Dengue_AZ

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

SOUTHERN ARIZONA HOUSEHOLD DENGUE INVESTIGATION

Date of visit (MM/DD /YYYY): ____/___/___

Team number: ___________

HOUSEHOLD ENROLLMENT FORM

Complete one form for each household.

1. Case-patient ID #: ________

2. Phone number (Número de Teléfono): ____________________________________

3. Household Latitude _____^o______._________’N Longitude ______^o______.__________’W

List all individuals that sleep in the household, starting with the head of household. (Mencione todas las personas que viven en este domicilio, comenzando con el jefe del hogar).

If there are not enough spaces, please write the additional information below this section.

Specimen Label

Specimen ID*

1. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

2. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

3. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

4. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

5. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

6. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

7. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

8. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

9. _

   Specimen Label

   _____________________________ Age : _____ yrs □ Male □ Female

10. _

    Specimen Label

    _____________________________ Age : _____ yrs □ Male □ Female

11. _

    Specimen Label

    _____________________________ Age : _____ yrs □ Male □ Female

12. ______________________________ Age : _____ yrs □ Male □ Female

*Specimen ID is the case-patient ID# followed by a number (e.g., 4-1 for the first household member of case-patient ID # 4. The case-patient should be denoted with an individual ID of 0 (e.g., 4-0).

Comments (Note each individual for whom a specimen was not collected, and reason[s] for non-participation, etc.):

4. Describe structure of the home (Describa la estructura de la casa): □ Mobile home/Casa móbil □ Single Family Dwelling/domicilio de una sola familia □ Duplex or Four-plex □Apartment/Apartamento □Multi-story Condominium/Condominio de varios niveles □Temporary shelter/Refugio temporero □Other: __________________________________

5. Do you store water in open containers on your property? Tiene usted agua almacenada en envases abiertos dentro de su propiedad?: □ Yes □ No

5a. If yes, what is the source of that water? Si tiene agua almacenada, cual es la fuente del agua?

□ Piped/Public -público □ Well/Pozo □ Rain water/agua de lluvia

□ Don’t know/no se □Other: _____________________

6. Have you had any visitors that have traveled from out of the country, for example Mexico, in the last three months? Ha tenido usted visitantes de otro país, por ejemplo de México?

Yes No Unknown

If YES..… 6a. Where were they from? De que país son?

Country: ________________________

7. Has anyone in your household had a fever in the last three months? Alguna persona en su casa ha tenido fiebre en los pasados tres meses? □ Yes □ No

8. Does your home have screened windows? Tiene su casa mosquiteros en las ventanas? □ Yes □ No

9. Do you usually leave your windows open? Usted deja sus ventanas abiertas regularmente? □ Yes □ No

10. Does your home have air conditioning? Tiene usted acondicionador de aire? □ Yes □ No

11. In the past three months have you seen mosquitos in your home? El los últimos tres meses ha visto mosquitos dentro de su casa? □ Yes □ No □ Unknown

12. Has anyone sprayed to kill mosquitoes in your home in the past three months? Han fumigado su casa contra mosquitos en los últimos tres meses?

□ Yes □ No □ Unknown

13. Do you use other approaches to keep mosquitoes out of your house? Usa usted otros métodos para eliminar mosquitos de su casa?

□ Yes □ No □ Unknown

13a. If yes, specify: ________________________________________________________

NOTES:

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)