Case Report Form

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

   Form Approved 
OMB No. 0920‐1011 
Exp. Date 03/31/2017 

CASE REPORT FORM

Undetermined agent and risk factors for chikungunya or dengue virus infections
among community service volunteers in the Dominican Republic, 2014
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Demographic Information and Travel History
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0. What is your name? ______________________________________(Last, First, MI)
1. What is your date of birth? _____/______/______
2. Sex: □ Male

□ Female

3. What countries outside of the continental United States have you ever visited before
this trip to the Dominican Republic (please also list such places as Puerto Rico, the
US Virgin Islands, and Guam)?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
This page will be removed after a unique identifier is applied and accuracy is checked.

Public reporting burden of this collection of information is estimated to average 70 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)

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

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Trip Illness History
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4. Have you experienced a fever since you arrived in the Dominican Republic?
□Yes □ No
If yes, please specify as accurately as possible the following information about
each of your illnesses with fever. If no, skip to Question 5.
Illness with fever #1
4.1a. Symptom onset: Month: ___________ Day: __________
4.1b.1-17. Please check all that apply
□ Chills
□ Headache
□ Runny nose
□ Sore throat
□ Red eyes
□ Eye pain/pain behind eyes
□ Cough
□ Nausea/Vomiting □ Diarrhea
□ Abdominal pain/discomfort
□ Muscle pain
□ Calf pain
□ Joint pain
□ Red or swollen joints
□ Skin rash
□ Minor bleeding (e.g., petechiae (small red/purple sometimes raised spots on skin), gum
bleed, nosebleed, excessive or unusual bruising)
□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy
menses)
4.1c. If you had joint pain, indicate the locations where you had the pain

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

4.1d. Approximately how long did this illness last? ______ days
4.1e. Did you activate your emergency CALM plan because of this illness?
□ Yes □ No
4.1f. Did you go to the doctor because of this illness?

□ Yes

□ No

4.1h. What was the diagnosis?
□Chikungunya □ Dengue □ Viral syndrome □ I don’t know
□ Other: If other, please specify ________________________
4.1i. Were you hospitalized for this illness? □ Yes

□ No

Illness with fever #2
4.2a. Symptom onset: Month: ___________ Day: __________
4.2b.1-17. Please check all that apply
□ Chills
□ Headache
□ Runny nose
□ Sore throat
□ Red eyes
□ Eye pain/pain behind eyes
□ Cough
□ Nausea/Vomiting □ Diarrhea
□ Abdominal pain/discomfort
□ Muscle pain
□ Calf pain
□ Joint pain
□ Red or swollen joints
□ Skin rash
□ Minor bleeding (e.g., petechiae (small red/purple sometimes raised spots on skin), gum
bleed, nosebleed, excessive or unusual bruising)
□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy
menses)
4.2c. If you had joint pain, indicate the locations where you had the pain

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

4.2d. Approximately how long did this illness last? ______ days
4.2e. Did you activate your emergency CALM plan because of this illness?
□ Yes □ No
4.2f. Did you go to the doctor because of this illness?

□ Yes

□ No

4.2h. What was the diagnosis?
□Chikungunya □ Dengue □ Viral syndrome □ I don’t know
□ Other: If other, please specify ________________________
4.2i. Were you hospitalized for this illness? □ Yes

□ No

*****If more than two illness with fever, please request additional answer sheets*****
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Experiences at Study Site
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5. Did the house that you were staying at have:
5a. Screens on the window? □ Yes
5b. Screens on the doors?
□ Yes
5c. Air-conditioning?
□ Yes

□ No
□ No
□ No

6. Do you remember being bitten by mosquitoes during your 2014 trip to the Dominican
Republic?
□ Yes
□ No
6.1 If yes, please indicate the time of day when you were bitten by mosquitoes
most often (please choose a single answer)
a) morning
b) afternoon
c) early evening
d) late evening
7. How frequently did you apply/use insect repellent during your trip to the Dominican
Republic?
a) Once daily
b) Multiple times a day (Please specify number of times per day ______)
c) Not every day, but when I noticed mosquitoes were around.
d) Never
e) Other (Please specify________________________________________)

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

8. Which of the following did you do during your travel to the Dominican Republic to
protect yourself from being bitten by mosquitoes? (Please circle all that apply):
a) Wore long sleeves shirts
b) Wore long pants
c) Wore a hat
d) Wore close-toed shoes (such as tennis shoes)
e) Bed nets
f) Mosquito coils
g) Used insecticide aerosols (to spray in room and not on skin)
h) Wore insecticide treated clothing
i) None of these
j) Other (Please specify _____________________________________)
9. Did you treat your clothing with insecticide (permethrin) before you traveled to the
Dominican Republic?
□ Yes
□ No
10. Did you travel to other areas (outside of your service location) of the Dominican
Republic?
□Yes
□ No
10.1 If yes, please indicate places and days spent there:
Location 1: _____________________ #days ______
Location 2: _____________________ #days ______
Location 3: _____________________ #days ______
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Pre-Travel Health Preparation for the June/July 2014 Trip to the Dominican Republic
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11. Did you seek pre-travel advice from a healthcare provider (doctor, nurse, nurse
practitioner, or physician assistant) before your summer 2014 trip to the Dominican
Republic?
□ Yes
□ No
12. If yes, what type of clinic did you go to prior to your trip to the Dominican Republic?
If no, please skip to question 18.
a) Your primary care provider or personal medical provider (e.g. pediatrician,
family practitioner, nurse practitioner, etc.)
b) A local public health department clinic
c) A travel medicine specialty clinic
d) Other (please specify: __________________________________)
13. Did you receive any specific information on health risks or diseases present in the
Dominican Republic during this appointment?
□ Yes
□ No

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

14. Did you receive any specific information about how to avoid mosquito bites during
this appointment?
□ Yes
□ No
15. If yes, what recommendations did the clinician give you to prevent mosquito bites?
a)
b)
c)
d)
e)

f)
g)
h)
i)
j)
k)

Wear long sleeves
Wear long pants
Wear a hat
Wear close-toed shoes (such as tennis shoes)
Applied insect repellent (bug spray or lotion) (Please specify brand name, color of
bottle- for example Deep Woods OFF has green bottle)
_____________________________________________________________
Bed nets
Mosquito coils
Insecticide aerosols (to spray in room and not on skin)
Insecticide treated clothing
None of these
Other (Please specify _____________________________________)

16. Did you receive any specific information about dengue during this appointment?
□ Yes
□ No
17. Did you receive any specific information about chikungunya during this
appointment? □ Yes
□ No
18. From what additional source(s) did you seek health information about the Dominican
Republic before your travel?
a)
Online/website(s) (please specify:_____________________________)
b)
Primary care physician
c)
Friend(s)/Family
d)
Travel/Trip coordinator
e)
Television
f)
Periodicals/Newspapers (please specify: ________________________)
g)
Magazines (please specify: ___________________________________)
h)
Other(please specify: ________________________________________)
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Pre-departure training (Program Orientation)
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19. Did you receive any specific information on health risks or diseases in the Dominican
Republic during your pre-departure training with your service organization?
□Yes
□ No

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

20. Did you receive any specific information about how to avoid mosquito bites during
this pre-departure training? □Yes
□ No
21. If yes, did this training make you more likely to use insect repellant while in the DR?
□ Yes
□ No
22. Did you receive any specific information about dengue during this pre-departure
training?
□Yes
□ No
23. Did you receive any specific information about chikungunya during this pre-departure
training? □Yes
□ No
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In-country training (Program Orientation)
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24. Did you receive any specific information on health risks or diseases in the Dominican
Republic during this in country training?
□Yes
□ No
25. Did you receive any specific information about how to avoid mosquito bites during
this in-country training?
□Yes
□ No
26. If yes, did this training make you more likely to use insect repellant while in the DR?
□ Yes
□ No
27. Did you receive any specific information about dengue during in country training?
□Yes
□ No
28. Did you receive any specific information about chikungunya during in country
training?
□Yes
□ No
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Knowledge of health and safety before travel, pre-travel health visit, and program
training
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29. Before signing up for this trip to the Dominican Republic and your training with your
service organization, how much did you know about dengue?
a) A lot
b) Some
c) A little
d) Nothing, never heard of it before going to the Dominican Republic (Skip
to question #34)

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

30. Before this trip to the Dominican Republic and your training, did you know that
dengue was transmitted by mosquitoes?
□Yes
□ No
31. Before this trip to the Dominican Republic and your training, did you think that you
could be exposed to dengue while in the Dominican Republic? □Yes
□ No
32. Before this trip to the Dominican Republic and your training, did you know that there
was no vaccine for dengue?
□Yes
□ No
33. Before this trip to the Dominican Republic and your training, did you know that there
was no treatment specifically for dengue?
□Yes
□ No
34. Before signing up for this trip to the Dominican Republic and your training with your
service organization, how much did you know about chikungunya?
a) A lot
b) Some
c) A little
d) Nothing, never heard of it before going to the Dominican Republic (Skip to
question #39)
35. Before this trip to the Dominican Republic and your training, did you know that
chikungunya was transmitted by mosquitoes? □Yes
□ No
36. Before this trip to the Dominican Republic and your training, did you think that you
could be exposed to chikungunya while in the Dominican Republic? □Yes □ No
37. Before this trip to the Dominican Republic and your training, did you know that there
was no vaccine for chikungunya?
□Yes
□ No
38. Before this trip to the Dominican Republic, did you know that there was no treatment
specifically for chikungunya?
□Yes
□ No
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Comments
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39. Please list any other comments you wish to share:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Unique ID # (e.g., SJ‐1‐A‐1):_____‐______‐_____‐_____   

Thank you for completing this questionnaire and participating in the study. If you
develop a fever within 2 weeks of returning home, please seek medical care with a health
care provider immediately and inform your service organization of this illness.