Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
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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Self Family Clinician Other (Specify):_______________ |
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Confirmed case Suspected case Not a case Other (Specify):_______________ |
QUESTIONNAIRE FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM, JUNE 2016
Section 2: Demographic Data: |
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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 |
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Section 3: Food allergies, special diets: |
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Yes |
Maybe |
No |
Don’t Know |
Did you 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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Dairy‐free Vegetarian/Vegan Kosher Gluten‐free Other religious diet:_______________ Other:______________ |
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Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:
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Section 4: Sources of food: |
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Yes No
Yes No |
Section 5: Food items: |
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*** To be completed with prison food menu. |
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Food item |
Yes |
No |
Don’t know |
Unknown |
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Have you eaten any additional food items in the past two weeks?:
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Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:
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Section 6: Hooch: Now I have a few questions about Hooch or Pruno. |
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Yes |
Maybe |
No |
Don’t Know |
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1a. How often do you drink hooch? daily weekly monthly less than monthly when it is available don’t know |
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2a. How many times did you drink hooch since June 1st? _______________ 2b. When did you first drink the hooch? __ __ / __ __ / __ __ __ __ 2c. On average, how much hooch did you drink each time? a sip a cup a pint more than a pint Other:______________ 2d. Did you share with other people? Yes No Don’t know How many people did you share with? __________________________________________ Are any of these people currently sick?__________________________________________ 2e. Do you still have hooch in your cell? Yes No Don’t know 2f. Where did you get the hooch?_____________________________________________ 2g. Do you know when the batch of hooch that you made was dug up or first drank? Yes No Don’t know If yes, when? __ __ / __ __ / __ __ __ __ |
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Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:
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Section 7: Clinical Information:. |
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__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) Not sick M M D D Y Y Y Y |
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_______ days (enter 999 if unknown) or Still Ill |
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Yes |
No |
Don’t Know |
Was the patient: |
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Date of hospitalization __ __ / __ __ / __ __ __ __ |
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Date of discharged __ __ / __ __ / __ __ __ __ or Still hospitalized |
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Admitted to ICU? Yes No Don’t know |
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Date of intubation __ __ / __ __ / __ __ __ __ |
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Date stopped intubation __ __ / __ __ / __ __ __ __ or Still Intubation |
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Date of HBAT administration __ __ / __ __ / __ __ __ __ |
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Did the patient have any of the following symptoms: |
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Yes |
No |
Don’t Know |
Symptom |
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Change in sound of voice |
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Abdominal Pain |
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Hoarseness |
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Diarrhea |
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Dry mouth |
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Constipation |
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Dysphagia (difficulty swallowing) |
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Blurred Vision |
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Shortness of breath |
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Diplopia (double vision) |
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Subjective weakness |
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Dizziness |
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Fatigue |
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Slurred Speech |
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Paresthesia (abnormal sensation, e.g. numbness) |
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Thick tongue |
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Nausea |
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Extraocular Palsy (paralysis of eye muscles) |
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If yes, is it bilateral? |
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If bilateral, is it symmetric? |
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Ptosis (drooping eyelids) |
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Facial Paralysis |
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If yes, is it bilateral? |
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If bilateral, is it symmetric? |
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Palatal weakness |
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If yes, is it bilateral? |
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Impaired gag reflex |
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Other sensory deficit(s) |
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Which ones?__________________________________________________________ |
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Other symptoms? |
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Which ones?___________________________________________________________
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Clinical history: |
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Yes |
No |
Don’t Know |
Comorbidity |
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HIV |
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TB |
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Hepatitis C |
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Hypertension |
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Diabetes |
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Other Comorbidity(ies)? |
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Which other(s)?______________________________________________ |
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 | Marlow, Mariel Asbury (CDC) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |