Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Rabies Awareness and Dog Ownership Characteristics Among Persons in Haiti
What is your age? ___________
What is your gender? _________
Where do you live?
Street _______________________________
Commune ___________________________
Department __________________________
How many people live with you, in your household? ________________
Are you the primary care taker for your dogs?
Yes
No
Unknown
How many dogs are you getting vaccinated today? ________________
How many dogs belong to your household? ____________________
Of the dogs belonging to your household, how many:
Stay on your property at all times ___________
Roam the street unsupervised sometimes _____________
Roam the street unsupervised at all times _____________
What level of care do you provide for your dog(s)? (Mark all that apply.)
None
Food
Water
Shelter
Veterinary Care
Other: (free response)
Declined to answer
If any of your dog(s) have never been vaccinated for rabies, what is the reason?
Dog is too young (number _______)
No money to buy vaccine (number _______)
No vaccine available from veterinarians (number _______)
No vaccine available from government (number _______)
No need to vaccinate (number _______)
Other (free response): (number _______)
Declined to answer
For any dogs that died in the past year, what was the cause of death? Indicate frequency of each.
Hit by Car ____________
Poisoned __________
Disease/illness ____________
Other: free response ________
I don’t know ________
Declined to answer
In the past year, have you ever owned a dog that died after displaying at least two of the following symptoms? If yes, how many?
Hypersalivation, Aggressiveness, Biting people or animals, Difficulty walking, Change in the dog’s voice
Yes, number __________
No
I don’t know
Do you provide care for any dogs that you do NOT own? (Mark all that apply.)
None
Food
Water
Shelter
Veterinary Care
Other: (free response)
Declined to answer
In the past year, have you or anyone in your household been bitten by a dog? Mark all that apply.
No
Yes, me
Yes, an adult family member (indicate number if more than one) __________
Yes, my child (indicate number if more than one) __________
Declined to answer
Do you know anyone who has ever died from a disease caused by the bite of a dog?
No
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Do you know anyone who has ever died from a disease called ‘rabies’?
No
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
Yes: Gender: _____ Age: ___________ Year of Death: ___________
How much do you know about a disease called rabies? Note: interviewer must evaluate.
I have never heard of rabies
Little knowledge (i.e., have heard of rabies/dog disease, but can’t identify transmission routes or severity of disease)
Basic understanding (knowledge that rabies is both a highly fatal disease and is transmitted by dog bite)
Extensive knowledge (basic understanding plus knowledge of non-bite routes of exposure AND wildlife reservoirs besides dogs without prompting)
Declined to answer
How severe is the disease called rabies?
Mild
Somewhat severe
Very severe, but possible to recover
Very severe, resulting in death
I don’t know
Declined to answer
How do humans get rabies from an infected animal? (Mark all that apply.)
Bite
Scratch
Observing the animal
Touching the animal
Contact with blood
Contact with saliva
Contact with urine/feces
Other: (free response)
I don’t know
Declined to answer
What animals can be infected with rabies? (Mark all that apply.)
Dogs
Cats
Livestock (Cattle, sheep, goats, etc.)
Poultry (Chickens, ducks, geese, etc.)
Horses
Mongoose
Fox
Wild Birds
Bats
Rodents
Other: (free response)
I don’t know
Declined to answer
If you thought that you had an exposure to an animal with rabies, what would you do?
Nothing
Wash wound
Consult with a traditional healer
Call a medical doctor
Call a veterinarian
Actively seek medical treatment at a pharmacy, hospital, clinic or outpost
Receive rabies post-exposure prophylaxis
Isolate the animal for observation
Submit animal for disease testing
Kill the animal
Kill and eat the animal
Other: (Free response)
Declined to answer
Where do you normally go to receive medical treatment? (Mark all that apply.)
Veterinary clinic
Pharmacy
Medical Clinic
Hospital
Traditional Healer
Other: (free response)
Declined to answer
How far do you need to travel to receive medical care at this location? (Indicate frequency if multiple locations were identified.)
<1km
1-5km
6-10km
11-20km
21-30km
>30km
I don’t know
Declined to answer
What are the primary obstacles for getting medical treatment in your community? (Mark all that apply.)
Lack of facilities to provide treatment
Lack of trained personnel at facilities to provide treatment
Lack of medicines at facilities for treatment
No means of transportation
No money to pay for treatment
Can’t miss work
Other: (free text)
I don’t know
Declined to answer
Public reporting burden of this collection of information 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/msword |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
Last Modified By | Eaton, Danice (CDC/OPHSS/CSELS) |
File Modified | 2015-10-30 |
File Created | 2015-10-30 |