Dengue_AZ

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

SOUTHERN ARIZONA HOUSEHOLD DENGUE INVESTIGATION

Date of visit (MM/DD/YYYY): ____/___/_2014_

Team number: ___________

IMMATURE MOSQUITO SURVEY FORM

Complete one form for each household.

Case Patient ID Number ID #: ______________-_____________

Container ID	Type of Container	Number of containers (indoors)
		Dry	Wet – water present
			Larvae/pupae absent	Larvae/pupae present
1	Bucket
2	Tire
3	Water Drum
4	Plastic container
5	Aluminum can
6	Styrofoam
7	Jar
8	Flower vase
9	Septic tank
10	Animal watering pan
11	Potted plant
12	Bird Bath/Fountains
13	Other artificial container: __________________
14	Tree: __________________
15	Toys
16	Pools
17	Sewers
18	Bamboo
19	Other – natural container (specify)
20	Tarps
21
22
23

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)