KAP Questionnaire

OMB Control No.: 0920-XXXX

Exp. date: XX/XX/20XX

General Information:

Housing Area: (circle neighborhood)

Las Palmas (intervention) La Cholla 1 (control)

Interviewer Initials: ________________________

Date of Interview: _________________________

Gender:

1. Male

2. Female

3. Prefer not to respond

Age:

1. 18-25 y

2. 26-50 y

3. 51 y or older

4. Prefer not to respond

Specify “at this time”:

Number of People in Household: ______________ How many are children (<18 y) _____________________

1. Did you recently move to this poblado? (within the last 6 months)

1. Yes Go to question 2

2. No Go to question 4

3. Don’t know

4. Refused to answer

2. Did you bring your dog(s) with you when you moved?

   1. Yes

   2. No

   3. Don’t own a dog

   4. Refused to answer

3. Where did you live before you came to Poblado Miguel Aleman?

1. Another town in Sonora

2. Another state (Specify:_______________)

3. Refused to answer

4. How many months during the year do you typically live in this poblado?

1. 0-3 months

2. 3-6 months

3. 6-12 months

4. I live here all year long

5. Refused to answer

5. What is the outside of your house made of? (Select all that apply)

   1. Galvanized iron

   2. Aluminum

   3. Tile

   4. Concrete

   5. Brick

   6. Stone

   7. Wood

   8. Plywood

   9. Adobe

   10. Other (Specify:______________________)

   11. Refused to answer

6. What is the floor of your house made of? (Select all that apply)

   1. Dirt

   2. Aluminum

   3. Tile

   4. Concrete

   5. Brick

   6. Stone

   7. Wood

   8. Plywood

   9. Adobe

   10. Other (Specify:______________________)

   11. Refused to answer

7. Do you have running water at your house (A tap, faucet, or pump?)

   1. Yes

   2. No

   3. Don’t know

   4. Refused to answer

Household Questions:

** Interviewer first explains what a tick is using an image.**

8. Have you seen ticks in your home in the last month?

   1. Yes

   2. No

   3. Don’t know

   4. Refused to answer

9. Have you seen ticks in your yard in the last month?

   1. Yes

   2. No

   3. Don’t know

   4. Refused to answer

10. Has any person in your home been bitten by a tick in the last month?

    1. Yes

    2. No  Go to question 12

    3. Don’t know  Go to question 12

    4. Refused to answer  Go to question 12

11. If ‘Yes’, were any of those people bitten by ticks children?

    1. Yes

    2. No

    3. Not applicable (no children)

    4. Don’t know

    5. Refused to answer

12. Has your house been treated with pesticides that kill ticks? (like sprays, pellets or granules)

    1. YesGo to question 14

    2. No

    3. Don’t know

    4. Refused to answer

13. Why have pesticides not been used inside or around your home? (Check all that apply)

    1. Didn’t know where to get them

    2. Nowhere to buy them

    3. No time to apply them

    4. Someone is coming

    5. Costs too much

    6. Don’t like to use pesticides (**Note to interviewer to record why they don’t like to use pesticides if participant volunteers the information)

    7. Not needed

    8. Don’t live here all year

    9. Don’t know

    10. Refused to answer

 Go to question 15

14. Who applied these pesticides?

    1. Homeowner or family member

    2. A pest control company

    3. Housing authority

    4. State/Federal mosquito control program

    5. Someone else, specify:__________________

    6. Don’t know

    7. Refused to answer

Dog Questions:

15. Do you own a pet dog? A pet dog is defined as a dog that lives inside or around your home and is fed by you or your household members.

    1. Yes

    2. No  Go to question 26

    3. Don’t know

    4. Refused to answer

16. How many dogs do you own? Please specify: _________

    1. Don’t know

    2. Refused to answer

17. Do you currently tie up, fence in, or keep your dog(s) in the house?

    1. Always

    2. Sometimes

    3. Never  Go to question 19

    4. Don’t know

    5. Refused to answer

18. Why do you contain your dog?

    1. So my dog doesn’t wander off

    2. So my dog doesn’t get hit by a car

    3. So my dog doesn’t get in fights

    4. So my dog doesn’t bite people

    5. Don’t know

    6. Other (Specify__________________________)

    7. Refused to answer

 Go to question 20

19. Why don’t you try to contain your dog?

    1. I don’t like to

    2. My dog is nice

    3. I don’t have anything to tie them up with or fence them in with

    4. My dog doesn’t wander off

    5. My dog is a watchdog

    6. Don’t know

    7. Other (Specify______________________)

    8. Refused to answer

20. Do you currently treat your dog(s) for ticks?

    1. Yes

    2. No  Go to question 23

    3. Don’t know  Go to question 23

    4. Refused to answer  Go to question 23

21. How do you treat your dog for ticks?

    1. Tick collar (non-Seresto)

    2. Seresto collar

    3. Liquid or drops

    4. Injection of ivermectin (either door to door or at a clinic)

    5. Dip

    6. Spray

    7. Brush

    8. Shampoo

    9. Other, specify:_________________

    10. Don’t know

    11. Refused to answer

22. How frequently do you apply/administer this treatment?

    1. Once a month

    2. Once every 3 months

    3. Once a year

    4. When I see a tick

    5. Don’t know

    6. Refused to answer

 Go to question 24

23. Why are you currently not treating any or all of your dog(s) for ticks?

    1. Can’t get the products

    2. No money to purchase products

    3. Don’t know how to use them

    4. No interest in using them

    5. Don’t think it is necessary

    6. Concerned about chemicals

    7. Other treatment (Specify:____________________)

    8. Don’t know

    9. Refused to answer

24. Are one or more of your dog(s) spayed or neutered? (Spayed or neutered means they have had a surgery to prevent them from having puppies)

    1. Yes  Go to question 26

    2. No

    3. Don’t know

    4. Refused to answer

25. Why aren’t (all of) your dogs spayed or neutered?

    1. Cannot afford the surgery

    2. I don’t think it is necessary

    3. I think it is cruel

    4. I think it is unnatural

    5. No one provides veterinary surgery in this area

    6. I want my dog to be a guard dog

    7. I want my dog to have puppies

    8. Don’t know

    9. Refused to answer

26. Do you support having an animal control program in PMA? (An animal control program is a program that picks up stray dogs, spays or neuters them, provides adoption services, or puts dogs to sleep that can’t be adopted)

    1. Yes

    2. No

    3. Don’t know

    4. Refused to answer

27. How often do you see dogs in your yard that aren’t yours? (i.e. ‘stray’ or ‘free roaming’ animals)

    1. Often (>3 times per week)

    2. Sometimes (1-3 times per week)

    3. Never

    4. Don’t know

    5. Refused to answer

RMSF Questions:

28. Have you ever heard of rickettsia?

    1. Yes

    2. No  Go to question 34 (if this option is checked then interviewer will provide education on signs and symptoms of rickettsia at the end of the survey)

    3. Don’t know

    4. Refused to answer

29. Do you know anyone who has had rickettsia?

    1. Yes

    2. No

    3. Don’t know

    4. Refused to answer

30. Do you know anyone who has died from rickettsia?

    1. Yes

    2. No

    3. Don’t know

    4. Refused to answer

31. Do you know the symptoms for rickettsia?

    1. Yes

    2. No Go to question 33

    3. Don’t know  Go to question 33

    4. Refused to answer  Go to question 33

32. Please indicate which of the following are symptoms of rickettsia. (Check all that apply)

    1. Fever

    2. Rash

    3. Nausea

    4. Vomiting

    5. Loss of appetite

    6. Abdominal pain

    7. Chills

    8. Headache

    9. Lethargy

    10. Could not describe (if this option is checked then interviewer will be instructed to provide education on signs and symptoms of ‘rickettsia’ at the end of the survey)

    11. Refused to answer

33. In the last month have you heard any education on ‘rickettsia’ on the radio, in the newspaper, or at community presentations?

    1. Yes

    2. No

    3. Don’t know

    4. Refused to answer

34. Do you know how to remove a tick from a person or dog?

    1. Yes

    2. No Go to directly observed section of questionnaire

    3. Don’t know Go to directly observed section of questionnaire

    4. Refused to answer Go to directly observed section of questionnaire

35. How do you remove a tick? (Check all that apply)

    1. Fingers

    2. Tweezers

    3. Some other instrument

    4. Don’t know

    5. Refused to answer

DIRECTLY OBSERVED SECTION:

INTERVIEWER: Request to count the number of ticks on the nearest available dog. If there are many dogs present, ask to see the one that has the most contact with the family.

1. 0 or no ticks present on dog

2. 1-10 ticks present on dog

3. 11-100 ticks present on dog

4. >100 ticks present on dog

5. Owner refused to allow tick count

6. No dogs available for tick count

Are there tick harborage sites located on the property? ☐Yes ☐No

If ‘YES’, what kinds of tick harborage sites present on the property outside the house? (Check all that apply)

1. Mattresses

2. Furniture

3. Wood pile

4. Carpet

5. Out buildings

6. Other, specify:____________________________

Follow up supplementary questions to be asked at the end of the intervention for the intervention community only

1. Did you participate in the intervention in Poblado Miguel Aleman last year?

   1. Yes  Go to question 3

   2. No

   3. Don’t know

   4. Refused to answer

2. Why did you not participate in the intervention in Poblado Miguel Aleman last year?

   1. Just moved here

   2. Didn’t know about it

   3. Didn’t want to participate

   4. Other, specify:_________________________

   5. Refused to answer

Skip to directly observed section of questionnaire

3. Did one or more of your dog(s) receive a grey Seresto collar last year to treat for ticks?

   1. Yes

   2. No

   3. Not applicable (does not own any dogs)  Go to question 6

   4. Don’t know

   5. Refused to answer

4. Did you have at least one of your dogs spayed or neutered in the last year?

   1. Yes

   2. No

   3. Don’t know

   4. Refused to answer

5. What factors kept you from getting your dog spayed/neutered in the last year?

   1. I didn’t know it was available

   2. I wasn’t interested in getting my dog fixed

   3. I did not think it was necessary

   4. I did not understand its purpose

   5. The timing was inconvenient

   6. The line was too long

   7. My dogs were already spayed/neutered

   8. No one offers veterinary surgery in this area

   9. Other, specify:_______________________________

   10. Don’t know

   11. Refused to answer

6. How would you describe the number of ticks in and around your home compared to last year?

   1. Much better than last year (far fewer ticks)

   2. Slightly better than last year (fewer ticks)

   3. About the same as last year

   4. Slightly worse than last year (more ticks)

   5. Worse than last year (far more ticks)

   6. Don’t know

   7. Refused to answer

7. Please indicate your overall level of satisfaction with the intervention.

   1. Extremely satisfied

   2. Satisfied

   3. Neutral, neither satisfied nor dissatisfied

   4. Dissatisfied

   5. Extremely dissatisfied

   6. Don’t know

   7. Refused to answer

8. How well do you feel the intervention (tick collars and yard treatments) worked at controlling ticks?

   1. Very well, I don’t see any ticks

   2. Well, I haven’t seen many ticks

   3. Ok, I’ve only seen a small decrease in the number of ticks

   4. Not at all, I haven’t seen any decrease in the number of ticks

   5. Don’t know

   6. Refused to answer

INTERVIEWER REQUEST: Request to count the number of ticks on the nearest available dog. If there are many dogs present, ask to see the one that has the most contact with the family.

1. 0 or no ticks present on dog

2. 1-10 ticks present on dog

3. 11-100 ticks present on dog

4. >100 ticks present on dog

5. Owner refused to allow tick count

6. No dogs available for tick count

9. Is the gray Seresto collar still on that dog?

   1. Yes

   2. No

   3. Owner refused to allow dog to be observed

   4. No dogs available to observe

10. Was the Seresto collar secured with a zip tie?

    1. Yes

    2. No

    3. Owner refused to allow dog to be observed

    4. No dogs available to observe

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