CASE report number |__ - |__|__|__|
Matched CONTROL #1 |__ - |__|__|__| - |__|
Matched CONTROL #2 |__ - |__|__|__| - |__|
NAME OF INTERVIEWER_______________________________________________
CASE: LAST NAME_______________________ FIRST NAME________________
Telephone Contact History
Date (mm/dd) Time (am/pm) Outcome/Comment Initials
1.__________ ___________ _________________ ______
2.__________ ___________ _________________ ______
3.__________ ___________ _________________ ______
4.__________ ___________ _________________ ______
5.__________ ___________ _________________ ______
6.__________ ___________ _________________ ______
7.__________ ___________ _________________ ______
8.__________ ___________ _________________ ______
9.__________ ___________ _________________ ______
10.__________ ___________ _________________ ______
11.__________ ___________ _________________ ______
12.__________ ___________ _________________ ______
13.__________ ___________ _________________ ______
14.__________ ___________ _________________ ______
OUTCOME CODES:
01 = completed interview 08 = no eligible respondent
02 = refused interview 09 = language barrier
03 = no answer 10 = interview terminated within questionnaire
04 = busy tone 11 = physical/mental impairment
05 = non-working number 12 = answering machine
06 = fax machine 13 = setting up a better time
07 = business phone 99 = unknown
CASE INTRODUCTION INTERVIEW
Hello, my name is ______________________ and I am working with x.
We are investigating an outbreak of diarrhea occurring among people who live in X. We are conducting a survey to help us determine what may have played a role in causing illness among people living in your/our community.
We realize that you may have already spoken to the Health Department; however, we are interested in finding out more about this illness so that we can develop guidelines for preventing and controlling illness.
You have been selected to participate in this survey because of your illness. The answers that you give will be kept secure. Your participation in these efforts will greatly enhance our understanding of this illness in your/our community.
This should take approximately 20-30 minutes. Your participation is voluntary and all information you give will be kept confidential to the extent legally possible. Some of the questions may be sensitive. You may refuse to answer any question at any time. Neither your name nor any identifying information will appear on any report. We will be happy to answer all your questions at the end of the interview. A final report will be available at the health department.
Do you agree to participate in this survey?
___ NO, END INTERVIEW…Thank you for your time.
___ YES IF YES, CONTINUE INTERVIEW... It would be helpful if you had a calendar in front of you, as we will be discussing specific dates.
SECTION A: CLINICAL INFORMATION
A1. When did your diarrhea begin? |__|__|-|__|__|-|0|4|
MM DD YY
IF RESPONDENT CANNOT REMEMBER EXACT DATE DIARRHEA BEGAN, PROMPT FOR WEEK DIARRHEA BEGAN. ENTER DATE OF WEDNESDAY OF THAT WEEK
A2. If not exact date diarrhea began, enter approximate date |__|__|-|__|__|-|0|4|
MM DD YY
After getting the date of onset for illness (a2), mark the MONTH preceeding that onset date on the calendar AND IN THE SPACE BELOW for use in asking the exposure questionS
THAT WOULD BE THE PERIOD FROM /___/___/___/ TO /___/___/___/.
A3. What was the maximum number of loose or watery stools you had in a 24-hour period during this illness?
NUMBER |__|__|
UNKNOWN.....................77
REFUSED.........................99
A4. Did you have blood in your stool?
YES............................................ 1
NO.............................................. 2
UNKNOWN...............................77
REFUSED...................................99
A5. Was there a period when your diarrhea went away for at least a day and then came back?
YES.................................................1
NO..................................................2 (GO TO A7)
UNKNOWN.................................77 (GO TO A7)
REFUSED.................................... 99 (GO TO A7)
A6. How many times did this happen?
|__|__| Times
A7. Do you currently have diarrhea?
YES................................................. 1 (GO TO A9)
NO...................................................2
UNKNOWN.................................77 (GO TO A9)
REFUSED.................................... 99 (GO TO A9)
A8. IF NO, what date did the diarrhea completely end (include all of the diarrhea free days if there were any)?
Date: |__|__| |__|__| 2004
MM DD
A9. In addition to diarrhea, which of the following symptoms did you have, and how long did you experience each from beginning to end, regardless of whether you felt better on some days in between? [READ THE LIST OF SYMPTOMS. IF YES, ENTER THE CORRESPONDING DURATION FOR EACH.] (U=UNKNOWN; R=REFUSED)
SYMPTOM |
0 days |
1 day |
2-5 days |
6-14 days |
>14 days |
U |
R
|
a. Nausea |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
b. Vomiting |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
c. Headache
|
0 |
1 |
2 |
6 |
14 |
77 |
99 |
d. Loss of appetite |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
e. Abdominal cramps |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
f. Bloating/Gas |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
g. Body/Muscle aches |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
h. Tiredness/Fatigue |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
i. Fever IF YES, GO TO A10, IF NO GO TO A11. |
0 |
1 |
2 |
6 |
14 |
77 |
99 |
A10. If yES TO fever, what was the highest temperature measured?
a. NUMBER |__|__|__| . |__| degrees F OR b. NUMBER |__|__|__| . |__| degrees C
Felt warm/feverish, but temperature not measured ….222.2
UNKNOWN...........................…………………….......777.7
REFUSED...........................………………………….. 999.9
A11. Have you experienced any weight loss as a result of your symptoms?
YES.................................................1
NO..................................................2
UNKNOWN.................................77
REFUSED.................................... 99
A12. Did you seek health care for any symptoms?
YES.................................................1
NO..................................................2 (GO TO A15)
UNKNOWN.................................77 (GO TO A15)
REFUSED.................................... 99 (GO TO A15)
A13. The following questions are about treatment for your illness.
(CHECK ALL THAT APPLY) Y N U R
A13a. Was a doctor or nurse consulted over the phone? 1 2 77 99
A13b. Did you visit a doctor’s office? 1 2 77 99
A13c. Did you visit an Emergency Room? 1 2 77 99
A13d. Were you hospitalized for more than 24 hours? 1 2 77 99 A13e. IF YES, how long hospitalized? |__|__| days
A14. Once your diarrhea began, how long were you ill before you contacted or visited a doctor or nurse?
NUMBER |__|__|__| days
UNKNOWN..........................................777
REFUSED…..........................................999
A15. What treatment did you use for your symptoms?
(CHECK ALL THAT APPLY):
Y N U R
A15a. Nothing [IF YES GO TO A16] 1 2 77 99
A15b. OTC antidiarrheal medications (i.e. Peptobismol) 1 2 77 99
A15c. Herbal remedies 1 2 77 99
A15d. Antibiotics/Antiparasitics 1 2 77 99
A15e. Any prescription medications 1 2 77 99
A15f. Dehydration medications (Pedialyte) 1 2 77 99
A15g. Drank more fluids 1 2 77 99
A15h. Received Intravenous fluids 1 2 77 99
A15i. Fever/Pain reliever 1 2 77 99
A15j. Other _________________________ 1 2 77 99
A16. When your illness began, were you employed – meaning you had a paid job performed either outside or inside the home?
YES..................................................1
NO...................................................2 (GO TO A19)
UNKNOWN..................................77 (GO TO A19)
REFUSED…................................. 99 (GO TO A19)
A17. IF YES TO EMPLOYED, during your illness, did you miss any time from work, for example because you called in sick or took time off to see a doctor?
YES..................................................1
NO...................................................2 (GO TO A19)
UNKNOWN..................................77 (GO TO A19)
REFUSED…................................. 99 (GO TO A19)
A18. If yes, how many days? |___|___| days (IF IN HOURS, i.e. <1 DAY, THEN
CODE AS ZERO)
UNKNOWN …………………..77
REFUSED……………………...99
A19. Did this illness prevent you from performing daily activities such as school, recreation, or vacation activities, or working within the home?
YES..................................................1
NO...................................................2 (GO TO A20)
UNKNOWN..................................77 (GO TO A20)
REFUSED…................................. 99 (GO TO A20)
A19a. If yes, how many days? |___|___| days (IF IN HOURS, i.e. <1 DAY, THEN
CODE AS ZERO)
UNKNOWN…………………………77
REFUSED……………………………99
A20. Did you continue to do water activities (swimming, water parks, etc.) while you had diarrhea?
YES………………………………1
NO……………………………….2
UNKNOWN……………………..77
REFUSED……………………….99
A21. Did you prepare food for others while you had diarrhea?
YES………………………………1
NO……………………………….2
UNKNOWN……………………..77
REFUSED……………………….99
A22. Did you participate in water activities (pool, water parks, etc.) in the month before your diarrhea ended?
YES………………………………..1
NO………………………………...2
UNKNOWN……………………....77
REFUSED…………………………99
A23. Are you aware of anyone in your immediate household or social group that had diarrhea in the month before your symptoms began?
YES……………………………….1
NO………………………………..2
UNKNOWN……………………...77
REFUSED………………………...99
A24. Are you aware of anyone in your immediate household or social group that had diarrhea while you had your symptoms?
YES……………………………….1
NO………………………………..2
UNKNOWN……………………...77
REFUSED………………………..99
A25. Are you aware of anyone in your immediate household or social group that had diarrhea in the month after your symptoms began?
YES……………………………….1
NO………………………………..2
UNKNOWN……………………...77
REFUSED………………………..99
A26. Do you have a weakened immune system? Conditions such as cancer, HIV, organ transplant and/or receiving steroid treatment can cause a weakened immune system. This does not include inhaled steroids for asthma therapy.
YES.................................................1
NO...................................................2
UNKNOWN..................................77
REFUSED…................................. 99
SECTION B. PERSON TO PERSON CONTACT AND CHILDCARE INFORMATION
B1. Now I would like to ask about the adults (>18 years of age) in your house. What are the adult’s sexes and did they have diarrhea in the month before you became ill? (QUESTION A2) /___/___/___/ to /___/___/___/.
ADULT |
What sex?
(1=MALE, 2=FEMALE) |
Had diarrhea?
YES NO UNK REF |
||||
ADULT 1 |
1 |
2 |
1 |
2 |
77 |
99 |
ADULT 2 |
1 |
2 |
1 |
2 |
77 |
99 |
ADULT 3 |
1 |
2 |
1 |
2 |
77 |
99 |
ADULT 4 |
1 |
2 |
1 |
2 |
77 |
99 |
ADULT 5 |
1 |
2 |
1 |
2 |
77 |
99 |
ADULT 6 |
1 |
2 |
1 |
2 |
77 |
99 |
READ: Now I would now like to ask you a few questions about your contact with children under 18 and persons with diarrhea in the month before you became ill (QUESTION A2) /___/___/___/ to /___/___/___/.
B2. Do you have children (<18 years old) living in your home?
IF INTERVIEWING AN ADOLESCENT: Do you have children (<18 years old) – other than yourself - living in your home?
YES.................................................................... 1
NO...................................................................... 2 (GO TO B9)
UNKNOWN......................................................... 77 (GO TO B9)
REFUSED..................................................... 99 (GO TO B9)
B3. IF YES, How many children live in your house?
NUMBER OF CHILDREN |__|__|
UNKNOWN 77
REFUSED 99
B4. What are the children’s age(s) in years, their sexes and did they have diarrhea in the month before your diarrhea began?
IF INTERVIEWING AN ADOLESCENT: Other than yourself, what are the children’s age(s) in years, their sexes and did they have diarrhea in the month before your diarrhea began?
CHILD |
AGE? (INDICATE YRS OR MONTHS) |
Does the child wear diapers? Y N |
What sex?
(1=MALE, 2=FEMALE) |
Had diarrhea?
YES NO UNK REF |
||||
CHILD 1 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 2 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 3 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 4 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 5 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 6 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 7 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 8 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 9 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 10 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 11 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 12 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 13 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 14 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
CHILD 15 |
|
1 2 |
1 |
2 |
1 |
2 |
77 |
99 |
B5. Were any children in your household in childcare outside of your home at any time in the month before you became ill?
YES.................................................................... 1
NO...................................................................... 2 (GO TO B7)
UNKNOWN......................................................... 77 (GO TO B7)
REFUSED..................................................... 99 (GO TO B7)
B5a. IF YES, did (he/she/they) participate in any water related activities, such as swimming, wading, or water table play, at his or her childcare outside of your home?
YES.................................................................... 1
NO...................................................................... 2
UNKNOWN......................................................... 77
REFUSED..................................................... 99
B6. IF YES TO B5, Were any children at your child’s childcare location in diapers?
YES.............................................................. 1
NO...................................................................2 UNKNOWN................................................. 77
REFUSED............................................. 99
B7. Were any children in your household in a day camp in the month before you became ill? By a day camp I mean a center with activities where children spend all or part of the day, often during the summer months when school is out. By comparison, a day care center is often for toddlers.
YES.............................................................1
NO..............................................................2 (GO TO B8) UNKNOWN............................................77 (GO TO B8)
REFUSED................................................99 (GO TO B8)
B7a. IF YES, did (he/she/they) participate in any water related activities, such as swimming, wading or water tables, at his or her day camp?
YES.................................................................... 1
NO...................................................................... 2
UNKNOWN......................................................... 77
REFUSED..................................................... 99
B8. In the month before illness, did you provide childcare in any of the following childcare settings? [Read THE LIST. cIRCLE ALL THAT APPLY]
SETTING |
YES |
NO |
UNKNOWN |
REFUSED |
a. Out-of-home childcare center |
1 |
2 |
77 |
99 |
b. In-home childcare center |
1 |
2 |
77 |
99
|
c. Out-of-home babysitter |
1 |
2 |
77 |
99 |
d. In-home babysitter |
1 |
2 |
77 |
99 |
e. Other f. Specify: |
1 |
2 |
77 |
99 |
B9. In the month before illness, did you have contact with any children in diapers?
YES.......................................... 1
NO........................................... 2 (GO TO B11)
UNKNOWN............................... 77 (GO TO B11)
REFUSED........................... 99 (GO TO B11)
B10. If yes, in the month before illness, did you change any diapers?
YES.................................................................... 1
NO...................................................................... 2 UNKNOWN......................................................... 77
REFUSED..................................................... 99
B11. In the month before you became ill, did you come in contact with anyone who had diarrhea?
YES.................................................... 1
NO...................................................... 2 (GO TO SECTION C)
UNKNOWN.......................................77 (GO TO SECTION C)
REFUSED..................................... 99 (GO TO SECTION C)
B12. IF YES, did they include:
[Read THE LIST. cIRCLE ALL THAT APPLY]
|
YES |
NO |
UNKNOWN |
REFUSED |
a. Children < 3 years of age |
1 |
2 |
99 |
77 |
b. Children 4 to <13 years of age |
1 |
2 |
99 |
77 |
c. Teenagers >13 to <18 years |
1 |
2 |
99 |
77 |
d. Adults 18 years or older |
1 |
2 |
99 |
77 |
B13. Did you provide direct care to a person with diarrhea?
YES............................................. 1
NO............................................... 2
UNKNOWN.................................... 77
REFUSED................................. 99
SECTION C. DIETARY EXPOSURES
I WOULD LIKE TO TALK ABOUT YOUR DIET DURING THE TWO WEEKS BEFORE YOUR DIARRHEA BEGAN (QUESTION A2), THAT WOULD BE THE PERIOD FROM /___/___/___/ TO /___/___/___/.
C1. In the month before your diarrhea began, did you eat any of the following food items? [READ THE LIST. ENTER ALL THAT APPLY]
FOOD |
Y |
N |
U |
R |
a. Lettuce or garden salad |
1 |
2 |
77 |
99 |
b. Cold cuts, chicken salad, egg salad, or tuna salad |
1 |
2 |
77 |
99 |
c. Other cold salads such as coleslaw, potato salad, or pasta salad |
1 |
2 |
77 |
99 |
d. Raw vegetables such as carrots, tomatoes, cucumbers, green onions |
1 |
2 |
77 |
99 |
e. Raw berries (e.g. strawberries and raspberries) |
1 |
2 |
77 |
99 |
f. Raw fruits with skin/peel (e.g., melons, apples) |
1 |
2 |
77 |
99 |
g. Cider or juice |
1 |
2 |
77 |
99 |
h. Raw shellfish |
1 |
2 |
77 |
99 |
i. Cooked shellfish |
1 |
2 |
77 |
99 |
C2. In the month before your diarrhea began, did you consume any of the following unpasteurized foods or drinks? This may include products supplied from health food stores, local farms, or imported from other countries.
[Read THE LIST. ENTER ALL THAT APPLY]
FOOD |
YES |
NO |
UNKNOWN |
REFUSED |
a. Unpasteurized milk |
1 |
2 |
77 |
99 |
b. Unpasteurized apple juice/cider |
1 |
2 |
77 |
99 |
c. Other unpasteurized juices |
1 |
2 |
77 |
99 |
d. Unpasteurized cheese (e.g. goat cheese, farmer’s cheese, queso fresco) |
1 |
2 |
77 |
99 |
e. Other Specify: |
1 |
2 |
77 |
99 |
SECTION D. DRINKING WATER EXPOSURES
I WOULD LIKE TO TALK ABOUT YOUR EXPOSURE TO DRINKING WATER IN THE MONTH BEFORE YOUR DIARRHEA BEGAN (QUESTION A2), THAT WOULD BE THE PERIOD FROM /___/___/___/ TO /___/___/___/.
D1 In the month before your diarrhea began, what were your sources of drinking water at home? [Read THE LIST. ENTER ALL THAT APPLY]
QUESTION |
YES |
NO |
UNKNOWN |
REFUSED |
a. Does not drink water at home |
1 |
2 |
77 |
99 |
b. Municipal or city water direct from tap |
1 |
2 |
77 |
99 |
c. Municipal or city water with additional filtration or treatment |
1 |
2 |
77 |
99 |
d. Refrigerator dispenser |
1 |
2 |
77 |
99 |
e. Private well water |
1 |
2 |
77 |
99 |
f. Private well water with additional filtration or treatment |
1 |
2 |
77 |
99 |
g. Commercially bottled water |
1 |
2 |
77 |
99 |
h. Other Specify: |
1 |
2 |
77 |
99 |
D2. In the month before your diarrhea began, what were your sources of drinking water outside the home, for example, at school or work?
[Read THE LIST. ENTER ALL THAT APPLY.]
QUESTION |
YES |
NO |
UNKNOWN |
REFUSED |
a. Does not drink water outside the home |
1 |
2 |
77 |
99 |
b. Municipal or city water direct from tap (including a water fountain) |
1 |
2 |
77 |
99 |
c. Municipal or city water with additional filtration or treatment |
1 |
2 |
77 |
99 |
d. Refrigerator dispenser |
1 |
2 |
77 |
99 |
e. Private well water |
1 |
2 |
77 |
99 |
f. Private well water with additional filtration or treatment |
1 |
2 |
77 |
99 |
g. Commercially bottled water |
1 |
2 |
77 |
99 |
i. Other Specify: |
1 |
2 |
77 |
99 |
D3. What was your usual source of ice in the month before your diarrhea began?
[Read THE LIST. ENTER ALL THAT APPLY]
SOURCE |
YES |
NO |
UNKNOWN |
REFUSED |
a. Do not use ice |
1 |
2 |
77 |
99 |
b. From your home |
1 |
2 |
77 |
99 |
c. From outside your home |
1 |
2 |
77 |
99 |
D4. In the month before your diarrhea began, did you drink any untreated water from a lake, river or stream?
YES............................................ 1
NO............................................ 2
UNKNOWN...............................77
REFUSED...................................99
I WOULD LIKE TO TALK ABOUT YOUR EXPOSURE TO RECREATIONAL WATER. WE WILL FIRST FOCUS ON THE PERIOD IN THE MONTH BEFORE YOUR DIARRHEA BEGAN (QUESTION A2, /___/___/___/ TO /___/___/___/).
E1. During the in the month before your diarrhea began, did you swim or enter recreational water (which means other than in a bathtub or shower)?
YES...............................................1
NO................................................2 (GO TO E18)
UNKNOWN................................77 (GO TO E18)
REFUSED…................................99 (GO TO E18)
E2. During the in the month before the diarrhea began, which recreational water settings did you swim in, wade in, or enter? [Read THE LIST. enter ALL THAT APPLY]
IF YES, on how many days did you swim or enter the water in the two weeks before you became ill? |
IF YES, did you put your face under the water? |
|
|||
Setting |
Y N U R |
Number of days? 1 2-5 6-10 >11 U R |
Y N U R
|
||
a. Lake, Pond, River or Stream |
1 2 77 99 |
1 2 3 4 77 99 |
1 2 77 99 |
||
b. Hot Tub, Spa, Whirlpool, Jacuzzi |
1 2 77 99 |
1 2 3 4 77 99 |
1 2 77 99 |
||
c. Recreational Water Park other than swimming pools (such as The Beach, Soak City, or Wyandot Lake) |
1 2 77 99 |
1 2 3 4 77 99 |
1 2 77 99 |
||
E3. During the in the month before your diarrhea began, did you swim, wade in or enter a swimming pool?
YES...............................................1
NO................................................2 (GO TO E18)
UNKNOWN................................77 (GO TO E18)
REFUSED…................................99 (GO TO E18)
read: THE FOLLOWING QUESTIONS ASK ABOUT TYPICAL SWIMMING ACTIVITIES DURING VISITS TO POOLS
E4. On a typical visit during the in the month before your diarrhea began, did you usually wade or play in the water without swimming?
YES………………....1
NO………………….2
UNKNOWN.............77
REFUSED….............99
E5. On a typical visit during the in the month before your diarrhea began, did you get water splashed in your face?
YES………………....1
NO………………….2
UNKNOWN.............77
REFUSED….............99
E6. On a typical visit during the in the month before your diarrhea began, did you put your face in the water?
YES………………....1
NO………………….2
UNKNOWN.............77
REFUSED….............99
E7. On a typical visit in the month before your diarrhea began, did you get any water in your mouth?
YES…………………1
NO……..…………...2 (GO TO E9)
UNKNOWN…........77 (GO TO E9)
REFUSED….…...... 99 (GO TO E9)
E8. On a typical visit during the in the month before your diarrhea began, did you swallow any of this water?
YES…………………..1
NO……..…………….2
UNKNOWN…..........77
REFUSED…..………99
E9. On a typical visit during the in the month before your diarrhea began, did you dive or jump into the water?
YES………………....1
NO………………….2
UNKNOWN.............77
REFUSED….............99
E10. On a typical visit in the month before your diarrhea began, did you use a slide to enter the water?
YES………………....1
NO………………….2
UNKNOWN.............77
REFUSED….............99
E11. During the in the month before your diarrhea began, please list the swimming pools that you swam in or entered [ENTER ALL THAT APPLY]
IF YES, on how many days in the month before you became ill? |
IF YES, please list dates |
(IF CANNOT RECALL EXACT DATES, prompt for week of swimming in that location and enter date of Wednesday of that week |
IF YES, did you put your face under the water? |
|
|||||
Name |
Y N U R |
Number of days? 1 2-5 6-10 >11 U R |
List dates (MM/DD/YY) |
List dates (MM/DD/YY) |
Y N U R |
||||
|
1 2 77 99
|
1 2 3 4 77 99 |
|
|
1 2 77 99 |
||||
|
1 2 77 99
|
1 2 3 4 77 99 |
|
|
1 2 77 99 |
||||
|
1 2 77 99 |
1 2 3 4 77 99 |
|
|
1 2 77 99 |
||||
|
1 2 77 99 |
1 2 3 4 77 99 |
|
|
1 2 77 99 |
||||
|
1 2 77 99 |
1 2 3 4 77 99 |
|
|
1 2 77 99 |
||||
|
1 2 77 99 |
1 2 3 4 77 99 |
|
|
1 2 77 99 |
||||
|
1 2 77 99 |
1 2 3 4 77 99 |
|
CONTINUED ON NEXT PAGE |
1 2 77 99 |
||||
SECTION F. EVENTS
NOW I WOULD LIKE TO TALK TO YOU ABOUT THE EVENTS THAT YOU ATTENDED DURING X
F1. During the months of X before your diarrhea began, did you attend any large social gatherings with 50 or more persons present such as picnics, county fairs or other events?
YES............................................ 1
NO............................................…2 (GO TO F3) UNKNOWN................................77 (GO TO F3)
REFUSED....................................99 (GO TO F3)
F2. IF YES, please name the events/parties/potlucks and tell us when
Name Date (MM/DD/YY)
SECTION G. TRAVEL HISTORY
NOW I WOULD LIKE TO TALK TO YOU ABOUT YOUR TRAVEL HISTORY IN THE MONTH BEFORE YOUR DIARRHEA BEGAN
(QUESTION A2, /___/___/___/ TO /___/___/___/).
G1. In the month before your diarrhea began did you travel outside American Samoa?
YES...............................................1
NO............................................…2 (GO TO G4)
UNKNOWN................................77 (GO TO G4)
REFUSED....................................99 (GO TO G4)
G2. If yes please specify where and when _____________________________
NOW I WOULD LIKE TO TALK TO YOU ABOUT YOUR CONTACT WITH ANIMALS IN THE MONTH BEFORE YOUR DIARRHEA BEGAN
(QUESTION A2, /___/___/___/ TO /___/___/___/).
H1. In the month before your diarrhea began, did you have contact with any animals, (at home, on a farm, at a zoo, at a fair, festival or other event)?
YES............................................ 1
NO............................................…2 (GO TO H3) UNKNOWN................................77 (GO TO H3)
REFUSED....................................99 (GO TO H3)
H2. IF YES, to which of the following animals?
Read THE LIST. ENTER AND ASK THE CORRESPONDING QUESTIONS.
Animal |
Contact with animal (feeding, petting, playing)? Y N U R |
Animal have diarrhea?
Y N U R |
|
1 2 77 99 |
1 2 77 99 |
|
1 2 77 99 |
1 2 77 99 |
|
1 2 77 99 |
1 2 77 99 |
|
1 2 77 99 |
1 2 77 99 |
|
1 2 77 99 |
1 2 77 99 |
|
1 2 77 99 |
1 2 77 99 |
g. Deer |
1 2 77 99 |
1 2 77 99 |
h. Goat/Sheep/Lamb
|
1 2 77 99 |
1 2 77 99 |
i. Horse
|
1 2 77 99 |
1 2 77 99 |
j. Pigs |
1 2 77 99 |
1 2 77 99 |
k. Poultry (chicken, turkey, etc.) |
1 2 77 99 |
1 2 77 99 |
l. Rabbit
|
1 2 77 99 |
1 2 77 99 |
m. Amphibian/reptile (frog, turtle, lizard, snake, etc.) |
1 2 77 99 |
1 2 77 99 |
n. Other Specify: |
1 2 77 99 |
1 2 77 99 |
H3. In the month before your diarrhea began, did you touch or shovel animal waste/ manure or walk through any area where animal waste/ manure was on the ground?
YES...............................................1
NO............................................…2
UNKNOWN................................77
REFUSED....................................99
H4. Did you visit, work on, or live on a farm in the month before your diarrhea began?
YES...............................................1
NO............................................…2
UNKNOWN................................77
REFUSED....................................99
SECTION I : DEMOGRAPHIC INFORMATION
CASE ID: A |__|__|__|
I1. What is your ZIP code? |__|__|__|__|__|
UNKNOWN…………77777
REFUSED…………... 99999
I2. What is your age?
|___|___|
Age
I3. What is your gender?
MALE ……….…… 1
FEMALE ………… 2
UNKNOWN……....77
REFUSED………....99
I4. What district do you live in? ________________________________
IF RESPONDENT ANSWERS “DON’T KNOW”, ASK:
I4a. What city do you live in?__________________________________
END OF QUESTIONNAIRE: This concludes our questionnaire. I would like to thank you very much for your time, patience, and cooperation in answering our questions. I would be happy to answer any questions you may have at this point.
If you have any questions in the future please contact X.
| File Type | application/msword |
| File Title | SECTION A: CLINICAL INFORMATION |
| Author | EPO |
| Last Modified By | Marsh, Carol E. (CDC/OPHPR/OD) |
| File Modified | 2014-05-23 |
| File Created | 2014-05-23 |