Self-reported Rash Symptoms and Exposure - MDHHS Questio

S

Form Approved

OMB No. 0923-0051

Exp. Date 03/31/2018

elf-reported Rash Symptoms and Exposure to Flint Water

MDHHS Questionnaire

Note to the interviewer: script in italics is clarification for you, and is not to be read aloud to the interviewee. Please do not prompt answers (e.g. read out options “Yes”, “No”, Don’t Know”, “Refused”) unless noted to.

INTRODUCTION SCRIPTS

For people referred through 211/CHECC and home visits:

Hello, my name is _________________________________, and I work for the [Michigan Department of Health and Human Services/Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention]. We are working with the [Michigan Department of Health and Human Services/Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention] looking into reported rash symptoms related to exposure to Flint tap water. We received your name because you have reported rash symptoms [to the 211 phone number OR to an MDHHS or CDC representative who visited your home recently]. We would like to ask you some questions about your health, the health of your family, and your tap water usage. Your answers will help us understand what symptoms have been reported since the City of Flint switched its water source. The questions will take about 20 minutes. May we go ahead now with the questionnaire?

For people referred through healthcare providers:

Hello, my name is _________________________________, and I work for the [Michigan Department of Health and Human Services/Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention]. We are working with the [Michigan Department of Health and Human Services/Agency for Toxic Substances and Disease Registry/Centers for Disease Control and Prevention] looking into reported rash symptoms related to exposure to Flint tap water. We received your name because you visited a healthcare provider to report rash symptoms and they forwarded your information to us. We would like to ask you some questions about your health, the health of your family, and your tap water usage. Your answers will help us understand what symptoms have been reported since the City of Flint switched its water source. The questions will take about 20 minutes. May we go ahead now with the questionnaire?

If yes, participation in this questionnaire is voluntary: if you feel uncomfortable answering any question, you do not have to answer and you may stop the interview at any time. However, any information you can provide will help us immensely.

IF NO, is there a convenient time when I can call you back?

Day: _________________ Time: ________________ AM / PM

Telephone: __________________________________________

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)

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 (0923-0051)

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)

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)

CASE No:

Self-reported Symptoms and Exposure to Flint Water

MDHHS Questionnaire

Date: Time interview began: _ _: _ _ AM / PM

Interviewers Initials:

BACKGROUND

1. First, I would like to ask if you contacted someone to report that you or someone you know had symptoms. Did you contact any person or organization to report these symptoms?

No

Yes

Don’t know

Refused

1a. Can you please tell me who you contacted? (check all that apply)

211

Genesee County Health Department

Health care professional

Emergency room

Don’t know

Refused

Other, please explain

1b. What prompted you to contact MDHHS or seek medical care?

________________________________________________________________________

________________________________________________________________________

1c. Are you calling for yourself or for someone else?

Self

Someone else

1d1. If they are calling for someone else: What is their name and relationship to you?

1d1a. Name:

1d1b. Relationship:

1d2. Could I please interview that person / May we continue with the interview?

(If child, ask parent if you can continue on with interview)

Yes, interviewed other person

Yes, interviewed parent or individual on phone who made contact for other person

Contact information: __________________________________________________

No, other person not available

No, refused to be interviewed

2. First, I have a few questions about you (or your child/friend, if interviewing for another person).

2a. How old are you?

2b. What is your sex?

Male

Female

2c. Do you currently work?

No

Yes

Refused

Don’t know

2c1. IF YES, can you please explain what you do? _

HISTORY OF ILLNESS

3. As I mentioned before, we received your name because you reported symptoms. I am going to ask you about these symptoms.

3a. Did you experience a rash?

No Yes Don’t know Refused	IF YES, on what parts of your body did the rash occur?		IF YES, how big was the rash? (at widest)
	Face Arms Feet Neck Hands Other Torso Legs Explain: _________		0-3 inches 3-5 inches > 5 inches Don’t know Refused
3a1. When did your rash start?	Date: ________________
3a2. Have your symptoms improved, gotten worse, or stayed the same since October 16, 2015? (Note: On October 16, 2015, City of Flint switched back to buying water from Detroit) Improved Gotten worse Stayed the same Refused Don’t know 3a3. Do you still have a rash?
No Yes Don’t know Refused
Can you please describe your rash for me?
3a4. Hives?	3a5. Raised bumps?	3a6. Dry or flakey skin?
No Yes Don’t know Refused	No Yes Don’t know Refused	No Yes Don’t know Refused
3a7. Itchy skin?	3a8. Painful skin?	3a9. Other?
No Yes Don’t know Refused	No Yes Don’t know Refused	____________________________________________________________________________________________________________
3a10. What activities cause the rash to occur?
Washing dishes Doing laundry Cooking	Showering Taking a bath Using a hot tub	Drinking water Other, please explain _________________
3a11. Once the rash appears, how long does it take to go away? ____________________________				Hours Days Has not gone away Don’t know Refused
3a12. What makes the rash feel better? _______________________________________________
3a13. What makes the rash feel worse? _______________________________________________
3a14. Were you taking any new medicines when the rash started?
No Yes Don’t know Refused IF YES, what kind? ________________________________________

Did you experience any other symptoms with the rash? Such as…

3b. Numbness or tingling?

IF YES, Where did the numbness or tingling occur?

No

Yes

Don’t know

Refused

Face

Neck

Torso

Arms

Hands

Legs

Feet

Other Explain__________

3c. Fever?

IF YES, how high?

Time Course

No

Yes

Don’t know

Refused

When did your fever begin?

When did your fever end?

3d. Shortness of Breath?

No

Yes

Don’t know

Refused

When did your s.o.b. begin?

When did your s.o.b. end?

3e. Wheezing?

No

Yes

Don’t know

Refused

When did your wheezing begin?

When did your wheezing end?

3f. Diarrhea?

No

Yes

Don’t know

Refused

When did your diarrhea begin?

When did your diarrhea end?

3g. Eye Irritation?

No

Yes

Don’t know

Refused

When did the irritation begin?

When did the irritation end?

3h. Hair Loss?

Please describe:

Quantity

Location on scalp

No

Yes

Don’t know

Refused

(e.g. strands, chunks)

(e.g. patchy, right side, etc.)

3i. Constipation

No Yes Don’t know Refused

When did the irritation begin?

When did the irritation end?

3j. Weakness

No

Yes

Don’t know

Refused

When did this symptom begin?

When did this symptom end?

3i. 3k. Muscle pain

No

Yes

Don’t know

Refused

3l. Constipation

No Yes Don’t know Refused

When did this symptom begin?

When did this symptom end?

When did this symptom begin?

When did this symptom end?

3m. Anything Else?

Please describe

Please describe:

Time Course:

Time Course

No

Yes

Don’t know

Refused

When did this symptom begin?

When did this symptom end?

Now I would like to ask you a few questions about your tap water use.

4. Is your home on municipal water, that is, do you get your water from the City of Flint?

No

Yes

Refused

Don’t know

4a. IF NO, can you tell me the source of your tap water? _______

4. Do or did you have contact with Flint Water at work or anywhere else in your community, such as at church or the gym?

No

Yes

Refused

Don’t know

5a. IF YES, can you please explain where? _____

5b. IF YES, when did you start using Flint water at this location? ________________________________________

5c. IF YES, when did you stop using Flint water at this location? _________________________________________

5d. Have your symptoms improved or gone away since you changed your water use at this location?

No

Yes

Refused

Have not changed water use

Don’t know

4. When your symptoms started, did you notice changes in your tap water quality (appearance, taste, smell) at home?

No

Yes

Refused

Don’t know

6a. IF YES, can you please describe the change in water quality? ___________________________________________________

4. When your symptoms started, did you notice changes in your water pressure at home?

No

Yes

Refused

Don’t know

7a. IF YES, did the water pressure: Increase? Decrease?

4. Did you receive a filter for your water at home?

No

Yes

Refused

Don’t know

8a. What type of filter are you using at home?

Brita

PUR

Other______________________________________________________________________________

8b. When did you receive the filter? Date: ________________________

8c. How are you using your filter?

____________________________________________________________________________

____________________________________________________________________________

4. Are you using a different water source than normal for the following activities?

Washing dishes

Doing laundry

Cooking

Showering

Taking a bath

Using a hot tub

Drinking water

Other, please explain _______________________________________________________________________

Refused

Don’t know

4. Have you changed your behavior or habits for bathing and/or showering?

No

Yes

Refused

Don’t know

IF YES, can you please explain how your bathing habits have changed in the following ways:
10a. Frequency	10b. Length	10c. Method
Shower less frequently Shower more frequently Don’t know Refused	Shorter showers Longer showers Don’t know Refused	Please explain: (e.g. use of wipes, sponges) ______________________________________________________________________________________________________

4. Do you add anything to your water before using it?

No

Yes

Refused

Don’t know

11a. IF YES, please explain what you add (optional: and the amount you use):

Ask about amount if it makes sense based on what they are adding ______________________________________________________________________________

4. Have you changed your tap water use in any other way?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

4. When did you start making these changes to your tap water use?

Date_________________

4. Have your symptoms improved, gotten worse, or stayed the same since you changed your water

use?

Improved

Gotten worse

Stayed the same

Refused

Don’t know

4. What most influenced you to start making these changes to your tap water use?

Symptoms

Concerns for health

Media

Doctor’s advice

Other, please explain __________________________________________________________________________

SEEKING CARE

Note: Please ask these questions of all participants, including those referred by Poison Control.

4. Did you seek medical attention for any of the symptoms we just talked about?

No

Yes

Refused

Don’t know

IF NO, it is important that you go see your primary care doctor or a physician for further evaluation. SKIP TO 15.

IF YES:

16a. Where did you go? (check all that apply)

Primary Care Provider

Emergency Department

Urgent care

Specialist (e.g. dermatologist, eye doctor, etc.)

Alternative health care provider

Other Explain: ________________________________________________________________________

16b. Were you hospitalized for this condition?

Yes

No

Refused

Don’t know

16b1. IF YES, when?

16c. Did you receive a diagnosis?

No

Yes

Refused

Don’t know

16c1. IF YES, what was the diagnosis? _____

16d. Did you receive treatment?

No

Yes

Refused

Don’t know

16d1. IF YES, what was the treatment? _____

16e. Do you give permission for us to speak to your doctor and access your medical records about these visits to your doctor/the hospital? Medical records are very useful and enable us to add additional details to the information you have already given us. We will not access any other part of your medical records.

No

Yes

Please provide your doctor’s name and contact information

16e1. Name: __________________________________________________

16e2. Phone Number: __________________________________________

17. Have you tried any treatments or medications on your own?

No

Yes

Refused

Don’t know

17a. IF YES, what was the treatment? _____

GENERAL HEALTH

Now I am going to ask you a few questions about your general health.

18. Has a doctor ever told you that you have any chronic health conditions, such as diabetes, heart disease, or COPD?

No

Yes

Refused

Don’t know

18a. IF YES, what are they?

18b. When were you told about with this / these conditions? Date:

18. Has a doctor ever told you that you have asthma or seasonal allergies?

No

Yes

Refused

Don’t know

19a. IF YES, what are they? _________________

19b. When were you told about with this / these conditions? Date:

18. Has a doctor ever told you that you have a skin condition, including psoriasis, eczema, or dermatitis?

No

Yes

Refused

Don’t know

20a. IF YES, what skin conditions? ­­­____________________

20b. When were you told about with this / these conditions? Date:

18. Do you have any allergies to metals, foods, or anything else?

No

Yes

Refused

Don’t know

21a. IF YES, what are they?

21b. When were you tested for this / these conditions? Date:

18. Do you currently take any medications?

No

Yes

Refused

Don’t know

22a. IF YES, what are they?

18. Are you currently a smoker?

No

Yes

Refused

Don’t know

23a. IF YES, how many packs per day?

18. If your problem is related to the water, we would like to schedule your home for water testing. EPA water quality experts would visit your home to take water samples, which would take from 30 to 60 minutes total, from arrival to departure. You must be present in the home during this time. Would you like the EPA to come test your water?

No

Yes

Refused

Don’t know

24a. IF YES, what is the your:

Address: _____

Street City State Zip

Phone Number: _____

Best Day(s) for Testing: _____

Please expect a call from an EPA representative in the next 48 hours to set up a visit to test the water in your home.

18. Is there anything else that you think I should know about?

That was the last question. Thank you for taking the time to answer our questions.

If you are interested in the results of this questionnaire and additional information on water disinfection, please refer to the Flint Water website at

http://www.michigan.gov/flintwater