Household Questionnaire

OMB Control No.:

Expiration date:

The Rocky Mountain spotted fever (RMSF) Rodeo Project is a trial pet health project happening in Poblado Miguel Aleman (PMA) in 2016, with approval from the PMA Council. PMA is teaming up with the University of Sonora Medical School, the Centers for Disease Control and Prevention (CDC), other partners for the project.

The RMSF Rodeo Project’s goal is to have less people get RMSF by improving pet health. This project will focus on three main areas, #1 - tick control on dogs #2 - tick control around the home, and #3 – community education

Participating households in the project area will receive:

1. Free tick collars & other tick treatments for your dogs for the summer (timed and checked by RMSF Rodeo team members)

2. Free pest management treatments for your yard (timed and checked by RMSF Rodeo team members)

3. Educational materials provided by the RMSF Rodeo team during home visits

Registered participants must agree to:

1. Ensure tick products or collars, provided by the RMSF Rodeo team, are placed on dogs and remain in place for the duration of the project.

2. Allow RMSF Rodeo teams to apply pest management treatments around the home and in the yard.

3. Allow RMSF Rodeo teams to check tick levels on dogs during routine visits.

4. Consider participation in knowledge attitudes and practices surveys before and following the program activities.

Timeline for 2016

For more information, please contact:

Owner’s information (Consenting Household Member, must be > 18 years old or head of household):

________________________________/______________________________/_________________________

_{First Name Last Name How many people live at this residence?}

Address: ________________________________/______________/______________________/___________________

_{Street Number and Name PO Box # Neighborhood (PROJECT HOUSE #}

Phone Number: ( ) ____-_______________ ( ) _____-_____________ ( ) ____-_________

_{Home Work Cell}

Email address: __________________________________________________________________________

What is the best method to reach you? (circle) Phone call / Home visit / Email

What is the best time to reach you? __________________________________________________________________

1) Do you require a local dialect interpreter? Yes / No 2) Are the dog(s) currently restrained? Yes / No / Mixed

3) Do you have a working outside water faucet? Yes / No 4) Have you seen ticks inside your home? Yes / No

Identify Dogs the Owner wishes to register in the RMSF Rodeo: (All owned dogs receive a tick collar and a nylon collar. If more than 5 dogs, continue with a separate sheet and attach to this record)

Dog Name	Breed/ Color	Age (indicate years or months if < 1 yr)	Sex (M/F)	Dog’s Behavior A: nice B: fearful C: mean	Tick Count: A: None B: 1-10 C: 11-100 D: >100

I declare that to the best of my knowledge all of the information provided above is true and correct. I acknowledge the requirements to participate in the RMSF Rodeo Project and would like to register and participate in the program.

Signature_________________________________________________Date___________________________

Additional Comments:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Environmental Assessment (Draw home, to include location of outdoor water faucet, dog areas and areas of potential tick harborage. Include brief house description, identifying characteristics.)

Public reporting burden of this collection of information is estimated to average 20 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