Risk Factor Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Risk Factor Questionnaire

Date: ____/____/_____ (DD,MM,YYYY)

Form Completed by:

Name: _____________________ Position: ________________District: ______________________

Phone Number/email: _____________________________________________________________

Section 1. Participant Information

ID Number: ________________________________________Age: ____Gender: Male Female.

Village/Town: _______________Parish: _____________Sub-County: _________________

District: _________________Nationality: _____________

Marital status Married Single Widowed

GPS Coordinates________________________________________________________________

Section 2. Epidemiological Risk Factors and Exposures

1. Education level None Primary Secondary Post-Secondary Other specify_____

2. Current Occupation:

Farmer Herdsman Housewife Student Child Health worker

Other, please specify occupation_________________________________________________

3. Do you or your household own domestic animals Yes No

4. If yes which ones goats sheep Cattle Pigs Poultry Dogs

cats others specify__________________________________

5. Do you have any contact with domestic animals Yes No

6. Do you drink raw milk Yes No

7. Do you eat raw/uncooked meat Yes No

8. Which domestic animals do you usually get in contact with(tick all that apply)

goats Cattle Pigs Poultry Dogs others specify________________

9. If yes, which type of contact during milking during grazing grooming slaughtering others specify__________________________________________________

10. Do you usually see wild animals in this village Yes No

11. If yes, which ones monkeys bats antelopes wild pigs others specify_______

12. Do you have any contact with wild animals Yes No

13. Which wild animals do you usually get in contact with(tick all that apply)

Bats monkeys wild Pigs wild birds rodents antelopes

others specify________________________________________________________

14. If yes, which type of contact during hunting accident slaughtering others specify__________________________________________________

15. Do you often do hunting Yes No Unk ,If yes, how often do you do hunting

16. Which animals are usually hunted_______________________________

17. Have you seen mosquitoes in this village Yes No

18. Are you usually bitten by mosquitoes Yes No

19. Do you usually come into contact with dead wild animals Yes No Unk

20. Have you ever eaten wild meat Yes No Unk if Yes which species

21. Do you usually travel outside your home or village/town, Yes No Unkn

22. If yes, specify location: _______________________________________________________

23. Do you often collect firewood from the forest Yes No Unk

24. Did you ever suffer from undiagnosed fever or illness , Yes No Unkn

25. Do you have el nino Rains Yes No Unkn

26. Do you some times get flooding in this area Yes No Unkn

27. If yes, which months do you get flooding_______________________________________

28. Do you use mosquito nets Yes No Unkn

29. If yes/No why__________________________________________________

30. Do you spray your animals against external parasites Yes No Unkn

31. Do you use PPE when handling aninals Yes No Unkn

32. Have you heard of someone acutely ill in the last one year with unexplained fever or diagnosis

Yes No Unkn

Knowledge & Attitude Questions

33. Have you heard about RVF and CCHF virus disease Yes No Unk

34. If yes, from who: Health worker Radio community leaders others specify_______

35. Do you know how to identify a suspect of RVF or CCHF virus disease Yes No Unk

36. If yes how bleeding High fever vomiting diarrhea others specify____________

37. Do you know the phone number to call in case you see a suspect case of RVF or CCHF disease

Yes No Unk

38. Do you believe RVF or CCHF disease really exists Yes No Unk

39. If no, why_________________________________________________________

40. Have you heard of any survivor of RVF or CCHF disease Yes No Unk

41. Would you relate with a survivor or RVF or CCHF disease Yes No Unk

42. If no, why fear of contracting disease fear of stigma from community

others specify___________

43. Do you know how RVF or CCHF disease is transmitted Yes No Unk

44. If yes, how body contact sick person through air through needle pricks contact with animals contact with dead person contact with body fluids of sick person

biting mosquitoes(insects) others specify________________________

45. If transmission through animals, which ones goats Cattle Pigs Poultry Dogs

monkeys bats antelopes wild pigs others specify_____________

46. How do you think you can protect yourself from acquiring RVF or CCHF disease

vaccination avoiding contact with animals traditional medicine avoiding sick people

others specify_____________________________________________

47. How do you think RVF or CCHF disease can best be healed or treated

traditional medicine spiritual healing Modern medicine Herbal medicine

others specify_____________________________________

48. Do you think you are at risk of contracting RVF or CCHF virus disease Yes No Unk

49. If yes/no, why___________________________________________

50. Do you know the cause of RVF and CCHF disease Yes No Unk

51. If yes which cause Virus Bats/monkey/other wild animals God/other higher power

witchcraft Evildoing/sin curse others specify_______________________________

52. Do you know how RVF/CCHF diseases is transmitted Yes No Unk

53. If yes, which of the following

1. From a person who is infected but doesn’t have any signs or symptoms?

Yes No Unk  

2. Eating/preparing  bush  meat   Yes No Unk

3. Eating fruits likely eaten by bats Yes No Unk 

4. Blood of an infected person   Yes No Unk

5. Sperm of an infected person Yes No Unk  

6. Breast milk of an infected person Yes No Unk

7. Shaking hands or other physical contact with an infected person

Yes No Unk    

8. Other fluids from an infect person   Yes No Unk

9. Others specify___________________________________________

54. Do you know how RVF/CCHF can be prevented Yes No Unk

55. If yes, which of the following

1. Avoiding contact  with blood and body fluids   Yes No Unk

2. Avoiding  funeral or burial rituals that require handling the body of someone who has died from CCHF or RVF Yes No Unk  

3. A suspected person reduces the chance of spreading CCHF or RVF by immediately going to hospital Yes No Unk

56. Would you buy from a shopkeeper who had contacted RVF but has recovered and declared well

  Yes No Unk

57. Would you  keep the information secret if a family member contracts CCHF or RVF Yes No

Unk

58. Would  you welcome someone back into their community/neighborhood after a neighbor has recovered from CCHF or RVF Yes No Unk

Section 3. Specimen Information

Specimen identification number:___________________

Specimen collection date:___/___/______ (MM/DD/YYYY)

Laboratory testing date:___/___/______ (MM/DD/YYYY)

Results/Titer level: IgM _____________ IgG _____________

1

Public reporting burden of this collection of information is estimated to average 30 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)