Follow-Up Questionnaire

A6 Page 7 – Persistence of Ebola Virus in Body Fluids of Ebola Virus Disease Survivors

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

Attachment 6 – Questionnaire for Follow-up Study Visits: Pilot and Modules A and B

AA1. Participant’s unique study ID number: _____________________

AA2. Study enrollment date: _____________________

AA3. Participant’s sex (male or female): _____________________

AA4. Participant’s age at study enrollment (in years): _____________________

If contact information has changed, list below:

AA5. Participant’s home residency (village/district/subcounty): _____________________

AA6. Participant’s contact information (address/es) ________________________________________

AA7. Participant’s contact information (telephone/s) _______________________________________

AA8. Participant’s contact information (email/s) _____________________________________________

AA9. Participant’s contact information (other) _____________________________________________

AA19. Today’s date: ____________________

AA20. Interviewer name/initials: _____________________

AA21. Study visit number and date __________________________

Thank you for participating in this study. I will be conducting your interview today, and it will last about 15 minutes. I ask all participants in this survey the same questions. All of your answers are confidential. I will mark a response to every question, but if you are not comfortable answering any question, you can tell me to mark “no answer.” You can also ask me to go back, or repeat any questions. Are you comfortable proceeding with the interview now?

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

I would like to ask you a few questions about the time period since we last saw you.

J1.

Since your last study visit, do you have any new health problems?

___ No, not that I know of

___ Yes

___ Other (specify) _______________

___ Don’t know/not sure

___ No answer

J2.

If answer yes to the above question, please specify

___ Eye/vision problems

___ Muscle pains

___ Joint pains

___ Weight loss

___ Feeling depressed (unable to concentrate, feeling very sad, poor appetite, other)

___ Sexual problems (specify) _______________

___ Other (specify) _______________

___ Don’t know/not sure

___ No answer

J3.

Since our last meeting, has anyone in your family become sick with Ebola?

No

Yes if yes, whom? (CIRCLE ALL RELEVANT: a)spouse, b) child, parent, c) in-laws, d) extended family, e) boy/girlfriend)

No answer/prefer not to answer

Don’t know/not sure

J4. Since our last meeting have you been sexually active?

__No (stop here, go to section K below)

__Yes (continue to the next question J5)

If yes: Since our last meeting, how often did you use a condom during sex? Choose one.

___ Never

___ Some of the time

___ Every time

___ Other (specify) _______________

___ Don’t know/not sure

___ No answer/prefer not to answer

Only for men:

J5

How often have you engaged in sexual activities with a partner since your last visit?

__every day

__> 3 times a week

__3 times weekly

__< 3 times weekly

__once every week

__once/one-off meeting

__Never

__No answer/prefer not to answer

The following questions (K1-K2) will be asked of lactating women only:

K1.

In the past 3 days, have you breastfed (provided your breast milk to any children, or allowed a child to suckle at your breast )? Choose one.

___ No

___ Yes

___ Other (specify) _______________

___ Don’t know/not sure

___ No answer / prefer not to answer

K2.

If not, why not? Check all that apply

___ I ran out of/stopped producing breast milk

___ I was worried about infecting my baby with Ebola

___ My husband/partner/family member/community leader told me not to breastfeed

___ My doctor told me not to breastfeed.

____ Other (please specify) _____________

___ Don’t know/not sure

___ No answer / prefer not to answer

L1.

Thank you very much for participating in the survey today. Do you have any other comments or concerns you would like to share about these topics?

Specify ___________________________________

For staff use only
	Date	Staff initials
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Data entry checked for completeness