Festival A Interview Form

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Festival A Interview Form

Unique ID: CA- - - or CO- - -

Case or Control (Circle one)

First Name:

Last Name:

First grader / High school student / Adult (Circle one)

Phone Number:

Phone attempts: Document on CALL LOG

Interviewer Name:

Date of interview:

SECTION A: Demographics

“Before I go any further I want to confirm that (you / your child) attended the County A Fest Abetween Monday, April 20th and Friday, April 24th, 2015. Is this correct?

Y(1) N(0) DK(9) (circle)

(If NO) ► “Thank you. At this time we are only interviewing persons that attended the Festival.”

(If YES) ► “Thank you for agreeing to participate.”

“Great. So first, I would like to ask some questions about your child.”

1. What is (your / your child’s) age?

_______years OR ________months

2. What is (your / your child’s) sex?

Male Female Refused (circle)

1. (If ADULT FEMALE) ► Are you currently pregnant?

Y(1) N(0) DK(9) (circle)

3. Do you consider yourself to be of Hispanic origin? Y(1) N(0) DK(9) (circle)

4. What is (your/ your child’s) race? (Mark one or more)

White

Black/African American

American Indian/Alaskan Native

Native Hawaiian or Other Pacific Islander

Asian

Other, specify: ___________________

Unknown

5. What is (your / your child’s) county of residence? __________________________

6. What is your city, state, and zip code of your home address?

______________________________ (city, state, zip code)

7. How many people live in your household including you? _____________

   1. How many of them are adults? ____________

   2. How many are children? ___________

8. (IF CASE IS STUDENT) What is the name of your child’s (CASE) school? _______________

9. (IF CASE IS STUDENT) What is the name of your child’s (CASE) classroom teacher who accompanied the class on the Festival A? ______________________

SECTION B: Clinical symptoms and illness

Now I would like to ask you about whether (you / your child) has been ill since Monday, April 20th.

10. Have (you / your child) been ill since April 20^th? Y(1) N(0) DK(9) (circle)

If No, skip to QUESTION 16 (ENROLL AS CONTROL).

11. On what day did (your / your child’s) illness begin?

___ / ___ / ___ (mm/dd/yy, prompt with calendar if necessary, this is [ONSET DATE])

1. How many days did the illness last? _______ days

Since April 20^th, did (you / your child) have:

12. Diarrhea? Y(1) N(0) DK(9) (circle)

(If YES) ►

1. What was the maximum number of stools in a 24-hour period? ____________

2. On what day did (your / your child’s) diarrhea begin?

___/___/____ (mm/dd/yy)

1. How many days did the diarrhea last? __________ DK(99)

13. Any bloody diarrhea? Y(1) N(0) DK(9) (circle)

    1. How many days did the bloody diarrhea last? __________ DK(99)

14. Now I would like to ask you about other symptoms you / your child may have had.

1. Nausea? Y(1) N(0) DK(9) (circle)

2. Vomiting? Y(1) N(0) DK(9) (circle)

3. Abdominal cramps? Y(1) N(0) DK(9) (circle)

4. Fever? Y(1) N(0) DK(9) (circle)

(If YES) ► Maximum (F): ____

5. Chills? Y(1) N(0) DK(9) (circle)

6. Headache? Y(1) N(0) DK(9) (circle)

7. Body aches? Y(1) N(0) DK(9) (circle)

8. Fatigue? Y(1) N(0) DK(9) (circle)

9. Constipation? Y(1) N(0) DK(9) (circle)

10. Other? Y(1) N(0) DK(9) (circle)

(If YES) ► Specify

15. Of the symptoms we just talked about, what was the first symptom that (you / your child) had? I can read them back to you if needed. ► Specify

Now I would like to ask you if anyone else in your household has had any of the following symptoms since April 20^th. Has anyone else in your household had?

16. Diarrhea? Y(1) N(0) DK(9) (circle)

17. Vomiting? Y(1) N(0) DK(9) (circle)

18. Abdominal cramps? Y(1) N(0) DK(9) (circle)

SECTION C: Medical Care for Illness (CASES only)

19. How many times did (you / your child) visit a doctor or other health professional for this illness? (Please include emergency room, urgent care, and clinic visits, including follow-up visits.) __ __ visits DK (99)

20. (Were you / Was your child) hospitalized overnight for this illness? Y(1) N(0) DK(9) (circle)

(If YES) ►

1. On what date (were you / was your child) first admitted to the hospital for this illness? _____/_____/_____ (mm / dd / yy) DK (999999)

2. How long (were you / was your child) hospitalized? _________ (days)

21. (Were you / Was your child) diagnosed with HUS? Y(1) N(0) DK(9) (circle)

Previous E. coli infection

“Now I would like to ask you some questions about previous illnesses (you / your child) may have had BEFORE attending the Fest A.

22. (Before attending the Fest A this April 2015), have (you / your child) EVER been told by a doctor that (you/ your child) had E. coli infection?

Y(1) N(0) DK(9) (circle)

SECTION D: Pre-existing medical conditions and medication use

“Now I would like to ask you a few questions about (your / your child’s) health in the month before this illness began. We would like to know about long-standing medical conditions or other specific medical conditions in the three weeks before this illness, which is from __ /__ /_____ (4 weeks prior) to __ /__ /_____ (ONSET DATE). You do not need to answer the questions if you don’t want to.”

23. Prior to this illness did (you / your child) have any of the following medical conditions?

PLEASE READ EACH CONDITION AND RECORD YES / NO / DK

				Yes		No	DK
A	Diabetes			1		0	9
B	Kidney Disease			1		0	9
	If YES ► Are you/your child on dialysis or awaiting dialysis?			1		0	9
C	Organ or Bone Marrow Transplant			1		0	9
D	Leukemia or Cancer			1		0	9
	If YES ► Treatment with radiation or chemotherapy in previous month?			1		0	9

“I would now like to ask some questions about medications that (you / your child) may have been taking in the month before (your / your child’s) illness began, which is from __ /__ /_____ (4 weeks prior) to __ /__ /_____ (ONSET DATE)”

24. In the month before (your/your child’s) illness began, did (you/your child) receive any of the following types of treatments or take any of the following types of medications?

	PLEASE READ EACH MEDICATION/TREATMENT		Yes	No	DK
A		Any oral steroid, such as Prednisone?	1	0	9
B		Any immune-suppressing medication, such as to treat juvenile arthritis?	1	0	9
		(If YES) ► Specify:

25. In the month before (your / your child’s) illness onset, which was __ /___ /_____ (ONSET DATE), did (you/your child) take any antibiotics? Y(1) N(0) DK(9) (circle)

(If YES) ► It may be helpful to get the pill bottle, do you want to do that now?

1. What is the name of the antibiotic(s) (you / your child) took?

2. B. What date did (you / your child) start taking the antibiotic?

3. C. When did (you / your child) stop taking the antibiotic?

4. D. Did (you / your child) miss any doses of antibiotics?

A. Antibiotic Name	B. Start date? (999999=DK)	C. Stop date? (777777= still taking, 999999=DK)	D. Miss any doses?
Ab1:			Y / N / DK
Ab2:			Y / N / DK
Don’t Remember			Y / N / DK

SECTION E. Hand-to-mouth habits

26. In general, (do you / does your child) always(1), almost always(2), sometimes(3), or never(4), chew on or bite their fingernails? (circle answer)

[SKIP to Section F IF HIGH SCHOOL STUDENT OR ADULT]

27. In general, (do you / does your child) always(1), almost always(2), sometimes(3), or never(4), suck their thumb or fingers? (circle answer)

SECTION F. Previous animal exposure

28. (Do you / does your child) live on a farm? Y(1) N(0) DK(9) (circle)

29. Which of these animals do you keep on your property? Please answer yes or no.(circle)

    1. Cattle Y(1) N(0) DK(9) (circle)

    2. Sheep

    3. Goats

    4. Other

       1. Specify other animals kept on property: _______________________

    5. None

“Now, I will ask about (you / your child’s) contact with animals at home or outside the home.”

30. In general, (do you / does your child):

1. Touch cattle: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

2. Feed cattle: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

3. Touch sheep: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

4. Feed sheep: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

5. Touch goats: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

6. Feed goats: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

7. Clean up animal manure or barn areas: Y(1) N(0) DK(9) (circle)

   1. (If yes), how often? Read options: daily (1), a few times a week (2), a few times a month (3), a few times a year (4)

SECTION G: Fest A Participation

“Let’s talk about the date(s) that you / your child attended Fest A. The Festival ran from Tuesday, April 21 through Thursday, April 23. Set up was on Monday, April 20. It was taken down Friday, April 24.”

31. On what date and time did you / your child attend Fest A?

(Circle the date and time attended)

MONDAY APRIL 20	TUESDAY APRIL 21	WEDNESDAY APRIL 22	THURSDAY APRIL 23	FRIDAY APRIL 24
AM	AM: 10-12	AM: 10-12	AM: 10-12	AM
	PM: 12-2	PM: 12-2	PM: 12-2

FOR HIGH SCHOOL STUDENTS ONLY / [SKIP to Question XX IF FIRST GRADER OR ADULT]

Now, I would like to know about what you did at the fairgrounds in preparation for Fest A.

32. For each of the following activities, please tell me yes or no. While at the fairgrounds, did you?

    1. Move or touch hay bales Y(1) N(0) DK(9) (circle)

       1. Wear gloves Y(1) N(0) DK(9) (circle)

    2. Move bleachers Y(1) N(0) DK(9) (circle)

    3. Sat on bleachers Y(1) N(0) DK(9) (circle)

    4. Move or set up cattle panels Y(1) N(0) DK(9) (circle)

[SKIP to Section H IF HIGH SCHOOL STUDENT]

33. Did anyone else from your household attend the Fest A?

Y(1) N(0) DK(9) (circle)

(If YES) ►

1. How many (additional) adults from your household attended the event?

What is your / your child’s (CASE’s) relationship with the adults?

1. Adult 1 ___________________________

2. Adult 2 ___________________________

3. Adult 3 ___________________________

2. How many (additional) children from your household attended the event?

What is your / your child’s (CASE’s) relationship with the children?

1. Child 1 ___________________________

2. Child 2 ___________________________

3. Child 3 ___________________________

IF YES to parent/guardian attending the MMF:

34. Did you bring a stroller into the dairy barn? Y(1) N(0) DK(9) (circle)

35. Did you receive a map of Fest A from the school? Y(1) N(0) DK(9) (circle)

“Now we have some questions about activities at the Festival. If you have the map, please get it now so that you (you and your child) can look at it as we review the next set of questions. There are two different maps, please choose the one for the date that you attended the festival (date circled above)”

FOR FIRST GRADERS OR OTHER CASES THAT CANNOT ANSWER INDEPENDENTLY - To Parent or guardian:

“To answer this section, you will need to ask your child to help you answer the questions, as they relate to the activities at the Fest A.”

Station 1 & 2 – Milking Parlor:

“Now I’m going to ask you some questions about station 1 & 2, where students learned about milking cows. If you have the map with you, this station is on the bottom of the map.”

Station 1 was the milking parlor, with the live cow, and where you could put your fingers in the milking cups to feel the suction.

36. Did you go to this station with your class? Y/M/N/DK

    1. Did you touch the cow by the wall? Y/M/N/DK

    2. Did you touch the metal milking cups that sucked your fingers? Y/M/N/DK

Station 2 was where you got to practice milking the fake cow named Twister.

37. Did you go to this station with your class? Y/M/N/DK

    1. Did you try to milk twister the wooden cow? Y/M/N/DK

Station 3 & 4 – Calves: Now I’m going to ask you some questions about station 3 & 4, where you learned about taking care of baby cows (calves). If you have the map in front of you, this station was in the middle of the map.

38. Did you go to this station with your class? Y/M/N/DK

    1. Did you touch the toys in the calves station ? Y/M/N/DK [Station34TouchToys]

    2. Did you touch/pet the baby cow in the pen? Y/M/N/D

    3. Did you touch/pet the adult/big cows? Y/M/N/DK

Station 5 & 6 – Circle of Farming: Now I’m going to ask you some questions about station 5 & 6, where you learned about the circle of farming, and got to see different kinds of cow food. If you have the map in front of you, this is the station in the middle left, with the bleachers, and circle of sawdust.

39. Did you go to this station with your class? Y/M/N/DK

    1. Did you touch any of the food that cows eat, including the sileage/stinky cow food, corn, beet pulp, grass, or cotton seed? Y/M/N/DK

    2. Did you touch the toys in the circle of farming? Y/M/N/DK

    3. Did you touch the container of cow poop/manure? Y/M/N/DK

Station 7 & 8 – Dairy Products: Now I’m going to ask you some questions about station 7 & 8, where you got to drink chocolate milk, and learned about dairy products. If you have the map in front of you, this station is on the bottom right part of the map, with the benches.

40. Did you go to this station with your class? Y/M/N/DK

    1. Did you wash your hands at the milk truck outside? Y/M/N/DK

    2. Did you drink chocolate milk? Y/M/N/DK

       1. If no, did you drink something else? Y/M/N/DK

       2. If Yes, what did you drink? Specify:

Station 9 & 10 – Hay Maze and Petting Zoo: Now I’m going to ask you some questions about station 9 & 10, where you got to go to the petting zoo, and go through the hay maze. If you have the map in front of you, these stations are at the top.

First, I’m going to ask you some questions about the petting zoo.

41. Did you go to this station with your class? Y/M/N/DK

    1. Did someone put hand sanitizer on your hands BEFORE you went to visit the animals in the petting zoo trailer? Y/M/N/DK

    2. Did you touch/pet the mini donkey? Y/M/N/DK

    3. Did you touch/pet the goat? Y/M/N/DK

    4. Did you touch/pet the baby cow? Y/M/N/DK

    5. Did you touch/pet the lamb? Y/M/N/DK

    6. Did you touch/pet the rabbit? Y/M/N/DK

    7. Did you touch/pet the miniature horse? Y/M/N/DK

    8. Did someone put hand sanitizer on your hands AFTER you went to visit the animals in the petting zoo trailer? Y/M/N/DK

Now I’m going to ask you some questions about the hay maze.

42. Did you go to this station with your class? Y/M/N/DK

    1. Did someone put hand sanitizer on your hands BEFORE going through the hay maze? Y/M/N/DK

    2. Did you touch or push the hay bales? Y/M/N/DK

    3. Did you put any of the hay in your mouth? Y/M/N/DK

    4. Did someone put hand sanitizer on your hands AFTER going through the hay maze? Y/M/N/DK

    5. Did you touch or play in the sawdust pile in the corner? Y/M/N/DK

Station 11 & 12 – Wagon Ride: Finally, now I’m going to ask you some questions about the wagon ride outside of the barn. If you have the map in front of you, this station was outside the barn, towards the right of the barn.

43. Did you go to this station with your class? Y/M/N/DK

44. During the festival, did you touch or step in poop or manure? Y/M/N/DK

SECTION H: Snacks and beverages the day of participation in Fest A

45. Did (you or your child) chew gum or candy DURING the Fest A activities or anytime while in the barn? Y(1) N(0) DK(9) (circle)

46. Did (you or your child) drink any beverages DURING the Fest A activities or anytime while in the barn? Y(1) N(0) DK(9) (circle)

47. Did (you or your child) eat snacks DURING the Fest A activities or anytime while in the barn? Y(1) N(0) DK(9) (circle)

    1. What were the snacks eaten in the barn?

    2. Where did (you / your child) eat the snacks in the barn? (for example, list stations)

    3. Did (you / your child) wash or sanitize (your / their) hands before eating the snacks?

48. Did (you or your child) eat snacks AFTER the Fest A activities and while still at the fairgrounds? Y(1) N(0) DK(9) (circle)

    1. What were the snacks eaten on the fairgrounds? _____________

    2. Where did (you / your child) eat the snacks? _______________

    3. Did (you / your child) wash or sanitize (your / their) hands before eating the snacks?

SECTION I: Lunch the day of participation in the Fest A

49. Where did (you or your child) eat lunch on the day of the Fest A?

At the Fairgrounds

1. Where on the fairgrounds did your class eat lunch? __________________________

School cafeteria

School classroom

Park (not on the fairgrounds)

Other: Specify ________________________

50. Did (you / your child) wash or sanitize (your / their) hands before eating lunch?

    1. If yes, where did they wash their hands?

Restroom at the fairgrounds

Hand washing truck at Fest A

Hand sanitizer

School classroom

School bathroom

Other; Specify: __________________________

51. Other than the activities organized by the Fest A, did (you / your child) engage in any activities while on the fairgrounds, such as playing in the grass, classroom exercise, or games? Y(1) N(0) DK(9) (circle)

    1. If YES, please describe these activities, when and where they were done.

       1. Activity _____________________________________________________

       2. Activity _____________________________________________________

52. On the day (you or your child) attended the Fest A, did (you or your child) come home:

    1. With dirty or stained clothing? Y(1) N(0) DK(9) (circle)

    2. With dirty shoes? Y(1) N(0) DK(9) (circle)

    3. A goody bag / goody bag items? Y(1) N(0) DK(9) (circle)

SECTION J: Knowledge, awareness and general hand washing habits

“Now I would like to ask you some questions about general hand washing and habits.”

53. In general, (were you / was your child) aware that some diseases can be transmitted by having contact with farm animals? Y(1) N(0) DK(9) (circle)

54. In general, (were you / was your child) aware that some diseases can be transmitted by having contact with surfaces, such as the ground, railings? Y(1) N(0) DK(9) (circle)

55. In general, (do you / does your child) always(1), almost always(2), sometimes(3), or never(4), wash your hands before eating? (circle answer)

56. At the festival, did someone tell you to wash (your / your child’s) hands after coming into contact with farm animals? Y(1) N(0) DK(9) (circle)

57. At the festival, did someone tell you to (your/ your child) not to eat or drink in the animal areas?

Y(1) N(0) DK(9) (circle)

CLOSING SCRIPT

Thank you for your time. Do you have any other observations or comments about this year’s Fest A?

Notes:

_____________________________________________________________________________

_____________________________________________________________________________

____________________________________________________________________________

Again, thank you so much for your time and for answering our questions. Your answers will help us identify what happened and what can be done in the future to prevent similar outbreaks of illness.

Do you have any questions for me?

1

Version 7: Updated on 1/24/21 6:48 A1/P1

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