Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Date: ____/____/_____ (DD,MM,YYYY)
Form Completed by: |
Name: _____________________ Position: ________________District: ______________________ Phone Number/email: _____________________________________________________________ |
Section 1. Participant Information |
ID Number: ________________________________________Age: ____Gender: Male Female. Village/Town: _______________Parish: _____________Sub-County: _________________ District: _________________Nationality: _____________ Marital status Married Single Widowed GPS Coordinates________________________________________________________________ |
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Section 2. Epidemiological Risk Factors and Exposures |
Farmer Herdsman Housewife Student Child Health worker Other, please specify occupation_________________________________________________
cats others specify__________________________________
goats Cattle Pigs Poultry Dogs others specify________________
Bats monkeys wild Pigs wild birds rodents antelopes others specify________________________________________________________
Yes No Unkn
Knowledge & Attitude Questions
Yes No Unk
others specify___________
biting mosquitoes(insects) others specify________________________
monkeys bats antelopes wild pigs others specify_____________
vaccination avoiding contact with animals traditional medicine avoiding sick people others specify_____________________________________________
traditional medicine spiritual healing Modern medicine Herbal medicine others specify_____________________________________
witchcraft Evildoing/sin curse others specify_______________________________
Yes No Unk
Yes No Unk
Yes No Unk
Unk
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Section 3. Specimen Information |
Specimen identification number:___________________ Specimen collection date:___/___/______ (MM/DD/YYYY) Laboratory testing date:___/___/______ (MM/DD/YYYY) Results/Titer level: IgM _____________ IgG _____________
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Public reporting burden of this collection of information is estimated to average 30 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 | Trevor Shoemaker |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |