Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
HEPATITIS A VIRUS (HAV) OUTBREAK
HAWAII, 2016—CONTROL QUESTIONNAIRE
Hepatitis
A Virus (HAV) Outbreak Hawaii,
2016—Control questionnaire
Section 1: Interviewer information (Questions 1-5 to be completed by interviewer prior to questionnaire administration) |
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__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y |
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Agency or Organization: _______________________________ |
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None Once Twice Three times Other (specify # times):________ Unknown |
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Self Parent Spouse Other (Specify):_______________ |
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__ __ / __ __ / __ __ __ __ — __ __ / __ __ / __ __ __ __ — (if unknown, enter 99/99/9999)
M M D D Y Y Y Y M M D D Y Y Y Y |
Section 2: Demographic Data: I’d like to begin by asking a few questions about yourself (your child) and your household. |
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State abbr. _____ County ____________ Zip Code _____________ |
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__ __ / __ __ __ __ (if unknown, enter 99/9999) M M Y Y Y Y |
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White Black/ African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Other (specify): ___________ Unknown |
Section 3: Travel: Next I have a couple of questions about any travel you (your child) might have done, either as part of your work or for pleasure. |
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Yes |
Maybe |
No |
Don’t Know |
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1a. List all US states where you might have purchased or eaten foods. This would include foods eaten at airports, bus or train stations. |
Enter 2-letter postal abbrv(s): __________ __________________________________ Unknown Did not travel to other US states |
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1b. List all countries outside the US where you might have purchased or eaten foods. |
List countries & Travel dates: __________ __________________________________ Unknown Did not travel to outside the US |
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Section 3 Comments. Please fill in any comments/notes from this section in the space provided below:
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Section 4: Food allergies, special diets, vitamins, & supplements: Now I have a few questions about food allergies and any special diets you (your child) may follow. I will also ask a few questions about vitamins and supplement you may have taken in the selected time period before your illness began. |
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Yes |
Maybe |
No |
Don’t Know |
Did you (your child) have: |
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1a. What foods? Please check all that apply. |
milk eggs peanuts tree nuts fish soy wheat shellfish other: ____________ |
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3a. Please describe |
: ___________________________________________ Unknown |
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4a. Please describe |
Type, variety, brand: ___________________________ Unknown |
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Section 5 Comments. Please fill in any comments/notes from this section in the space provided below:
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For
Sections 6 and 50: Read
each type of store, point of purchase, or food outlet in the top
section and ask respondent to list names for each category. The
lists of store/restaurant types are meant to prompt the respondent.
Please list the names of all points of purchase/restaurants
mentioned, regardless of category, in the space provided below. You
do not need to record a yes or no response for each category, only
record the specific names and approximate locations reported in the
space below.
Section 5: Sources of food at home: Now I have a few questions about where the food came from that you ate at home in the selected time period before your illness began. This isn’t necessarily where you shopped during that week, but where what you actually ate came from. I’m going to list several types of stores, for each type please tell me the names of each store you would have eaten food from during the selected time period before you were sick. |
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List Store/Retail Names and Locations: _______________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ |
Section 5.1: Sources of food outside the home: Now I have a few questions about where the food came from that you ate outside your home such as restaurants or fast food chains. I’m going to list several types of restaurant, for each type please tell me the names of each place you would have eaten food from during the selected time period. |
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List Restaurant Names and Locations: _______________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ |
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Fish and Seafood: Now I have some questions about fish and seafood you (your child) might have eaten in the selected time period. You (your child) may have eaten this at home or away from home. This does not include canned items, but these foods could have been eaten alone or as part of a dish, sauce, or dip. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the selected time period before you (your child) got sick. |
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No |
Don’t Know |
Did you (your child) eat any: |
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1a. From where? Restaurant(s) Meal Date(s): _____________________________ Restaurant Name: _____________________ Address: ________________________ Grocery Store(s) Purchase Date(s): ____________________ Meal Date(s): ______________________________ Store Name: ______________________ Address: ___________________________ Other: ________________ Meal Date(s): ___________________________ Name: __________________________ Address: ___________________________ |
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1b. What are the name(s) of the sushi item(s) (for Instance Spicy Tuna, Dragon Roll, California Roll, Maguro Nigiri)? This may include items you shared with meal companions. (Investigator: use an online restaurant menu if available). Please note where (i.e. restaurant, store) each roll was purchased/consumed, if case has multiple sushi exposures.
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1c. What were the types of sushi you ate? For example did your meal include: |
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Special Roll (examples California or Dragon Roll): ____________________________ Spicy Tuna Roll Nigiri (small clump of rice with piece of seafood on top) Maki (smaller roll usually with seaweed) Inari (pouch of fried tofu filled with rice) Sashimi (Raw fish without rice) Poke (Hawaiian-style Sashimi of Raw fish chunks) Other (specify): ___________________________________ |
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1d. What were the seafood ingredients in the Sushi? |
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1e. What were the other ingredients in the sushi? |
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1f. What were the sides/garnishes eaten with your sushi? |
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wasabi soy sauce white/yellow ginger pink ginger ginger color unknown eel sauce ponzu sauce mayo tempura flakes spicy mayo sriracha radish sprouts sprouts (other) sesame seeds shiso leaves masago (generally orange-red, about the size of a pencil tip, and a bit crunchy) other sauce/side/garnish (specify): ________________________________ |
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1g. What other food items did you eat during your sushi/sashimi meal? |
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Soy Beans (Edamame) Seaweed Salad Garden/House Salad If yes, what salad dressing?:___________________________ Dumplings/Pot Stickers Soup: If yes, What kind: Miso, Wonton, Hot & Sour (CIRCLE) Other (Specify):____________ Deep Fried Spring Roll or Egg Roll, If yes, Type: Vegetarian, Shrimp (CIRCLE) Other (Specify):______________ Fresh (Non-fried) Spring Roll, Type: Vegetarian, Shrimp (CIRCLE) Other (Specify):______________ Ice Cream: Green Tea, Red Bean, Mango (CIRCLE) Other (Specify):______________ Other (Specify): |
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1h. How did you pay for your sushi items? Credit card Cash Check Other: ____________________ |
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1i. Do you have a receipt from your sushi meal/purchase? |
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2a. Was it eaten at home? |
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Was it Fresh Frozen Unknown Type/Brand of fish:____________________________________________________ Describe the dish: ____________________________________________________ Place purchased: ____________________________________________________ Purchase date(s): ____________________________________________________ Meal date(s): ____________________________________________________ |
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2b. Was it eaten away from home? |
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Was it Fresh Frozen Unknown Type/Brand of fish: ____________________________________________________ Describe the dish: ____________________________________________________ Place eaten: ____________________________________________________ Meal date(s): ____________________________________________________ |
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11a. What was the: Type, variety, brand:____________________________ Unknown |
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Section 9 Comments. Please fill in any comments/notes from this section in the space provided below:
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Public reporting burden of this collection of information is estimated to average 20 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)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | fke8 |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |