Questionnaire for Prison Outreak of Clostridium Botulinu

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Section 1: Interviewer information (Questions 1-5 to be completed by interviewer prior to questionnaire administration)
Subject ID: ______________________			Inmate #: _______________________
Date of Interview:	__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y
Interviewer Information Name: ____________________ Agency or Organization: _______________________________
Location of interview:______________________________________
Respondent was:		Self Family Clinician Other (Specify):_______________
Respondent is:		Confirmed case Suspected case Not a case Other (Specify):_______________

QUESTIONNAIRE FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM, JUNE 2016

Section 2: Demographic Data:
Birth month and year	__ __ / __ __ __ __ (if unknown, enter 99/9999) M M Y Y Y Y
Sex: Male Female Unknown
Hispanic or Latino origin? Yes No Unknown
How would you describe your race?		White Black/ African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Other (specify): ___________ Unknown
What is your cell/ward location in the prison:__________________________________________
What are your prison duties or job (kitchen staff, lawn crew, janitorial):_______________________________________

Section 3: Food allergies, special diets:
Yes	Maybe	No	Don’t Know	Did you have:
				Any allergies that prevent you from eating a certain food(s)?
				1a. What foods? Please check all that apply.	Milk Eggs Peanuts Tree nuts Fish Soy Wheat Shellfish other: ____________
				Do you follow any of the following special or restricted diets?
				Dairy‐free Vegetarian/Vegan Kosher Gluten‐free Other religious diet:_______________ Other:______________
Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 4: Sources of food:

1. In the past two week, did you eat foods from?

Prison cafeteria	Food brought to you in the prison by friend or relatives
Food prepared in cell	Food shared from other prisoners
Prison shop	Food bought or traded from other prisoners
Other:________________________

3. In the past two weeks have you stored food in your cell?

Yes No

4. In the past two weeks have you consumed food prepared in your cell?

Yes No

Section 5: Food items:
Did you eat any of the follow food items served in the prison cafeteria?: *** To be completed with prison food menu.
Food item	Yes	No	Don’t know	Unknown
Have you eaten any additional food items in the past two weeks?:
Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 6: Hooch: Now I have a few questions about Hooch or Pruno.
Yes	Maybe	No	Don’t Know
				Have you ever drank hooch since you entered the prison?
				1a. How often do you drink hooch? daily weekly monthly less than monthly when it is available don’t know
				Have you drank hooch since June 1st?
				2a. How many times did you drink hooch since June 1st? _______________ 2b. When did you first drink the hooch? __ __ / __ __ / __ __ __ __ 2c. On average, how much hooch did you drink each time? a sip a cup a pint more than a pint Other:______________ 2d. Did you share with other people? Yes No Don’t know How many people did you share with? __________________________________________ Are any of these people currently sick?__________________________________________ 2e. Do you still have hooch in your cell? Yes No Don’t know 2f. Where did you get the hooch?_____________________________________________ 2g. Do you know when the batch of hooch that you made was dug up or first drank? Yes No Don’t know If yes, when? __ __ / __ __ / __ __ __ __
Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 7: Clinical Information:.
What date did you first feel sick?				__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) Not sick M M D D Y Y Y Y
How many days total were you sick?				_______ days (enter 999 if unknown) or Still Ill
Yes	No	Don’t Know	Was the patient:
			Hospitalized overnight?
			Date of hospitalization __ __ / __ __ / __ __ __ __
			Date of discharged __ __ / __ __ / __ __ __ __ or Still hospitalized
			Admitted to ICU? Yes No Don’t know
			Intubated?
			Date of intubation __ __ / __ __ / __ __ __ __
			Date stopped intubation __ __ / __ __ / __ __ __ __ or Still Intubation
			Did patient receive HBAT
			Date of HBAT administration __ __ / __ __ / __ __ __ __
Did the patient have any of the following symptoms:
Yes	No	Don’t Know	Symptom
			Change in sound of voice
			Abdominal Pain
			Hoarseness
			Diarrhea
			Dry mouth
			Constipation
			Dysphagia (difficulty swallowing)
			Blurred Vision
			Shortness of breath
			Diplopia (double vision)
			Subjective weakness
			Dizziness
			Fatigue
			Slurred Speech
			Paresthesia (abnormal sensation, e.g. numbness)
			Thick tongue
			Nausea
			Extraocular Palsy (paralysis of eye muscles)
			If yes, is it bilateral?
			If bilateral, is it symmetric?
			Ptosis (drooping eyelids)
			Facial Paralysis
			If yes, is it bilateral?
			If bilateral, is it symmetric?
			Palatal weakness
			If yes, is it bilateral?
			Impaired gag reflex
			Other sensory deficit(s)
			Which ones?__________________________________________________________
			Other symptoms?
			Which ones?___________________________________________________________
Clinical history:
Yes	No	Don’t Know	Comorbidity
			HIV
			TB
			Hepatitis C
			Hypertension
			Diabetes
			Other Comorbidity(ies)?
			Which other(s)?______________________________________________

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)