Community Suyrvey - English

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Rabies Awareness and Dog Ownership Characteristics Among Persons in Haiti

1. What is your age? ___________

2. What is your gender? _________

3. Where do you live?

   1. Street _______________________________

   2. Commune ___________________________

   3. Department __________________________

4. How many people live with you, in your household? ________________

5. Are you the primary care taker for your dogs?

   1. Yes

   2. No

   3. Unknown

6. How many dogs are you getting vaccinated today? ________________

7. How many dogs belong to your household? ____________________

8. Of the dogs belonging to your household, how many:

   1. Stay on your property at all times ___________

   2. Roam the street unsupervised sometimes _____________

   3. Roam the street unsupervised at all times _____________

9. What level of care do you provide for your dog(s)? (Mark all that apply.)

1. None

2. Food

3. Water

4. Shelter

5. Veterinary Care

6. Other: (free response)

7. Declined to answer

10. If any of your dog(s) have never been vaccinated for rabies, what is the reason?

    1. Dog is too young (number _______)

    2. No money to buy vaccine (number _______)

    3. No vaccine available from veterinarians (number _______)

    4. No vaccine available from government (number _______)

    5. No need to vaccinate (number _______)

    6. Other (free response): (number _______)

    7. Declined to answer

11. For any dogs that died in the past year, what was the cause of death? Indicate frequency of each.

    1. Hit by Car ____________

    2. Poisoned __________

    3. Disease/illness ____________

    4. Other: free response ________

    5. I don’t know ________

    6. Declined to answer

12. In the past year, have you ever owned a dog that died after displaying at least two of the following symptoms? If yes, how many?

Hypersalivation, Aggressiveness, Biting people or animals, Difficulty walking, Change in the dog’s voice

1. Yes, number __________

2. No

3. I don’t know

13. Do you provide care for any dogs that you do NOT own? (Mark all that apply.)

1. None

2. Food

3. Water

4. Shelter

5. Veterinary Care

6. Other: (free response)

7. Declined to answer

14. In the past year, have you or anyone in your household been bitten by a dog? Mark all that apply.

1. No

2. Yes, me

3. Yes, an adult family member (indicate number if more than one) __________

4. Yes, my child (indicate number if more than one) __________

5. Declined to answer

15. Do you know anyone who has ever died from a disease caused by the bite of a dog?

    1. No

    2. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    3. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    4. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    5. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    6. Yes: Gender: _____ Age: ___________ Year of Death: ___________

16. Do you know anyone who has ever died from a disease called ‘rabies’?

    1. No

    2. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    3. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    4. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    5. Yes: Gender: _____ Age: ___________ Year of Death: ___________

    6. Yes: Gender: _____ Age: ___________ Year of Death: ___________

17. How much do you know about a disease called rabies? Note: interviewer must evaluate.

1. I have never heard of rabies

2. Little knowledge (i.e., have heard of rabies/dog disease, but can’t identify transmission routes or severity of disease)

3. Basic understanding (knowledge that rabies is both a highly fatal disease and is transmitted by dog bite)

4. Extensive knowledge (basic understanding plus knowledge of non-bite routes of exposure AND wildlife reservoirs besides dogs without prompting)

5. Declined to answer

18. How severe is the disease called rabies?

1. Mild

2. Somewhat severe

3. Very severe, but possible to recover

4. Very severe, resulting in death

5. I don’t know

6. Declined to answer

19. How do humans get rabies from an infected animal? (Mark all that apply.)

1. Bite

2. Scratch

3. Observing the animal

4. Touching the animal

5. Contact with blood

6. Contact with saliva

7. Contact with urine/feces

8. Other: (free response)

9. I don’t know

10. Declined to answer

20. What animals can be infected with rabies? (Mark all that apply.)

1. Dogs

2. Cats

3. Livestock (Cattle, sheep, goats, etc.)

4. Poultry (Chickens, ducks, geese, etc.)

5. Horses

6. Mongoose

7. Fox

8. Wild Birds

9. Bats

10. Rodents

11. Other: (free response)

12. I don’t know

13. Declined to answer

21. If you thought that you had an exposure to an animal with rabies, what would you do?

1. Nothing

2. Wash wound

3. Consult with a traditional healer

4. Call a medical doctor

5. Call a veterinarian

6. Actively seek medical treatment at a pharmacy, hospital, clinic or outpost

7. Receive rabies post-exposure prophylaxis

8. Isolate the animal for observation

9. Submit animal for disease testing

10. Kill the animal

11. Kill and eat the animal

12. Other: (Free response)

13. Declined to answer

22. Where do you normally go to receive medical treatment? (Mark all that apply.)

1. Veterinary clinic

2. Pharmacy

3. Medical Clinic

4. Hospital

5. Traditional Healer

6. Other: (free response)

7. Declined to answer

23. How far do you need to travel to receive medical care at this location? (Indicate frequency if multiple locations were identified.)

1. <1km

2. 1-5km

3. 6-10km

4. 11-20km

5. 21-30km

6. >30km

7. I don’t know

8. Declined to answer

24. What are the primary obstacles for getting medical treatment in your community? (Mark all that apply.)

1. Lack of facilities to provide treatment

2. Lack of trained personnel at facilities to provide treatment

3. Lack of medicines at facilities for treatment

4. No means of transportation

5. No money to pay for treatment

6. Can’t miss work

7. Other: (free text)

8. I don’t know

9. Declined to answer

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