Zika Shedding Study Questionnaire

Emergency Zika Package II: Persistence of zika virus in body fluids and case-control investigation of etiologic agents associated with Guillain-Barré Syndrome

Att. J -- Shedding questionnaire

Zika Virus Shedding Questionnaire - Asymptomatic

OMB: 0920-1106

Document [docx]
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Form Approved

OMB Control No. 0920-XXXX

Exp. Date: XX/XX/XXXX

Attachment J. Baseline and follow-up questionnaires

Zika Shedding Study Form

Baseline Questionnaire

To be completed by study personnel in consultation with participant

Patient Name: _____________________________________________________________

Study ID #: ______ Study Visit Date: ____/____/_____ Study Visit #: ________ Coupon #: ________

Participant Age: ____________ Date of Birth: ____/_____/_____

Address: __________________________________________________________________________________

Street Address

________________________________________________________________________________

City State Zip Code

(_______) ______ - _______ (______) _______-______

Primary Phone Number Secondary Phone Number

Travel History in the past 14 days

Have you visited any municipalities in Puerto Rico or countries outside Puerto Rico in the past 14 days?

Country/Municipality visited:___________ Travel start date:__/__/__ Travel end date: __/__/__

Country/ Municipality visited:___________ Travel start date:__/__/__ Travel end date: __/__/__

Country/ Municipality visited:___________Travel start date:__/__/__ Travel end date: __/__/__

Clinical Information

__Asymptomatic __Symptomatic

If symptomatic complete the section below by circling the right answer and providing the duration of the symptoms or signs in days. If asymptomatic move to question 1 below

Date of first symptom: ______/______/_______ Date of first fever: ______/______/_______

Symptom



Duration in Days

Symptom



Duration in days

Fever

Yes

No


Nausea

Yes

No


Red eye

Yes

No


Vomiting

Yes

No


Rash

Yes

No


Itching

Yes

No


Rash type: __Maculopapular __ Petechial __Purpuric __Other Distribution: _________

Swelling

Yes

No


Pain/burning with urination

Yes

No


Eye pain

Yes

No


Difficulty urinating

Yes

No


Cough

Yes

No


Pelvic or groin pain

Yes

No


Joint pain

Yes

No


Abdomen/lower back pain

Yes

No


Headache

Yes

No


Painful ejaculation (men only)

Yes

No


Intolerance to light

Yes

No


Penile discharge (men only)

Yes

No


Yellow eyes or skin

Yes

No


Blood in stool

Yes

No


Enlarged lymph nodes

Yes

No


Blood in urine

Yes

No


Diarrhea

Yes

No


Blood in semen (men only)

Yes

No


Other: ____________________________________

No

Questions

Responses

1

What is your current marital status? Choose one.

Child …0

Married …1

Living together as married …2

Separated …3

Divorced …4

Widowed …5

Never married …6

Don't Know …99

Refuse to Answer …77

2

What is the highest level of education you completed?


No school….0

Grades 1 through 8.....1

Grades 9 through 11….2

Grades 12 or GED…3

Some college, Associate’s or Technical Degree…4

Bachelor’s Degree…5

Any post graduate studies…6

Don't Know…99

Refuse to Answer …77

3

What best describes your employment status? Are you:


Child…0

Employed full-time…1

Employed part-time…2

A homemaker…3

A full-time student…4

Retired…5

Unable to work for health reasons…6

Unemployed…7

Other…8

Don't Know…99

Refuse to Answer …77

4

What was your household income last year from all sources before taxes?


$0 to $9,999 1

$10,000 to $19,999 2

$20,000 to $29,999 3

$30,000 to $39,999 4

$40,000 to $49,999 5

$50,000 to $59,999 6

$60,000 to $79,999 7

$80,000 or more 8

Don't Know 99

Refuse to Answer 77

5

How many people live in your household, including yourself? Household means all of the people that you live with.

____ Range 1-100

Don't Know 99

Refuse to Answer 77

6

Do you currently have health insurance or health care coverage?

No 0

Yes 1

Don’t Know 99

Refuse to Answer 77

7

How would you describe the house where you live?

One-story house 1

Two-story house 2

Apartment/condo building 3

Other: ________________________

Don't Know 99

Refuse to Answer 77__

8

How many of the windows in your house have intact screens?

None 0

Some 1

All 2

Don't Know 99

Refuse to Answer 77 77

9

Do you use air conditioning in your home?

No 0

Yes, in all rooms 1

Yes, but only in the bedroom 2

Other 3

Don’t Know 99

Refuse to Answer 77

10

Usually, do you leave your doors or windows open?

Never 0

Daytime only 1

Night-time only 2

Always 3

Other 4

Don’t Know 99

Refuse to Answer 77


11

In the past 30 days did you use mosquito coils (e.g., Cobra, espiral, caracol) or natural repellents in your house or patio to keep mosquitoes away?


No 0

Yes 1

Don’t Know 99

Refuse to Answer 77

12

In the past 30 days, how often have you used mosquito repellent?


Never 0

Daily 1

Weekly 2

Monthly 3

Rarely 4

Don’t Know 99

Refuse to Answer 77


Further questions for adults only

13

In the past 7 days how many different persons have you had oral, vaginal or anal sex?

____ Range 1-1000

Don't Know 99

Refuse to Answer 77

14

In the past 7 days, how many times have you had anal or vaginal sex?

____ Range 1-1000

Don't Know 99

Refuse to Answer 77

15

Of the [fill with “# of times engaged in vaginal or anal sex” (q14)] times you had sex in the past 7 days, how many times did you or your partner use a condom?

____ Range 1-1000

Don't Know 99

Refuse to Answer 77

16

For men only: In the past 7 days how many times have you ejaculated (had an orgasm) including sex and masturbation?

____ Range 1-1000

Don't Know 99

Refuse to Answer 77

17

Have you ever in your life shot up or injected any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.

No 0

Yes 1

Don’t Know 99

Refuse to Answer 77

18

When was the last time you injected any drug? That is, how many days or months or years ago did you last inject?

[Interviewer: Enter the number below. If today, enter "000" ]

____Years Range 1-1000

____Months Range 1-1000

Don't Know 99

Refuse to Answer 77





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Public reporting burden of this collection of information is estimated to average 10 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-XXXX



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AuthorSamuel, Lee (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2021-01-24

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