Zika Shedding Study Questionnaire

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

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