Family interview

Emergency Epidemic Investigation Data Collections - Expedited Reviews

Appendix 2 Family interview questionnaire

2014015-XXX_Parechovirus_Multi

OMB: 0920-1011

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1011 can be found here:

Document [docx]

Download: docx | pdf

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Human Parechovirus 3 (HPeV3) Investigation

Part II: Questionnaire for Family Interview

Please note that this questionnaire has 17 pages and contains 8 parts:

Part A: Demographic information about the infant who was ill with HPeV3

Part B: Summary of mother’s peripartum period

Part C: Summary of infant’s illness with HPeV3

Part D: Review of infant’s general health

Part E: Infant’s surroundings and household contacts in the week before illness

Part F: Family and friend visits in the week before illness

Part G: Childcare or healthcare worker visits in the week before illness

Part H: Other information

Interview form for ___________________________________________ (please insert infant’s name)

Date of interview: ________________ (MM/DD/YYYY)

Name of interviewer: _________________________________________________________

Interviewer’s institution: ______________________________________________________

Primary interviewee (eg mother): ________________________________________________

Phone number to call: ________________________________________ Home

________________________________________ Cell

________________________________________ Work

________________________________________ Other

Secondary interviewee (eg father): _______________________________________________

Phone number to call: ________________________________________ Home

________________________________________ Cell

________________________________________ Work

________________________________________ Other

When initiating the interview, please use the following paragraph:

Hello, my name is ____________________________, and I am a _____________________________ at the________________________________________.

Along with Children’s Mercy hospital, the CDC and the Kansas and Missouri state health departments, we are investigating recent cases infants diagnosed with parechovirus. I understand that your son/daughter _____________________ was recently hospitalized. Is that correct?

I’m calling today to ask if you would be willing to answer a few questions regarding your son’s/daughter’s recent illness. It should take about 15 minutes. We are hoping to understand more about what happened around the time of the illness. We hope that this will help us to understand parechovirus infections better and prevent future transmission. Are you willing to speak with me today about this?

Yes: That’s great, thank you very much.

No: Is there a more convenient time for me to call you back?

Call back time: Day: _______________ Time: _______________

No: Is there anyone else in the house that is able to talk with me today?

Was consent given? Yes No

Final interview was conducted with: _____________________________________________

Relationship to infant (case patient): ____________________________________________

Part A: HPeV3 case-patient information

Infant’s First Name: _______________________ ____

Infant’s Last (Family) Name: __________________________

Date of Birth: __________________ (MM/DD/YYYY) Sex: Female Male Unknown

First name of first parent/guardian: _____________________________________

Last (Family) name of first parent/guardian: ______________________________

Email address: ___________________________________________________

Residence address: __________________________________________________________________

__________________________________________________________________________________

First name of second parent/guardian: _____________________________________

Last (Family) name of second parent/guardian: ______________________________

Email address: ___________________________________________________

Residence address: __________________________________________________________________

__________________________________________________________________________________

Part B: Summary of mother’s peripartum period

The questions below are directed towards the mother of the infant

Please adjust phrasing of questions according to who is being interviewed

I would first like to ask you a few questions about yourself and about the period of time from the week before birth up to when your son/daughter became ill.

What is your date of birth? ___________________ (MM/DD/YYYY) OR Age (years): ________

What is your occupation? _____________________________________________________________

Did you have any non-pregnancy-related illnesses during this period? Anything from a mild cold to hospitalization is important here. (Cold, fevers, rashes, abdominal pain, diarrhea or vomitting). And can you remember when that occurred?

(if rash is mentioned, please ask for a detailed description – location, duration and general descriptors e.g. flat, raised, red, bumpy, scaly, blistering, fluid-filled blisters etc)

Shape1

Did you seek medical care for any of these symptoms or illnesses at a doctor’s office, clinic, urgent care center or hospital? Yes No

If yes, please describe:

Shape2 (dates, hospital name, symptoms, admitted)

After the birth of your son/daughter, did you breastfeed him/her? Yes No

Has the baby been exclusively breast fed since birth? Yes No

If no, did you also use formula? Yes No

How often was formula used? _______________________________________________________

Are you currently still breastfeeding him/her? Yes No

If no, for how long did you breastfeed him/her? __________________________________________

Is there a family history of neurologic disorders, including seizures? Yes No Unknown

Shape3 If yes, please describe:

Part C: Summary of infant’s illness

I will now ask a few questions about your son’s/daughter’s illness.

Date of first symptoms: ______________________ (MM/DD/YYYY)

Shape4 What symptoms did your son/daughter first show?

Please describe any other symptoms that followed and when they occurred:

Shape5

Was he/she at home when the illness began? Yes No Unknown

If no, where was he/she? ____________________________________________________________

Did you seek medical care for any of these symptoms at a doctor’s office, clinic or urgent care center before your son/daughter was admitted to hospital? Yes No

If yes, please give details (where, when, name of physician etc): _____________________________

__________________________________________________________________________________

When did you take him/her to hospital? _____________________ (MM/DD/YYYY)

Hospital name: _____________________________________________________________________

Hospital floor and room number: ________________________________________________________

Admitting physician’s name: ____________________________________________________________

Were they transferred to another hospital? Yes No Unknown

If yes, transfer date: _____________________ (MM/DD/YYYY)

If yes, receiving hospital name: ________________________________________________________

If yes, doctor’s name: ________________________________________________________________

Part D: Review of infant’s general health

Before your son/daughter became ill and required admission, was he/she on any medications?

Medication	For what reason?	Date Started (MM/DD/YYYY)	Date stopped (MM/DD/YYYY)

Before this illness, did you take your son/daughter to the hospital for any reason? Yes No

Before this illness, did you take your son/daughter to an outpatient clinic? Yes No

Shape6 If yes to either, please describe (dates/hospitals/symptoms/providers):

Part E: Infant’s surroundings and household contacts in the week before illness

I would now like to ask you some questions about who your son/daughter might have had close contact with in the week before their illness.

Does your infant (who was ill) attend day care? Yes No Unknown

Shape7 If yes, please describe the frequency of attendance, location/setting, the approximate number of other children at the setting and the age of the other children at the setting:

If speaking to the mother, please skip to Person 2, under household contacts

Now I would like to ask you about the people who may have had contact with your child, starting with yourself:

Person 1

Name: ____________________________________________________________________________

Age: ________________ Relationship to infant: ____________________________________

Occupation: ________________________________________________________________________

Were you ill in the week before your son/daughter became ill? Yes No Unknown

(please ask specifically about respiratory and diarrheal symptoms)

If yes, what kind of symptoms did you have? _____________________________________________

__________________________________________________________________________________

If yes, did you receive any treatment? ___________________________________________________

__________________________________________________________________________________

Household contacts

Could you now please describe the other members of your household, including both adults and children:

Person 2

Name: ____________________________________________________________________________

Age: ________________ Relationship to infant: ___________________________________

Occupation or school/preschool: ________________________________________________________

Were they ill in the week before your son/daughter became ill? Yes No Unknown

(please ask specifically about respiratory and diarrheal symptoms)

If yes, what kind of symptoms did they have? _____________________________________________

__________________________________________________________________________________

If yes, did they seek medical care and where? _____________________________________________

__________________________________________________________________________________

If yes, did they receive any treatment? __________________________________________________

__________________________________________________________________________________

Person 3