ACE Adult/Child/Pet Survey

Participant ID:

Form Approved

OMB No. 0923-0051

Exp. Date 03/31/2018

ACE ADULT SURVEY

Interviewer__________

Date _____________ Start time _________ End time____________

Participant Name:____________________________________________________

Person’s role (e.g., visitor, responder, etc.):________________________________________

Public reporting burden of this collection of information is estimated to average 25 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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)

General Survey Module A: Location/Exposure

Hello, my name is ________[Name]_________________. I am with ________[Agency]________________, and we are assisting the Virgin Islands Department of Health.

We are contacting you because in _________[Insert month/year]_____________, it is possible you may have been exposed to a chemical on St. John in the U.S. Virgin Islands.

We were provided your contact information by _______[insert source]______________.

The name of the chemical is methyl bromide, which is used in some pesticides.

We are investigating indoor spraying of this chemical at _______[location]___________ on ____________[date]________________. From now, I will refer to that exposure as “the incident”.

We would like to speak with you about any potential exposures or health effects you may have had to better understand how you may have been affected.

Do you have time to talk now, or would there be a better time?

[Proceed depending upon response.]

[Administer full consent form here.]

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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)

I would like to begin by verifying the date and location of the potential exposure.

1. Were you in ______[specific zone which will be considered exposure zone]________ at any time between [Start Date/Time] and [End Date/Time]?

Yes

No Say to the respondent: Thank you for your time. You did not have a potential exposure to the chemical.

Record the end time and do not ask any further questions. This person is not eligible for the survey.

2. I would like to know how long you were in the area where you might have been exposed between [Start Date] at [Time] and [End Date/Time]. Record the following answers in the table provided. Fill out the table for one location before continuing on to the next location.

	Location 1:	Location 2:	Location 3:
Where were you when you were (first/next) in the area? Probe for as much location information as possible (need to include building number, floor number, unit number, etc.) Need to be as specific as possible for location and movement in the vicinity (for example, first inside the unit, the in the hallway, then outside the building, etc.). Then, continue to b. Do not ask about all locations first. Collect all information about one location before continuing to the next.
How long were you in this location? Record whether in minutes or hours.
Were you inside or outside while you were there? If outside, skip questions d, e, and f.	In Out	In Out	In Out
If inside, were there any open windows while you were there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
If inside, was there any ventilation, such as an air conditioner running, while you were there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Did you smell an odor? If no or unsure skip questions h and i.	Yes No Unsure	Yes No Unsure	Yes No Unsure
Can you please describe the odor?
Would you describe the odor as light, moderate or severe?	Light Moderate Severe	Light Moderate Severe	Light Moderate Severe

3. Did you leave the area because of any specific health concerns?

Yes

No

Ask questions A11 to A14 only to pesticide sprayers. Skip to A8 if not a pesticide sprayer.

11. Have you used pesticides with methyl bromide in the past?

Yes

No Go to question A15.

11. How long have you been using pesticides with methyl bromide?

_____________________ months

11. How frequently do you use pesticides with methyl bromide?

Once every few days

Once or twice per month

Once every few months

Less than once every few months

11. When spraying pesticides with methyl bromide, do you routinely use any personal protective equipment (PPE)? If yes, what kind of PPE do you use?

___________________________________________________________

Ask question A15 only to first responders. Otherwise skip question A15, and go to question A.

11. When you came into the exposure area when you responded, were you using any personal protective equipment (PPE)? If yes, what kind of PPE did you use?

__________________________________________________________

11. Were you decontaminated, meaning your clothing was removed or your body was washed?

Yes

No

A6. Is there any additional information that you think we should know about your exposure?

Yes Record the information on the lines provided below

No

General Survey Module B: Health status

Now I would like to ask you some questions about any symptoms you may have experienced after the incident.

1. Within 48 hours of having been [in the area where they stated they had been], did you have any symptoms of an illness?

Yes

No Go to next module

2. I’m going to ask you some questions about symptoms that could be related to the methyl bromide that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom.

	Did you experience [Symptom] within 48hours of the incident? If yes, go to ii. If no, repeat i for next symptom.		Were you experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv.		Was your [Symptom] worse after the incident? Continue to iv (if listed); otherwise, repeat i for next symptom.		Are you still experiencing [Symptom]? Repeat i for next symptom.
Symptom	Yes	No	Yes	No	Yes	No	Yes	No
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Fever
Difficulty breathing/feeling out-of-breath
Coughing
Vomiting
Irritation, pain, or burning of skin
Fatigue/tiredness
Teeth itching
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

General Survey Module D: Medical Care

1. Did you receive medical care or a medical evaluation within 1 month of [specified time of exposure]?

Yes  Go to Question D3

No

Skip D2 if respondent did not have new or worsening symptoms.

2. Was there any reason you did not seek medical care?    

Symptoms were not bad enough    

Don’t like to go to the doctor

Didn’t want to take time

Worried about who would pay for the medical visit

Worried about losing job

Other (Please specify): ______________________________________

Unsure

For those individuals who did not seek medical care, go to the next module.

3. Were you provided with care by an EMT or paramedic?

Yes

No  Go to Question D5

4. On what date were you provided care by an EMT or paramedic?

____/____/______

MM DD YYYY

5. Were you provided with care at a hospital?

Yes

No  Go to Question D15

6. On what date were you first provided care at a hospital? If you had any additional visits to the hospital, please provide me the dates of those visits. Record the date that the respondent first went to the hospital and then the date of any subsequent visits.

1^st date of hospital visit: ____/____/______

MM DD YYYY

2^nd date of hospital visit: ____/____/______

MM DD YYYY

3^rd date of hospital visit: ____/____/______

MM DD YYYY

7. What is the name of the hospital(s)?

8. How did you get to the hospital? If the respondent had more than one hospital visit, tell them that you are referring to their first visit.

EMS/Ambulance

Water ambulance

Drove self

Driven by relative, friend, or acquaintance

Other (Please specify):

9. Were you treated only in the emergency department or were you admitted to the hospital?

Treated in emergency department (Outpatient)  Go to Question D15

Admitted (Hospitalized)

10. How many nights were you hospitalized, including any nights in an intensive care unit (ICU)?

________ Nights

11. Were you placed in an Intensive Care Unit or ICU?

Yes

No  Go to Question D15

12. How many nights were you in the ICU?

________ Nights

13. Were you on a ventilator?

Yes

No  Go to Question D15

14. How many nights were you on a ventilator?

________ Nights

15. Besides at a hospital or by an EMT or paramedic, were you seen by a doctor or other medical professional in any location?

Yes

No  Go to Question D17

16. Read i-iv to the respondent and record information in the table below.

On what dates were you provided care by a doctor or other medical professional? (mm/dd/yyyy)	What is the name of the doctor or other medical professional?	What service did this doctor or medical professional provide?	What is the address of the office?

17. Were you prescribed any new medicines when you were examined after the potential exposure?

Yes

No  Skip Question D18

18. What is the name of the medicine or medicines you were prescribed? If respondent does not know the name of the medication, ask: What is the medicine for?

If aged 13-17, read: We will be doing medical chart reviews and will be asking your parent or guardian for permission to review your medical record for the visit related to the incident. Continue to next module.

If aged 18 or older, go to Question D20.

20. If aged 18 or older, read: To understand the situation more fully, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your medical records for the medical treatment you received because of this exposure?

Yes  Review the medical records release form with the respondent and collect their signature

No

General Survey Module F: Medical History

Now I’m going to ask you a few questions about illnesses you may have had and the kinds of medicines you may have used.

1. Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical Condition
Asthma?	Yes No Unsure
Chronic obstructive pulmonary disease (COPD) or emphysema?	Yes No Unsure
Heart Disease?	Yes No Unsure
Neurological conditions such as Parkinson’s disease or multiple sclerosis?	Yes No Unsure
Skin conditions, such as eczema, psoriasis, or others?	Yes No Unsure
Any other medical conditions?	Yes (Please specify) _____________________ No Unsure

4. Do you currently smoke cigarettes, cigars, or pipes?

Yes Go to instruction box before Question F5

No

4. Have you smoked regularly in the past?

Yes

No Go to instruction box before Question F7

4. When did you last quit? Was it…Read all choices to the respondent.

Less than one year ago

1–2 years ago

3–4 years ago

5 or more years ago

If respondent is male, go to next module

4. Were you pregnant at the time of the potential exposure?

Yes

No

Don’t Know

4. Were you breastfeeding?

Yes

No

4. If you were pregnant at the time of the exposure, and have since delivered, did your child have any health problems at birth?

Yes (If yes, please specify details ___________________________)

No

General Survey Module J: Exposure of Other People Present

1. Were there any other individuals present with you while you were in or near the affected area?

Yes

No  Go to next module

2. In order to accurately evaluate the impact of the incident, we are trying to interview as many people who were in the area as possible. Fill in the following table with the information given for Question J2 a-c.

   1. Can you tell me the names of everyone else who was present with you?

   2. Which are children, and what are their ages?

   3. Can you tell me the phone number and e-mail address of the people who do not live with you?

Name	Age (if child)	Phone	E-mail

General Survey Module K: Pets

1. Did you have any pets or assistance animals that were in area during the potential exposure?

Yes

No  Go to next module

2. How many of your pets or assistance animals were with you?

________ Pets/Assistance animals

We will ask further questions about your pet(s) or assistance animal(s) later in the survey.

Continue to next module

General Survey Module L: Demographic and Contact Information

Now, I have some general questions about you.

1. Do you consider yourself to be Hispanic or Latino?

Yes

No

2. What race do you consider yourself to be?

Check all that apply:

Black or African American

White

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

3. What is the highest level of education you completed?

Grade 8 or less

Some high school

High school graduate or equivalent

Some university/college

Technical or trade school

Junior or community college

University/college graduate

Graduate school or higher

4. If necessary, ask. Otherwise, check appropriate box. Are you male or female?

Male

Female

5. What is your date of birth?

____/____/______
MM DD YYYY

6. What is your current address?

Street Apt

City State __ __ Zip Code:

7. What is the best telephone number to reach you? Please specify if this is a cellular phone, house phone, or work phone.

( __ __ __ ) __ __ __ ‑ __ __ __ __

Cell

House

Work

8. Are there any more telephone numbers where you can be reached?

If yes, collect all other numbers and specify whether cell, house, or work number.

( __ __ __ ) __ __ __ ‑ __ __ __ __

Cell

House

Work

( __ __ __ ) __ __ __ ‑ __ __ __ __

Cell

House

Work

9. Do you have an email address where you can be reached?

Yes

No Go to Question L10

What is your email address?

11. We wanted to confirm how to spell your name. Can you please verify that for us now? (record on first page—correct if necessary)

General Survey Module N: Conclusion Statements

1. Is there anything else you want to tell us related to this exposure?

2. If Exposure of Other People Present Module did not identify children under the age of 13 that were present, go to Question N3. If children under the age of 13 were identified, read: I would now like to ask you some questions regarding any children you have under the age of 13 that were with you when you were potentially exposed.

Refer to Module J to recall child’s name and then go to the Child Survey Section

3. If the Pets Module did not identify that the respondent had a pet or assistance animal in the affected area during the incident, go to the “Closing Statement.” If pets or assistance animals were identified, read: I would now like to ask you some questions regarding any pets or assistance animals you have that were in the affected area.

Go to the Pet Survey Section

Closing Statement:

That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.

ACE CHILD SURVEY

Child’s Name: _______________________________________________________

Child’s role (e.g., visitor, resident, etc.)___________________________________________

General Survey Module A: Location/Exposure

I would like to begin by verifying the date and location of the potential exposure.

1. Who was [Child’s name] with in [specific zone which will be considered exposure zone]?

Respondent

Record name and Participant ID of person with same exposure:

____________________________________________________  Go to Question A3

Someone else who has been interviewed

Record name and Participant ID of person with same exposure:

____________________________________________________  Go to Question A3

Someone who has not been interviewed

Record name of person with same exposure:

____________________________________________________

2. I would like to know how long your child was in the area where he/she might have been exposed between [Start Date] at [Time] and [End Date/Time]. Record the following answers in the table provided. Fill out the table for one location before continuing on to the next location.

	Location 1:	Location 2:	Location 3:
Where was your child when he/she was (first/next) in the area? Probe for as much location information as possible (need to include building number, floor number, unit number, etc.) Need to be as specific as possible for location and movement in the vicinity (for example, first inside the unit, the in the hallway, then outside the building, etc.). Then, continue to b. Do not ask about all locations first. Collect all information about one location before continuing to the next.
How long was he/she in this location? Record whether in minutes or hours.
Was he/she inside or outside while he/she was there? If outside, skip questions d, e, and f.	In Out	In Out	In Out
If inside, were there any open windows while he/she was there?	Yes No Unsure	Yes No Unsure	Yes No Unsure
If inside, was there any ventilation, such as an [air conditioner/heater] running, while he/she was there?	Yes No Unsure	Yes No Unsure	Yes No Unsure

3. Did your child leave the area because of any specific health concerns?

Yes

No

7. Was your child decontaminated?

Yes

No

6. Is there any additional information that you think we should know about your child’s exposure?

Yes Record the information on the lines provided below

No

General Survey Module B: Health status

Now I would like to ask you some questions about any symptoms your child may have experienced after the incident.

1. Within 48 hours of having been [in the area where they stated they had been], did your child have any symptoms of an illness?

Yes

No Go to next module

2. I’m going to ask you some questions about symptoms that could be related to the methyl bromide that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom.

I’m going to ask you some questions about symptoms that could be related to the methyl bromide that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom.

	Did your child experience [Symptom] within 48hours of the incident? If yes, go to ii. If no, repeat i for next symptom.		Was your child experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv.		Was your child’s [Symptom] worse after the incident? Continue to iv (if listed); otherwise, repeat i for next symptom.		Is your child still experiencing [Symptom]? Repeat i for next symptom.
Symptom	Yes	No	Yes	No	Yes	No	Yes	No
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Fever
Difficulty breathing/feeling out-of-breath
Coughing
Vomiting
Irritation, pain, or burning of skin
Fatigue/tiredness
Teeth itching
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

General Survey Module D: Medical Care

1. Did your child receive medical care or a medical evaluation within 1 month of [specified time of exposure]?

Yes  Go to Question D3

No

Skip D2 if child did not have new or worsening symptoms.

2. Why didn’t you seek medical care for [Child’s name]?    

Symptoms were not bad enough    

Don’t like to go to the doctor

Didn’t want to take time

Worried about who would pay for the medical visit

Worried about losing job

Other (Please specify):________________________________________

Unsure

For those individuals who did not seek medical care, go to the next module.

3. Was [Child’s name] provided with care by an EMT or paramedic?

Yes

No  Go to Question D5

4. On what date was he/she provided care by an EMT or paramedic?

____/____/______

MM DD YYYY

5. Was [Child’s name] provided with care at a hospital?

Yes

No  Go to Question D15

6. On what date was [Child’s name] first provided care at a hospital? If he/she had any additional visits to the hospital, please provide me the dates of those visits. Record the date that the chiod first went to the hospital and then the date of any subsequent visits.

1^st date of hospital visit: ____/____/______

MM DD YYYY

2^nd date of hospital visit: ____/____/______

MM DD YYYY

3^rd date of hospital visit: ____/____/______

MM DD YYYY

7. What is the name of the hospital(s)?

8. How did [Child’s name] get to the hospital? If the respondent had more than one hospital visit, tell them that you are referring to their first visit.

EMS/Ambulance

Water ambulance

Drove self

Driven by relative, friend, or acquaintance

Other (Please specify):

9. Was [Child’s name] treated only in the emergency department or was he/she admitted to the hospital?

Treated in emergency department (Outpatient)  Go to Question D15

Admitted (Hospitalized)

10. How many nights was he/she hospitalized, including any nights in an intensive care unit (ICU)?

________ Nights

11. Was he/she placed in an Intensive Care Unit or ICU?

Yes

No  Go to Question D15

12. How many nights was he/she in the ICU?

________ Nights

13. Was he/she on a ventilator?

Yes

No  Go to Question D15

14. How many nights was he/she on a ventilator?

________ Nights

15. Besides at a hospital or by an EMT or paramedic, was [Child’s name] seen by a doctor or other medical professional in any location?

Yes

No  Go to Question D17

16. Read i-iv to the respondent and record information in the table below.

On what dates was your child provided care by a doctor or other medical professional? (mm/dd/yyyy)	What is the name of the doctor or other medical professional?	What service did this doctor or medical professional provide?	What is the address of the office?

17. Was [Child’s name] prescribed any new medicines when he/she was examined after the potential exposure?

Yes

No  Go to Question D19

18. What is the name of the medicine or medicines he/she was prescribed? If respondent does not know the name of the medication, ask: What is the medicine for?

20. To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your child’s medical records for the medical treatment (he/she) received because of the incident?

Yes  Review the medical records release form with the respondent and collect their signature

No

General Survey Module F: Medical History

Now I’m going to ask you a few questions about illnesses your child may have had and the kinds of medicines he/she may have used.

1. Prior to the incident, have you ever been told by a doctor or other health care provider that your child has or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical Condition
Asthma?	Yes No Unsure
Neurological conditions such as cerebral palsy??	Yes No Unsure
Skin conditions, such as eczema, psoriasis, or others?	Yes No Unsure
Any other medical conditions?	Yes (Please specify) _____________________ No Unsure

General Survey Module L: Demographic and Contact Information

Now, I have some general questions about [Child’s name].

1. Do you consider [Child’s name] to be Hispanic or Latino?

Yes

No

2. What race do you consider your child to be?

Check all that apply:

Black or African American

White

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

4. If necessary, ask. Otherwise, check appropriate box. Is your child male or female?

Male

Female

4. What is your child’s date of birth?

____/____/______
MM DD YYYY

Child Survey Module N: Concluding Instructions

If there are more children under age 13, get a new child survey and ask about next child.

If there are no more children under age 13, return to the General Survey Module N: Conclusion Statements and go to Question N3.

ACE PET SURVEY

Now I am going to ask you about each of your [pets/assistance animals] and their experience with the incident. [From now on, I will refer to assistance animals as pets.]

If more than 1 pet, read: I will ask you about Pet 1 first, then Pet 2, etc. You can decide which pet you want to tell me about first.

Pet # ____

1. What type of animal is your pet?

Dog

Cat Other (Please specify):

Bird

2. What is your pet’s name? ___________________________

3. What is your pet’s breed or type? ___________________________

If pet is dog or cat, continue with Question 4. If bird or other, go to Question 6.

4. What is your pet’s hair length? Read all choices to the respondent and check appropriate box.

Short

Medium

Long

Hairless

If pet is cat, go to Question 6.

5. How much does your dog weigh? Would you say…Read all choices except “Don’t Know” to respondent and check appropriate box.

Less than 20 pounds,

Between 20-50 pounds

More than 50 pounds

Don’t Know

6. How old is your pet? If older than 12 months, report in years. Check the appropriate box.

_________ Months Years

7. Where in [affected area] did your pet go? Probe for as much location information as possible.

9. How long was your pet in [the affected area]

9. In the 48-hour period following [time period of concern], did your pet get sick? If yes, ask; Did your pet die? circle appropriate response.

a. Get sick? Yes No Don’t Know

b. Die? Yes No Don’t Know

9. If respondent answered “yes” to any part of 10, read: Please tell me what happened to your pet. Otherwise, go to the ending instructions.

9. If sick: Was your pet examined by a veterinarian?

Yes

No  Go to ending instructions

Don’t Know  Go to ending instructions

9. What is the name of the veterinarian who examined the pet, or the name of the veterinarian’s practice?

If respondent is under age 18, go to ending instructions.

9. Are you willing to let us get a copy of your pet’s veterinary records for the medical treatment your pet received?

Yes

No

Either ask about next pet or, if all pets have been discussed, do the following based on respondent’s answer to Question 13:

• If “yes” to 13, review the veterinary records release form with the respondent, collect their signature, and then go to the “Closing Statement” in the General Survey module.

• If “no” to 13 or the question was skipped because it did not apply or the respondent was aged 13-17, go to the “Closing Statement” in the General Survey Module.

7