Interview Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Legionnaires’ Disease Interview Questionnaire

Face Sheet

Case ID _______________________

ODRS # _______________________

Patient Name _______________________________________

Patient Address _____________________________________

______________________________________

______________________________________

Phone Number _______________________________________

Person Supplying Information (if different from above):

Name: _________________________________________

Street: _________________________________________

City: ______________________ State: _____________ Zip: _____________

Phone (H): ( __ __ __ ) __ __ __ - __ __ __ __ Phone (W): ( __ __ __ ) __ __ __ - __ __ __ __

Relationship to subject (check one):

____ spouse ____ child _____ nurse/aid ____ other (specify: _______________________)

CONSENT & QUESTIONNAIRE

Interviewer Name (Last) _____________________ Name (First) ________________________

Organization: ______________________________

The Alabama Department of Public Health is asking residents, staff, and visitors to [Hospital A] questions about their water usage because of a cluster of respiratory illnesses among residents that may have been related to the water system.  We are asking questions about water usage and health status. The information will be used for public health purposes only, and will be kept secure to the extent allowed by law. The interview will take about 15 minutes to complete. Your cooperation is voluntary and very much appreciated. You can refuse to answer any of the questions. If you agree to participate, the information that you provide us could help to prevent water-borne illnesses from occurring in other places.

Would you be willing to be interviewed? Yes No If “no”, end interview.

During the interview, I will be asking you some questions about your [visits to/stay at location]. It may be difficult to remember details from that time. Because accurate details will help us in our investigation, you may want a calendar or appointment book nearby.

(If conducting by telephone):

Would you like me to call you back so that you have time to locate some of these items or to call back at a more convenient time? Yes No

If “yes”: When would be a good time to call back?

Date: __ __/ __ __ Time: ______ AM PM

Number to Call ( __ __ __ ) __ __ __ - __ __ __ __ (Also record information on contact log).

Interviewee:

<Case Status>:  Confirmed Case  Suspect Case

<What was the patient’s outcome?  RECOVERED  STILL ILL  DIED>

What is your connection to UAB?

______ Visitor ______ Employee _____ (Other) Specify___________________

Building:

Room #: __________

Person Supplying Information (if different from above):

Relationship to subject (check one):

____ spouse ____ child _____ nurse/aid ____ other (specify: _______________________)

Sex:  male  female

Date of Birth _______________________ (mmddyyyy)

I am going to ask you some questions about respiratory sickness and about the time you have spent at the UAB. If a family member or friend can help you remember, feel free to ask for their input too.

Illness Information:

1. Have you had pneumonia since May 1, 2013? Y N DK

2. I have that your first symptom started on <insert onset date> _____________. Is this correct?

 YES  NO  No Symptoms  DK

1. If no, what was the first date you started feeling sick? _____________ (mmddyyy)

3. When you were sick, did you experience any of the following symptoms?

Symptom	Yes	No	DK
fever
Cough
Chills
Body aches
Shortness of breath
Nausea / vomiting
Nasal congestion
Sore throat
Diarrhea
Abdominal pain

4. Were you hospitalized or seen in the ER for your respiratory illness?  YES  NO

If yes, which hospital(s)?

a.) Hospital #1:

Name of Hospital _______________________________________________________

City ________________________________State___________

Date of Admission: ________________ (mmddyyy)

Date of Discharge: _________________ (mmddyyy)

b.) Hospital #2:

Name of Hospital _______________________________________________________

City ________________________________State___________

Date of Admission: ___________________ (mmddyyy)

Date of Discharge: ___________________ (mmddyyy)

Exposure Information

<Calculate incubation period: count 10 days prior to symptom onset. Use the specific dates to inquire about exposures >

Incubation period:

_________________ (mmddyyy) to _____________________ (mmddyyy)

For residents:

5. When did you move into UAB? ______________(mmddyyyy)

6. I’d like to ask about the places on the UAB campus you may have visited before you became ill. From <Use patient’s incubation period>, did you visit any of the following locations?

Building or area	Date(s) (mmddyyy)	Locations in building/room #s	Reason/activities

7. Do you usually take showers? Y N DK

1. If “yes”, where is the shower you use? Select all that apply.

 my room (confirm room number)____________

 hallway shower (specify )_____________

 other (specify) ______________

2. How many times per week do you use shower?  1  2-3  4-7 DK

3. On average, how many minutes do you spend in the shower?

 1-5  6-10  10-15 >16 DK

8. Do you usually take baths? Y N DK

1. If “yes”, where is the bath you use? Select all that apply.

 my room (confirm room number)____________

 hallway shower (specify )_____________

 other (specify) ______________

2. How many times per week do you bathe?  1  2-3  4-7 DK

3. On average, how many minutes do you spend in the bath tub?

 1-5  6-10  10-15 >16 DK

8. Who brushes your teeth? (Select all that apply)

 Self  Family member/friend  Facility staff  Other_____________

1. What kind of toothbrush is used? (Select all that apply)?

 regular mechanical  water pick  Other_____________

Medical Devices

8. Do you use a CPAP (continuous positive airway pressure)o r BiPAP (Bilevel Positive Airway Pressure) machine? Y N DK

1. If yes, where do you get the water for the machine?

tap Sterile/distilled water DK

8. Do you use an oxygen machine? Y N DK

1. If yes, where do you get the water for the machine?

tap  sterile/distilled water DK

8. Do you use a nebulizer? Y N DK

1. If yes, where do you get the water for the machine?

tap  sterile/distilled water DK

8. Do you use a humidifier? Y N DK

1. If yes, where do you get the water for the machine?

tap  sterile/distilled water DK

8. Do you drink water from the tap? Y N DK

1. If yes, how many glasses per day? _______________

8. Do you remember any interruptions in your room’s water supply over the summer?

Y N DK

8. Do you recall any changes in the quality of your water over the summer? Y N DK

If “yes”, please explain ________________________________

8. Where do you eat your meals?

 your room  facility dining room DK

a) If facility dining room, which building(s) ________________________________

If residents eat in facility dining room

2. How many meals per week do you eat in the dining room?____________

3. Do you drink water with your meals? Y N DK

8. Did you keep your windows open during <use incubation period>? Y N DK

8. Did you spend time outside on facility grounds during <use incubation period>? Y N DK

8. Have you ever noticed the lawn being watered during <use incubation period>? Y N DK

8. Do you ever spend time in any rooms other than the one(s) you live in? Y N DK

If “no” or “don’t know”, go to question next question.

Room #	Dates visited (mmddyyyy)	Did you shower in that apartment?	Did you help someone else shower?	Did you drink tap water?
		Y N DK	Y N DK	Y N DK
		Y N DK	Y N DK	Y N DK
		Y N DK	Y N DK	Y N DK

8. Thinking about the period of time just before you became ill, <use incubation period>, I would like to know if you participated in any activities at [location]. We can use this calendar of activities to help. <Use the activity calendar to identify activities the patient remembers participating in during the incubation period. List the type of activity, location, and date for each activity>

Activity	Location	Date

ACTIVITIES OUTSIDE OF UAB

Now I’m going to ask you questions about your activities outside of [location].

8. On average, how many times a week do you leave UAB? ______ DK

8. What places do you go when you leave UAB?

a) __________________________________________________________________________

b) __________________________________________________________________________

c) __________________________________________________________________________

8. Do you go to medical appointments outside of UAB? Y N DK

1. If yes, where?

i)______________________________________________________________

ii)______________________________________________________________

iii______________________________________________________________

MEDICAL PROBLEMS SECTION

These questions refer to health problems that you may have had before you became ill with Legionnaires’ Disease.

Have you ever been told by a healthcare provider that you had:

	Check one:
Condition	YES	NO	DK	Comments
Chronic kidney disease
Weakened immune system (Cancer, Chemotherapy , Radiation Therapy, immuno-suppressive meds, HIV, organ transplant)
Diabetes
Chronic lung disease (COPD, emphysema)
Asthma
Heart disease or CHF
Liver disease
Other conditions

27) Health behaviors:

	Check one:
	YES	NO	Quantity per day (packs or drinks)	Duration (years)
Are you currently a smoker?
Are you a former smoker?
Do you drink alcohol?

_____________________________________

That is the end of the questionnaire. Thank you for taking the time to answer all of the questions. Do you have any questions for me? If we have additional questions in the future, may we contact you again?  YES  NO

Interviewer Comments:

1

Public reporting burden of this collection of information is estimated to average 15 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)