Community Member Questionnaire

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Undetermined Mode of Transmission: Zika Virus among Utah Community Members, 2016

Public reporting burden of this collection of information is estimated to average 15 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)

Household Member Log

Household ID
Home Address Street address: ______________________________________________________ City: ________________ State: _____ Zip: _________County: ___________________ (Best way to contact them in the future) Phone: ______________________________or e-mail: ________________________________________
List first and last name for each person who meets definition of a Household Resident and verify that they have been at this address for the last month. Can you tell me the names of all the people who stayed in your house for at least two nights per week since mid-June (June 15) until now?
No.	Name of Resident	Age (*Record in complete months if child <2 years)		Sex	Record of consent for INTERVIEW	Date interview conducted	Record of consent for SPECIMENS	Specimens collected
01			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
02			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
03			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
04			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
05			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
06			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached)	Blood Urine None
07			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
08			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
09			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
10			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
11			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None
12			 years  months	 F  M	 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached		 Consent obtained  Consent refused  Parental consent provided  Parental consent refused  Person never reached	Blood Urine None

Community Evaluation Questionnaire

HH ID:___________________________ ­­­­­

Interviewer Information

Interviewer Name (First, Last): ________________________________________________________

State/Local/Territorial Health Department: ______________________________________________

Language survey was conducted in: __________________________

Informant Information  Not applicable

If not the specific individual, who is providing information for this form?

HH ID Number: ______________________________________________

Relationship to resident: ____________________________________________

Reason individual unable to provide information him/herself:

 Child  Mentally handicapped  Other: _______________________

Exposures

Now I would like to ask you about your time outdoors or potential exposure to mosquitoes.

1. O Since June 15, 2016, how much time on average have you spent outdoors each day?

 less than 1 hour  1-4 hours  5-10 hours  more than 10 hours  Don’t know

How often did you wear mosquito repellant when you were outdoors for 15 minutes or more?

 Always  Most of the time Sometimes Never  Don’t know

Since June 15, 2016, did you get any mosquito bites?

 Yes  No  Don’t know

For windows and outside doors that you have left open this summer, how many of these have screens?

All  Most  Some  None  Don’t know

 We never leave any windows or doors open

Resident’s Travel and Potential Flavivirus exposure

Now I would like to ask you about if you might have been exposed to Zika virus or related viruses before.

Did you travel outside the United States (or to a US territory: Puerto Rico, USVI, Am Samoa) in the last year (since July 2015)?  Yes  No

If yes: Name of country(s): _____________________________________

Dates of travel: Start date:____/_____/______ End date: ____/_____/______

Name of country(s): _____________________________________

Dates of travel: Start date:____/_____/______ End date: ____/_____/______

Name of country(s): _____________________________________

Dates of travel: Start date:____/_____/______ End date: ____/_____/______

Name of country(s): _____________________________________

Dates of travel: Start date:____/_____/______ End date: ____/_____/______

Name of country(s): _____________________________________

Dates of travel: Start date:____/_____/______ End date: ____/_____/______

Name of country(s): _____________________________________

Dates of travel: Start date:____/_____/______ End date: ____/_____/______

Were you born or lived for several years outside the United States?  Yes  No  Unknown

If yes, where? _________________________________________________________________

Medical Information

Since June 15, 2016, have you had any of these symptoms? We are talking about symptoms that would have been new for you, not long standing problems?

Fever  Yes  No If yes, first date with this ____/_____/______

How many days did it last? ________

(Note, here we would count their report of subjective fever. Interviewer, please use calendar aid)

Rash  Yes  No If yes, first date with this ____/_____/______

How many days did it last? ________

(here we are NOT asking about a rash that was just on one arm or one leg, like poison ivy)

Conjunctivitis (redness of the white part of the eyes)

 Yes  No If yes, first date with this ____/_____/______

How many days did it last? ________

(here we are NOT asking about red, itchy eyes that you may know you get because of allergies)

Joint Pain  Yes  No If yes, first date with this ____/_____/______

How many days did it last? ________

(here we are NOT asking about pain that was definitely from an injury)

For this illness, did you go to a clinic/hospital to be checked?  Yes  No

If yes, what did the doctor/nurse decide that you had? __________________________________

((Use this additional space if more than one episode, or additional notes))

For females age ≥12 years and <45 years: Are you pregnant or think you might be pregnant?

 Yes  No  Unknown

Information related to blood specimens and interpretation of results

If NO blood specimen is consented for. Thank you again for your willingness to provide the information. If we have any additional questions, is it okay to contact you again?

 Yes  No (If yes, verify contact details on household list)

If blood specimen is consented for, complete specimen collection form, and ask these additional questions:

We would like to ask you just a few more questions about your health so we can better understand your blood test results.

To the best of your knowledge, have you ever received these vaccines (these are vaccines that may be given to persons who travel out of the country)

Yellow fever vaccine  No  Unsure  Yes, year of last dose__________

Japanese encephalitis vaccine  No  Unsure  Yes, year of last dose__________

Tick-borne encephalitis vaccine  No  Unsure  Yes, year of last dose__________

Has your doctor told you that you have any medical conditions that limit your ability to fight infections?

 Yes  No  Unknown

Are you taking any medications that suppress your immune system?

 Yes  No  Unknown

In the past 2 months, did you receive a blood transfusion or organ transplant?

 Yes  No  Unknown

For this last question, we will ask you to read it and point to the answer.

In the last year, have you ever had unprotected sex with someone who had recently returned from a country where Zika has been spreading? (By recently returned, we mean your partner had returned sometime during the 2 months before the time you had unprotected sex)

Your Answer  Yes  No  Unknown

Thank you very much for your willingness to answer these questions and provide a blood sample.

We will next contact you directly about your results of the blood test. It may take several weeks to get the final results.