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: ________________________________________
|
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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. |
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. |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Staples, J. Erin (CDC/OID/NCEZID) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |