Case Interview Form

Case Interview Form

Participant Information

Question	Response	Variable Name
Case Last Name		Lname
Case First Name		Fname
Alternate Names/Nicknames/Aliases:		Alias
Age		Age
Date of Birth		DOB
If proxy interviewed, name and relationship to case patient:

Check the database for the patient’s estimated infectious period.

Start of infectious period: ____________________________

End of infectious period: ________________________________

Explain to the patient that you have been asked by the health department to help determine why there have been more cases of tuberculosis, or TB. Explain that you will be asking a series of questions to try to identify where the health department might be able to find other people who have TB, as well as to figure out where the patient might have gotten sick. Acknowledge that the patient has already participated in many interviews with health care providers. Reassure the patient that all answers will be kept confidential, and that the purpose of the interview is to learn information that can help stop the spread of TB and prevent other people from getting sick (emphasize protection of families). Thank the patient for his or her time and for speaking with us.

Note that throughout the interview, the period of interest is

2 years before the start of the infectious period to the end of the infectious period.

Ask patient whether they are from the Tribe A Reservation.
If not, ask where patient came from and when he/she came to the area.

Discuss symptom onset date. Confirm based on chart data.

“We are interested in learning where you could have been exposed to TB in the 2 years before you got sick with TB. People sick with TB often have a bad cough, or might lose a lot of weight. TB is spread through the air when a person who is sick coughs or speaks and does anything that brings up air from the lungs. How do you think that you got TB?” Mention household exposure (i.e. people you visited or people who visited you). Attempt to elicit names of sick contacts who might have been source patients. Note when and where the exposure occurred. Emphasize that these people are not in trouble, and we are not trying to blame anyone. We are trying to make sure we can find all sick people and treat them.

“TB is commonly spread among people staying in the same household. We’re worried about people who may have been staying with you or people you may have stayed with when you were coughing a lot or started feeling sick. I know it might be hard to remember, but please try your best. During [infectious period], where did you live, and who was staying with you?” Emphasize protecting family.

Time period(s)	Last time visited	Location	People in household

“TB can also be spread to people you spend a lot of time around, even if you don’t stay in the same household. During [infectious period], could you tell us where you worked, where you hung out, and who else was usually there?” Emphasize protecting friends and family. Mention work sites, bars, friends’ homes.

Location	Dates of first attendance	Dates of most recent attendance	Frequency of attendance	Contacts present

Ask patient how else he/she passes time. As examples, you could mention cards, bingo, video lottery. Record locations and contacts present.

Activity	Location	Dates of first attendance	Dates of most recent attendance	Contacts present

Ask the patient whether he/she visits friends or family or attends social events ON any of the reservations in the area, or whether friends/family from on a reservation visited the patient. Ask for location and dates of visit. Record exposed contacts.

Ask the patient whether he/she visits friends or family or attends social events OFF the reservations in the area, or whether friends/family from off the reservations visited the patient. Ask for location and dates of visit. Record exposed contacts.

Explain to patient that certain activities make the body less able to fight off a TB infection, and make a person more likely to become sick.

Ask about the following TB risk factors. Circle response.

Smoking commercial tobacco during the year before diagnosis?

0=None

1=Less than Daily

2=Daily

3=Does not recall or refuses

Smoking traditional tobacco during the year before diagnosis?

0=None

1=Less than Daily

2=Daily

3=Does not recall or refuses

If so:

What substance:_____________________

Participates in “sweats” (traditional sweat lodge purification ceremony): Y N

Location: ______________________

Alcohol use (“drinking”) within 1 year before diagnosis?
0=Never

1=Rarely (1-2 times ever)

2=Occasionally (more than 1 or 2 times, but less than most days or nights)

3=Frequently (most days or nights of the week)

4=Does not recall or refuses

Note the locations where patient drank alcohol? Smoked?

With whom would the patient usually drink? Smoke?

Among the group that the patient drank with/smoked with, did anyone possibly have TB?

Non-injection drug (“taking anything for recreation, e.g. marijuana”)
use within 1 year before diagnosis

0=Never

1=Rarely (1-2 times ever)

2=Occasionally (more than 1 or 2 times, but less than most days or nights)

3=Frequently (most days or nights of the week)

4=Does not recall or refuses

What kinds of drugs were used before diagnosis? Circle all that apply.

Marijuana Crack or cocaine Methamphetamine Heroin Prescription drugs

Other drugs: ________________________________

Note the locations where non-injection drugs were used:

Drug use with anyone with possible TB?

Injection drug use (“shooting up”) within 1 year before diagnosis

0=Never

1=Rarely (1-2 times ever)

2=Occasionally (more than 1 or 2 times, but less than most days or nights)

3=Frequently (most days or nights of the week)

4=Does not recall or refuses

What kinds of drugs were used before diagnosis? _______________________

Note the locations where injection drugs were used or obtained:

Drug use with anyone with possible TB?

ANY drug use prior to the year before diagnosis

What kinds of drugs were used? _____________________________________

Note the locations where drugs were used or obtained:

Drug use with anyone with possible TB?

Does the patient have any other ideas about places where TB might have spread
(i.e., where people were coughing a lot) or people we should contact?

Any other contacts not yet discussed:

Name of Contact (and contact info if available)	Where and when had contact	How often had contact? (1=daily, 2=few times/week, 3=weekly or less, 99=unk)	Activities Together	Smoked together? (0=no, 1=yes, 99=unk)	Drank together? (0=no, 1=yes, 99=unk)	Drugs together? (0=no, 1=yes, 99=unk)	Comments

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