Form 21 Attachment 6 Form 4a Demographic and Exposure Informatio

Form Approved  
 OMB Number 0925‐XXXX 
Exp. Date: XX/XX/XXX 
Public reporting burden for this form is estimated to average 10 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, 
Bethesda, MD 20892‐7974, ATTN: PRA (0925‐XXXX). Do not return the completed form to this address. 
Study ID: __ __
__
CEIRS Human Influenza Surveillance Study
Form 4A: Demographic and Exposure Information

__ __ __ __ __

Demographic Information
Enrollment Date:

______/______/_______ (mm/dd/yyyy)

Enrollment Location:

□ JHH

□ BMC

□ Linkou

□ Taipei

□

Keelung
Age:

__

__________ years old

Gender:

□ Male

__

□ Female

Pregnancy:

□ No □ Yes □ Unknown □ NA
If pregnant, which trimester of pregnancy? □ First □ Second □ Third □ Unknown □ NA
If female, is the subject pregnant?

Breastfeeding:
If female, is the subject breastfeeding?

□ No □ Yes □ Unknown

Ethnicity:
Hispanic or Latino

□ No □ Yes □ Unknown

Race:

□ American Indian or Alaska Native
□ Asian
□ Native Hawaiian or Other Pacific Islander
□ Black or African American
□ White
Height:
________ inches (calculate from ft & in, e.g. 5ft, 3in = 63 inches)
Weight: ________ pounds (lbs)
BMI:
________
Obesity:
Is the subject considered to be obese (ie. is the subject’s BMI ≥30)?
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Form 4A: Demographics

□ No □ Yes □ Unknown
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Study ID: __ __ __ __ __ __ __ __ __ __
First 3 numbers of subject’s zip code: ___ ___ ___

Primary Living Situation:
Where does the subject reside?

□ Private residence
□ Long term facility / nursing home (including rehabilitation facility)
□ Retirement home / assisted living
□ Dormitory
□ Homeless/shelter
□ Unknown
□ Other, specify: _____________________
Is the subject currently employed (working for pay)?:

□ No

□ Yes

If yes, how many hours a week does the subject typically work? ______ hours
What is the highest level of education?
Choose only one of the following:

□ Elementary School
□ High School
□ Trade School
□ College
□ Graduate school
□ Unknown
□ Other
Influenza Vaccination Information

□ No □ Yes

Did the subject receive an influenza vaccine this year?

□ Unknown

If Yes:
What date was the vaccine administered?
How was the vaccine administered?

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______ / ______ / _______ (mm/dd/yyyy)

□ Injection / Shot □

Form 4A: Demographics

Nasal Spray

□ Unknown

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Study ID: __ __ __ __ __ __ __ __ __ __

Exposure Assessment
Within the past 5 days has the subject had contact with any animals besides pets? (for example, farm animals,
wild animals, industrial food preparation)
Exposed to poultry?
If Yes, duration of poultry exposure?
Exposed to wild birds?
If Yes, duration of wild bird exposure?
Exposed to swine?
If Yes, duration of swine exposure?

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
____Days
□ Unknown
□ No □ Yes □ Unknown
□ Unknown
____Days
□ No □ Yes □ Unknown
____Days
□ Unknown

Type of exposure, (i.e. setting in which exposed to animals)?
Large Farm (confined animal feeding)
Farm
Backyard Flock
Food Preparation
Slaughterhouse

□ No
□ No
□ No
□ No
□ No

□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown
□ Yes □ Unknown

Other, specify: _____________________________
Unknown
Within the past 5 days has the subject been exposed to human with confirmed influenza?

□ No □ Yes □ Unknown
□ Unknown
____Days

If Yes, duration of human exposure?
Travel History:
List all travel destinations for the subject over the past month.

______________________________________

_________________________________________________________________________________________

Subject Notes:

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Form 4A: Demographics

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