Follow-up Questionnaire for Asymptomatic Passengers and

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Follow-up Questionnaire for Asymptomatic Passengers and Crew, MERS CoV Aircraft Contact Investigation

Identifying and Residency Information (complete from 1^st questionnaire)

Passenger’s name:____________________________________________________

Home Phone: _________________________ Mobile Phone: __________________

E-mail address: _________________________________

Flight Information: Date: ____/____/14 Destination:_____________________

Attempt(s) to reach passenger

Date	Time	Outcome (circle one)	Message left/e-mail sent
		Interview completed / not completed
		Interview completed / not completed
		Interview completed / not completed
		Interview completed / not completed
		Interview completed / not completed

Name of person answering the questions (if not traveler): _________________________

Relationship of person answering questions (if not traveler):_______________________

Name of Interviewer: ________________________ Date of interview: (____/____/14)

Agency/Affiliation of Interviewer: ______________________________________

Follow-up for asymptomatic contacts [should be 14 days since the flight and will likely be less than 14 days from the date initially interviewed]

Script:

Thank you for agreeing to this follow-up call from (circle one): CDC/Health Department.

We are calling you to find out if you have become sick since our last conversation and if you saw a doctor.

Are you willing to answer a few questions? YES NO

If NO, thank the person for their time.

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You flew on ___/___/14. Fourteen days after this time period is [today’s date or state other date].This 14-day period is the monitoring period.

A. Illness History

1. Have you been ill since we last spoke with you?  Yes  No

IF YES, go to question #2. IF NO, thank the person for their time.

2. Have you had any of the following symptoms?

Specify date of onset in mm/dd/yy format for each Yes answer.

1. Fever (measured temp of > 100.4⁰ F (38⁰ C)  Yes (_____°) Temp if known  No  Don’t Know

2. Coughing  Yes  No  Don’t Know

3. Difficulty breathing or shortness of breath  Yes  No  Don’t Know

4. Wheezing  Yes  No  Don’t Know

5. Pain with coughing or breathing  Yes  No  Don’t Know

6. Other symptom(s):  Yes List___________________ No  Don’t Know

If NO to 2. a-e, END.

3. What date did you first become ill with these symptoms? Date____/____/14

4. Are you still sick?  Yes  No

4a. If NO, when did you feel better? Date__/__/14

5. Did you see a doctor for this illness?  Yes  No

If YES,

1. What date were you seen? Date__/__/14

2. Did you receive any treatment for the illness?  Yes  No

   1. If YES, specify: _____________________________________

3. Were you tested by a medical provider for the illness (including, but not limited to, providing a blood sample or nasal or throat swab) since the day of your flight [insert date of flight]?  Yes  No

   1. If YES – Specify test or what kind of specimen was tested for you (e.g., blood, nasal swab, throat swab): _______

      1. Date (mm/dd/yy) ____/____/14

      2. Facility where tested_____________________

4. Were you admitted to the hospital (kept overnight, not just in emergency room)?  Yes  No If yes, which hospital? ________________

6. Do you have any medical conditions that you are treated for regularly?

 Yes (Specify: ______________)  No  Don’t Know

7. For women: Are you currently pregnant?  Yes  No  Don’t Know

B. GEOGRAPHIC EXPOSURES

8. Have you visited the Middle East since [insert date that is 14 days before the flight date]*?

 Yes  No If NO, skip to Question 27.

1. If YES : Dates of visit (mm/dd/yy) ___/____/14 to ___/_____/14

2. List country(ies): ___________________________

3. (Omit for crew) What was the purpose of your trip? (check all that apply)

 Visit family/friends  Personal travel  Business  Study Other; specify: _____

9. While you were in the Middle East, did you:

1. Have any close contact with someone who was sick with the MERS coronavirus?  Yes  No

2. Have any close contact with someone who was sick with a serious respiratory infection, such as pneumonia?  Yes  No

b. Visit a health care facility?  Yes  No

c. (Omit for crew) Work in a health care facility?  Yes  No

Household Contacts

10. Has anyone in your household or someone else you have had close contact with had fever, cough, difficulty breathing (or symptoms similar to what you described)?

 Yes ***  No  Don’t Know

1. Name: ____________________________________

Relationship: __________________________________

Symptoms: _________________________________________

Date of onset (mm/dd/yy): ____/____/____

Address: ____________________________________________

Phone #: ________________________

2. Name: ____________________________________

Relationship: __________________________________

Symptoms: _________________________________________

Date of onset (mm/dd/yy): ____/____/____

Address: ____________________________________________

Phone #: ________________________

*** Note this person’s name and contact information on the form for follow-up by local health department.

IF FEVER PLUS ANY RESPIRATORY SYMPTOMS (2 b-e).

• If ill person has not received health care, read symptomatic contact script.

• Send completed questionnaire to the health department.

CONSULT MEDICAL OFFICER IF FEVER ALONE OR WITH ONLY “OTHER” SYMPTOMS, OR RESPIRATORY SYMPTOMS WITHOUT FEVER.

THE END

Script: Thank you for taking the time to answer these questions.

Do you have any questions for me?

Public reporting burden of this collection of information is estimated to average 10 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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)