Appendix 3 - Example of Hantavirus Questionnaire

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Appendix 3. Hantavirus Pulmonary Syndrome Questionnaire
Form Approved
OMB No. 0920XXXX                    Exp. Date XX/XX/XXXX












Hantavirus Questionnaire





















Public reporting burden of this collection of information is estimated to average XX 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-XXXX)
Contact information
First I want to make sure we have the correct contact information for you.
1. Last name______________________________ 2. First name ______________ 3. M.I_____
4. Date of Birth____________________________5. Sex
6. Address________________________________7.City_____8.State_____9. Zip_______
10. Phone 1:_______________________Home/Work/Cell/Other Phone 2:________________
11.  Are you Hispanic or Latino?
    • Yes
    • No
12.   What is your race? (Select one or more responses.)
    • American Indian or Alaska Native
    • Asian
    • Black or African American 
    • Native American or Other Pacific Islander
    • White
13.     (If surrogate is answering the questions), What is your relationship to the case?
    • Spouse or domestic partner
    • Sibling
    • Friend
    • Other, specify: 
14.    What is your occupation? ___________________________


Section B: These next questions may require you to look at a calendar (as we are trying to collect accurate information about your stay and your lodging)

1. Did you visit [INSERT LOCATION] between <date> And <date>?
    • Yes 
    • No

1b. Did you stay overnight at [INSERT LOCATION] during your visit?

    • Yes proceed to question  2
    • No


2. How many different locations did you stay?
____________
2b.  Name(Location)        Date Stayed               Type of Lodging
1_________________________________________________
2._________________________________________________
3._________________________________________________
4._________________________________________________

3.  What type of place did you stay at (record dates)?
    • “Signature cabin”
 _____________ (< ask if it was a cabin  numbered in the 900s>>)
    • Regular Tent-Cabin
______________

    • Wood of log cabin
_______________
          i.    With a bath:
                ____________
         ii.    Without a bath:
                 ____________
    • Lodge (please specify):
    • Other (please specify) :
3b. Which part of the [INSERT LOCATION] was the lodging located, what room number was the lodging, could you describe to me the lodging structure.







LODGING AREA 1
LODGING AREA 2
LODGING AREA 3
LODGING AREA 4
LODGING AREA 5

4.  Did you see any live or dead rodents?
      (Inside/Outside)

Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
 _____

5.  What type of rodent (s) did you see?   (check all that apply) can also add ground squirrels as an option



Mouse
  Rat
Other:
Mouse
  Rat
Other:
Mouse
  Rat
Other:
Mouse
  Rat
Other:
Mouse
  Rat
Other:

6.  Did you see any rodent droppings?
       (Inside/Outside)
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
 _____

7.  Did you see any rodent nests?
       (Inside/Outside)
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
 _____

8.  Did I you see or hear any other signs of rodent activity (e.g. noises, mouse holes, gnaw marks, food)?
       (Inside /Outside)
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
   I/O
Y/N/DK
 _____

9.  Did  you handle :
       Rodents      Y    N     DK
       Droppings  Y    N     DK
       Nests           Y    N     DK
       Other, specify: __________
7a.  Type of rodent:_________________
7b.  Did you wear gloves:  Y   N   DK
7c.   Did you wash your hands after handling:   Y  N
    DK

10. Did you get bitten or scratched by any wildlife?
       Yes
       No
8b.  Which species of animal: _______________
8c.   Cleaning procedure:    _________________

11.  Did you clean, dust or sweep any part of the lodging?
       Y  N   DK

12.  Did you eat food inside your lodging? __ Y  N  DK
12b. Did you store food inside your lodging? __ Y   N  DK
  If yes, proceed to 13 and 14_____________

13.  Did you put food in the bear box?    Y  N  DK
14.  Did you notice any mouse activity or mouse droppings in the bear box?    Y    N   DK

15.  During your stay, did you sleep?
       On the floor with or without a mattress
       Off the floor ( e.g. bed or cot)
       Other, specify: ___________________

16.  Was any of your luggage or personal belongings placed under the beds or stored on the floor?
       Yes
       No
If so, were these materials subsequently placed on the beds?
    Yes
    No

17.  If you slept in a tent cabin which bed did you sleep on (when facing the cabin door):
        Bed to the left
        Bed to the right
        Bed against the back wall
18. Can you describe the condition of your mattress:        New    Old   ?


19.  When you slept: (use diagram for clarification-may be best to carefully define what each of these positions means)
    • Did your head face the wall?
    • Was your head next to the heater?
    • Was your head facing the door?
    • Was your head away from the door?
    • Was your head near the window?
20. What kind of linens did you use?
    • Provided by the park
    • Own linens brought from home
21.  What kind of pillow did you use?
    • Provided by the park
    • Own pillow brought from home
22.  Did you:
    • Turn the heater on at any point in your stay?
    • Use a fan in your cabin?
    • Sleep with your window flaps open?
    • Sleep on your stomach?

23.  How many hours did you stay in your lodging each day
    • For sleeping at night only
    • For sleeping plus 2-3 hours per day
    • Was in the lodging for most of the day and night
( 15 hours per day or longer) _____________
How long were you in bed/sleeping in your lodging each   night_________
Did you (or anyone) get up in the middle of the night and leave the cabin (e.g. bathroom, fresh air)____________
Did anyone in your party open the door in the middle of the night_______
19.  When you slept: (use diagram for clarification-may be best to carefully define what each of these positions means)
    • Did your head face the wall?
    • Was your head next to the heater?
    • Was your head facing the door?
    • Was your head away from the door?
    • Was your head near the window?
20. What kind of linens did you use?
    • Provided by the park
    • Own linens brought from home
21.  What kind of pillow did you use?
    • Provided by the park
    • Own pillow brought from home
22.  Did you:
    • Turn the heater on at any point in your stay?
    • Use a fan in your cabin?
    • Sleep with your window flaps open?
    • Sleep on your stomach?

23.  How many hours did you stay in your lodging each day
    • For sleeping at night only
    • For sleeping plus 2-3 hours per day
    • Was in the lodging for most of the day and night
( 15 hours per day or longer) _____________
How long were you in bed/sleeping in your lodging each   night_________
Did you (or anyone) get up in the middle of the night and leave the cabin (e.g. bathroom, fresh air)____________
Did anyone in your party open the door in the middle of the night_______
24.  How and where do you believe you were infected? ___________
25.  During your stay, did you or any members of your party perform, any of the following activities? If yes, location (s) this activity occurred:
    a. Cleaning:  __________
    b. Dusting:    __________
    c. Sweeping:  _________
    d. Moving/ rearranging: __________
    e. Digging in the ground/ collecting natural souvenirs/artifacts: _____________
    f. Building a campfire and handling or collecting firewood:  ____________
    g. Feeding/ leaving food out for wildlife: _________
    h. Other activities that may  have resulted in dust (explain): ___________

26.  Which of the following activities did you do during your trip?
    • Visitor’s center
    • Museum
    • Gallery
    • Native American village (if yes, did they enter any of the dugout structures?)
    • Nature Centers
    • Horseback riding
    • Rock climbing
    • Hiking
    • Biking


    • Valley tour
    • River activities (e.g. swimming, wading, tubing
    • Other (<<can you describe any other activities or places you may have visited during your trip>>)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section C: Medical History                                     << I’d like for you to take a moment and tell me about your illness>>
1.  On what date did you first begin to feel ill after your visit to Yosemite?
______________________ (mm/dd/yy)
2. What were the first symptoms you had?
______________________________________________________________________________________________
3. Which of the following symptoms did you  have: (circle those that apply)
    a. Fever
    b. Upper respiratory symptoms (e.g. cough, runny nose)
    c. Muscle ache
    d. Abdominal pain
    e. Chills
    f. Nausea/vomiting
    g. Diarrhea
    h. Headache
    i. Cough
    j. Shortness of breath
4. When did you first see a doctor?
    • Yes
    • No
Name                                             Phone#
1. _________________________________
2. What was the initial diagnosis (if known)?
____________________________________
5. Were you hospitalized for this illness?
    • Yes
    • No

Name and phone # of hospital and /or provider?
________________________
Did you stay overnight? ______
Were you in the Intensive Care Unit? ______
Did you require a ventilator/breathing tube? ______
Date admitted/ Date Discharged? ______________
6. Was anyone who stayed with you in Yosemite have been ill afterwards?
    • Yes
    • No
Name  of person: ____________________________
Phone number: ______________________________
Relationship: _________________________________
7.  Do you suffer from any medical conditions:
    • Cardiovascular disease (e.g. CHF)
    • Pulmonary disease (e.g. COPD, Asthma)
    • Diabetes
    • Renal disease
    • Liver disease
    • Autoimmune /Connective Tissue ( e.g. RA., SLE)
    • Cancer
    • Organ transplant
    • Suppressed Immune System (e.g. HIV, prednisone therapy)
    • Other, please specify
8.  Have you taken any medications within 4 weeks of presentation of current illness:
    • Antibiotics: ________________________________________________________________
    • Anti-convulsants: __________________________________________________________
    • Antidepressants and psychiatric drugs: _________________________________________
    • Antihistamines: ____________________________________________________________
    • Anti-inflammatory /analgesics: _______________________________________________
    • Anti-virals: ________________________________________________________________
    • Asthma medications: ________________________________________________________
    • Chemotherapeutics:  ________________________________________________________
    • Insulin: ___________________________________________________________________
    • Steroids: __________________________________________________________________
    • Other:_____________________________________________________________________


9. Do you smoke?
    • Yes 
    • No
How much do you smoke each day?
    •  < 1pk/day
    •   1-2 pk/day
    •   >2 pk/day


Section D:  << I’m going to asking you a few more questions about recent travel- just to find out if there any  other places that you may have been >>
1. Have you traveled away from home (includes day and over night trips)
    • Yes 
    • No
    • Unsure/Don’t  know
If Yes the answer the following for each trip:
City         State                  Country                      Dates
___________________________________________
___________________________________________
___________________________________________
2.  Have you traveled away outside the U.S. (includes day and overnight trips):
    • Yes
    • No

If Yes the answer the following for each trip:
City         State                  Country                      Dates
___________________________________________
___________________________________________
___________________________________________
3. Were there other people who stayed overnight with you (e. g. in the same room, same campground, same party)?
    • Yes 
    • No
For other attendees, specific
Name                                   Relationship          Phone #

1. ________________________________________
2. ________________________________________
3. ________________________________________
4. ________________________________________
<Is possible to talk to someone that you stayed with during your visit?  We will be discussing with them may of the same questions that we have already talked about today.

Again, the information  you  provide is essential to us finding out if there was  something from  your visit that made people ill making sure that no other people are put at risk.

Thank you very much for your time today.  Do you have any questions today?  If you think of anything after we talk today, here is a number to call (               ).  At times, other questions may come to mind, if they do would you mind if I contact you again.  If so, what time works best for you?

Thank you and have a good day.