO 354 ] No (0) [GO TO 353A] Yes (1)
A	[IF YES TO 353] Date of visit: [Continue on additional page if necessary]	__ __ / __ __ / __ __ D D M M Y Y
354	Have you visited a traditional healer in the last one month?	[GO TO 355 ] No (0) [GO TO 354A] Yes (1)
A	[IF YES TO 354] When did you visit the traditional healer? [Continue on additional page if necessary]	__ __ / __ __ / __ __ D D M M Y Y

355	Have you attended a funeral for someone other than the index case-patient in the last one month?	[GO TO 356 ] No (0) [GO TO 355A] Yes (1)
A	[IF YES TO 355] Did the person die of Ebola?	No (0) Yes (1) Don’t know (8)
B	What was the date of the funeral?	__ __ / __ __ / __ __ D D M M Y Y
C- F	Did you………? [Circle all that apply]. CODE = 0 if not circled = 1 if circled [Continue on additional page if necessary]	Wash or clean the body (C) Dress or wrap the body (D) Carry the body (E) Clean the bowels of the body (F)
356	Have you had direct contact with or spent significant time (> 1 hour) close to someone else who has been diagnosed with Ebola or who has been very ill with fever, diarrhea, vomiting or bleeding?	[END OF INTERVIEW ] No (0) [GO TO 356A] Yes (1)
	[IF YES TO 356] What is the name of the person? Name:	_______________________________ (Code: _____)
A	Date of last contact:	__ __ / __ __ / __ __ D D M M Y Y

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.]

Contact Questionnaire, V1.2, 13 Jan 2015