FY2016Q2 - Follow-Up Rash Investigation

Form Approved

OMB No. 0923-0051

Exp. Date 03/31/2018

Attachment B - Follow-Up of rash investigation participants >2 weeks after their dermatology appointment – Questions and Potential Actions

Name:

Case No.

Date:

Call Length:

Dermatology visit date:

Water testing date:

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]. As part of the Flint rash investigation you were seen by a dermatologist. Would you mind if I asked you a few follow up questions to see how that appointment went and how you have been doing since then? If now is not a good time for you, is there another time when I can call to follow up with you?

Condition	Question		Answer/Notes	Potential follow up actions
Ask all	1. After you were seen by the dermatologist, you were mailed a copy of the records from the dermatology appointment. Did you receive a copy of these records?		1. Yes 2. No	Notify Janese Bouters ([email protected])
	2. Your primary care doctor was also mailed a copy of the records from your dermatology appointment. Do you know if your primary care doctor also received a copy of these records?		1. Yes 2. No
	3. Have you been able to follow up with your primary care physician since you were seen by the dermatologist?		1. Yes 2. No
NO If not seen by primary care doctor	If no	Why not? (Ask open ended question) 1. Haven’t had time? 2. Rash has resolved? 3. Appointment is scheduled and upcoming? 4. Don’t think it will be useful? 5. Don’t have a primary care doctor? 6. Don’t have transportation to get to your primary care doctor? 7. Other reason?		Notify Lily Tyndall Snow (TyndallSnowL @michigan.gov)
YES If seen by primary care doctor	1. When did you see your primary care doctor?		Date:
	2. Did your primary care doctor prescribe any medications based on the recommendations of the dermatologist?		1. Yes 2. No	Notify Jevon McFadden ([email protected]) for communication back to dermatologists
	If yes	3. What medications or other treatment did they prescribe? How effective were they?	Meds: Effectiveness:
	4. Did your primary care doctor prescribe any other medications in addition to those recommended by the dermatologist that have seemed to help?		1. Yes 2. No
	If yes	5. What medications or other treatment did they prescribe? How effective were they?	Meds: Effectiveness:
	6. During this most recent visit to your primary care doctor, did they give you a referral for your rash and/or other symptoms?		1. Yes 2. No
	If yes	What type of specialist did they refer you to? Back to a dermatologist, or to another type of specialist?	Specialist:

Public reporting burden of this collection of information is estimated to average 10 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)

Ask all	1. Since you were seen by the dermatologist, how has your rash or other symptoms been doing? Is it the same? Better? Worse? Gone away?			1. Better 2. Same 3. Worse Other:
	If the same or worse	2. Would you mind if we contacted the dermatologist you saw to let them know?		1. Yes 2. No	Notify Jevon McFadden
	3. Do you feel like going to the dermatologist was beneficial overall?			1. Yes 2. No
	If no	Is there anything you wish had been handled differently?
	4. Have you changed your showering habits since you were seen by the dermatologists?			1. Yes 2. No
	If yes	5. Do you shower more often? Less often? Shower longer duration? Shorter duration? Still not showering?		1. Less often 2. Longer duration 3. Shorter duration 4. Still not showering
	6. Is there anything more that we (the rash investigation team) can do to help?			1. Yes 2. No	Notify Jevon McFadden
If EPA water testing done	1. As part of the rash investigation, a team from EPA did water testing at your house. Did you receive a call with results of your water testing?			1. Yes 2. No	Notify Jennifer Gray ([email protected]) if results unclear to participant
	If yes		2. What were you told about the results of that water testing?

Phone attempts: Date/No._________/_____ Date/No._________/______ Date/No._________/________ Date/No._________/________ Date/No.________/_______

Additional Notes: