SHIGELLOSIS OUTBREAK CASE-CONTROL QUESTIONNAIRE - Gennes

Emergency Epidemic Investigation Data Collections - Expedited Reviews

Appendix 1- Questionnaire

Undetermined risk factors and modes of transmission for Shigella sonnei infection among residents of Genesee and Saginaw Counties – Michigan, 2016

OMB: 0920-1011

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Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

















SHIGELLOSIS OUTBREAK CASE-CONTROL QUESTIONNAIRE

GENESEE-SAGINAW COUNTIES



Respondent report number |__ - |__|__|__| __ Case __ Control

DATE OF INTERVIEW|__|__|-|__|__|-|__|__|


RESPONDENT: LAST NAME__________________ FIRST NAME________________

TELEPHONE NUMBER_____________________________

ADDRESS_______________________________

COUNTY OF RESIDENCE ____________________


Name of interviewer_______________ Phone number of interviewer________________

[IF CASE] PulseNet ID_____________________



Telephone Contact History

Date (mm/dd) Time (am/pm) Outcome/Comment Initials

1.__________ ___________ _________________ ______

2.__________ ___________ _________________ ______

3.__________ ___________ _________________ ______

4.__________ ___________ _________________ ______

5.__________ ___________ _________________ ______

6.__________ ___________ _________________ ______

7.__________ ___________ _________________ ______



OUTCOME CODES:

01 = completed interview 08 = no eligible respondent

02 = refused interview 09 = language barrier

03 = no answer 10 = interview terminated within questionnaire

04 = busy tone 11 = physical/mental impairment

05 = non-working number 12 = answering machine

06 = fax machine 13 = setting up a better time

07 = business phone 99 = unknown


SECTION A: CLINICAL INFORMATION

FIRST, I WOULD LIKE TO ASK YOU ABOUT YOUR ILLNESS.


A1. When did your diarrhea begin? |__|__|-|__|__|-|0|4|

MM DD YY


IF RESPONDENT CANNOT REMEMBER EXACT DATE DIARRHEA BEGAN, PROMPT FOR WEEK DIARRHEA BEGAN. ENTER DATE OF WEDNESDAY OF THAT WEEK

A2. If not exact date diarrhea began, enter approximate date |__|__|-|__|__|-|0|4|

MM DD YY


After getting the date of onset for illness (a2), mark the MONTH preceeding that onset date on the calendar AND IN THE SPACE BELOW for use in asking the exposure questionS


THAT WOULD BE THE PERIOD FROM /___/___/___/ TO /___/___/___/.


A3. What was the maximum number of loose or watery stools you had in a 24-hour period during this illness?


NUMBER |__|__|

UNKNOWN.....................77

REFUSED.........................99


A4. Did you have blood in your stool?


YES............................................ 1

NO.............................................. 2

UNKNOWN...............................77

REFUSED...................................99


A5. Was there a period when your diarrhea went away for at least a day and then came back?


YES.................................................1

NO..................................................2 (GO TO A7)

UNKNOWN.................................77 (GO TO A7)

REFUSED.................................... 99 (GO TO A7)


A6. How many times did this happen?


|__|__| Times



A7. Do you currently have diarrhea?

YES................................................. 1 (GO TO A9)

NO...................................................2

UNKNOWN.................................77 (GO TO A9)

REFUSED.................................... 99 (GO TO A9)


A8. IF NO, what date did the diarrhea completely end (include all of the diarrhea free days if there were any)?


Date: |__|__| |__|__| 2004

MM DD


A9. In addition to diarrhea, which of the following symptoms did you have, and how long did you experience each from beginning to end, regardless of whether you felt better on some days in between? [READ THE LIST OF SYMPTOMS. IF YES, ENTER THE CORRESPONDING DURATION FOR EACH.] (U=UNKNOWN; R=REFUSED)

SYMPTOM

0 days

1 day

2-5 days

6-14 days

>14 days

U

R


a. Nausea

0

1

2

6

14

77

99

b. Vomiting

0

1

2

6

14

77

99

c. Headache


0

1

2

6

14

77

99

d. Loss of appetite

0

1

2

6

14

77

99

e. Abdominal cramps

0

1

2

6

14

77

99

f. Bloating/Gas

0

1

2

6

14

77

99

g. Body/Muscle aches

0

1

2

6

14

77

99

h. Tiredness/Fatigue

0

1

2

6

14

77

99

i. Fever

IF YES, GO TO A10,

IF NO GO TO A11.

0

1

2

6

14

77

99



A10. If yES TO fever, what was the highest temperature measured?

a. NUMBER |__|__|__| . |__| degrees F OR b. NUMBER |__|__|__| . |__| degrees C

Felt warm/feverish, but temperature not measured ….222.2

UNKNOWN...........................…………………….......777.7

REFUSED...........................………………………….. 999.9


A11. Have you experienced any weight loss as a result of your symptoms?


YES.................................................1

NO..................................................2

UNKNOWN.................................77

REFUSED.................................... 99

A12. Did you seek health care for any symptoms?

YES.................................................1

NO..................................................2 (GO TO A15)

UNKNOWN.................................77 (GO TO A15)

REFUSED.................................... 99 (GO TO A15)


A13. The following questions are about treatment for your illness.

(CHECK ALL THAT APPLY) Y N U R

A13a. Was a doctor or nurse consulted over the phone? 1 2 77 99

A13b. Did you visit a doctor’s office? 1 2 77 99

A13c. Did you visit an Emergency Room? 1 2 77 99

A13d. Were you hospitalized for more than 24 hours? 1 2 77 99 A13e. IF YES, how long hospitalized? |__|__| days


A14. Once your diarrhea began, how long were you ill before you contacted or visited a doctor or nurse?


NUMBER |__|__|__| days


UNKNOWN..........................................777

REFUSED…..........................................999


A15. What treatment did you use for your symptoms?

(CHECK ALL THAT APPLY):

Y N U R


A15a. Nothing [IF YES GO TO A16] 1 2 77 99

A15b. OTC antidiarrheal medications (i.e. Peptobismol) 1 2 77 99

A15c. Herbal remedies 1 2 77 99

A15d. Antibiotics/Antiparasitics 1 2 77 99

A15e. Any prescription medications 1 2 77 99

A15f. Dehydration medications (Pedialyte) 1 2 77 99

A15g. Drank more fluids 1 2 77 99

A15h. Received Intravenous fluids 1 2 77 99

A15i. Fever/Pain reliever 1 2 77 99

A15j. Other _________________________ 1 2 77 99


A16. When your illness began, were you employed – meaning you had a paid job performed either outside or inside the home?


YES..................................................1

NO...................................................2 (GO TO A19)

UNKNOWN..................................77 (GO TO A19)

REFUSED…................................. 99 (GO TO A19)



A17. IF YES TO EMPLOYED, during your illness, did you miss any time from work, for example because you called in sick or took time off to see a doctor?

YES..................................................1

NO...................................................2 (GO TO A19)

UNKNOWN..................................77 (GO TO A19)

REFUSED…................................. 99 (GO TO A19)

A18. If yes, how many days? |___|___| days (IF IN HOURS, i.e. <1 DAY, THEN

CODE AS ZERO)

UNKNOWN …………………..77

REFUSED……………………...99


A19. Did this illness prevent you from performing daily activities such as school, recreation, or vacation activities, or working within the home?

YES..................................................1

NO...................................................2 (GO TO A20)

UNKNOWN..................................77 (GO TO A20)

REFUSED…................................. 99 (GO TO A20)

A19a. If yes, how many days? |___|___| days (IF IN HOURS, i.e. <1 DAY, THEN

CODE AS ZERO)

UNKNOWN…………………………77

REFUSED……………………………99


A20. Did you continue to do water activities (swimming, water parks, etc.) while you had diarrhea?


YES………………………………1

NO……………………………….2

UNKNOWN……………………..77

REFUSED……………………….99


A21. Did you prepare food for others while you had diarrhea?


YES………………………………1

NO……………………………….2

UNKNOWN……………………..77

REFUSED……………………….99

A22. Did you participate in water activities (pool, water parks, etc.) in the month before your diarrhea ended?

YES………………………………..1

NO………………………………...2

UNKNOWN……………………....77

REFUSED…………………………99


A23. Are you aware of anyone in your immediate household or social group that had diarrhea in the month before your symptoms began?


YES……………………………….1

NO………………………………..2

UNKNOWN……………………...77

REFUSED………………………...99


A24. Are you aware of anyone in your immediate household or social group that had diarrhea while you had your symptoms?


YES……………………………….1

NO………………………………..2

UNKNOWN……………………...77

REFUSED………………………..99


A25. Are you aware of anyone in your immediate household or social group that had diarrhea in the month after your symptoms began?


YES……………………………….1

NO………………………………..2

UNKNOWN……………………...77

REFUSED………………………..99


A26. Do you/your child have a weakened immune system? Conditions such as cancer, HIV, organ transplant and/or receiving steroid treatment can cause a weakened immune system. This does not include inhaled steroids for asthma therapy.

YES.................................................1

NO...................................................2

UNKNOWN..................................77

REFUSED…................................. 99



SECTION B. PERSON TO PERSON CONTACT AND CHILDCARE INFORMATION


B1. Now I would like to ask about the adults (>18 years of age) in your house. What are the adult’s sexes and did they have diarrhea in the month before you became ill? (QUESTION A2) /___/___/___/ to /___/___/___/.


ADULT

What sex?


(1=MALE,

2=FEMALE)


Had diarrhea?



YES NO UNK REF

ADULT 1

1

2

1

2

77

99

ADULT 2

1

2

1

2

77

99

ADULT 3

1

2

1

2

77

99

ADULT 4

1

2

1

2

77

99

ADULT 5

1

2

1

2

77

99

ADULT 6

1

2

1

2

77

99

READ: Now I would now like to ask you a few questions about your contact with children under 18 and persons with diarrhea in the month before you became ill (QUESTION A2) /___/___/___/ to /___/___/___/.


B2. Do you have children (<18 years old) living in your home?

IF INTERVIEWING AN ADOLESCENT: Do you have children (<18 years old) – other than yourself - living in your home?


YES.................................................................... 1

NO...................................................................... 2 (GO TO B9)

UNKNOWN.........................................................77 (GO TO B9)

REFUSED...........................................................99 (GO TO B9)


B3. IF YES, How many children live in your house?


NUMBER OF CHILDREN |__|__|

UNKNOWN 77

REFUSED 99


B4. What are the children’s age(s) in years, their sexes and did they have diarrhea in the month before your diarrhea began?

IF INTERVIEWING AN ADOLESCENT: Other than yourself, what are the children’s age(s) in years, their sexes and did they have diarrhea in the month before your diarrhea began?

CHILD

AGE?

(INDICATE YRS OR MONTHS)

Does the child wear diapers?

Y N

What sex?


(1=MALE,

2=FEMALE)


Had diarrhea?


YES NO UNK REF

CHILD 1


1 2

1

2

1

2

77

99

CHILD 2


1 2

1

2

1

2

77

99

CHILD 3


1 2

1

2

1

2

77

99

CHILD 4


1 2

1

2

1

2

77

99

CHILD 5


1 2

1

2

1

2

77

99

CHILD 6


1 2

1

2

1

2

77

99

CHILD 7


1 2

1

2

1

2

77

99

CHILD 8


1 2

1

2

1

2

77

99

CHILD 9


1 2

1

2

1

2

77

99

CHILD 10


1 2

1

2

1

2

77

99

CHILD 11


1 2

1

2

1

2

77

99

CHILD 12


1 2

1

2

1

2

77

99

CHILD 13


1 2

1

2

1

2

77

99

CHILD 14


1 2

1

2

1

2

77

99

CHILD 15


1 2

1

2

1

2

77

99



B5. Were any children in your household in childcare outside of your home at any time in the month before you became ill?

YES.................................................................... 1

NO...................................................................... 2 (GO TO B7)

UNKNOWN.........................................................77 (GO TO B7)

REFUSED.......................................................... 99 (GO TO B7)


B5a. IF YES, did (he/she/they) participate in any water related activities, such as swimming, wading, or water table play, at his or her childcare outside of your home?

YES.................................................................... 1

NO...................................................................... 2

UNKNOWN.........................................................77

REFUSED.....................................................99


B6. IF YES TO B5, Were any children at your child’s childcare location in diapers?

YES.............................................................. 1

NO...................................................................2 UNKNOWN................................................. 77

REFUSED............................................. 99

B7. Were any children in your household in a day camp in the month before you became ill? By a day camp I mean a center with activities where children spend all or part of the day, often during the summer months when school is out. By comparison, a day care center is often for toddlers.


YES.............................................................1

NO..............................................................2 (GO TO B8) UNKNOWN............................................77 (GO TO B8)

REFUSED................................................99 (GO TO B8)


B7a. IF YES, did (he/she/they) participate in any water related activities, such as swimming, wading or water tables, at his or her day camp?

YES.................................................................... 1

NO...................................................................... 2

UNKNOWN......................................................... 77

REFUSED..................................................... 99


B8. In the month before illness, did you provide childcare in any of the following childcare settings? [Read THE LIST. cIRCLE ALL THAT APPLY]


SETTING

YES

NO

UNKNOWN

REFUSED

a. Out-of-home childcare center

1

2

77

99

b. In-home childcare center

1

2

77

99


c. Out-of-home babysitter

1

2

77

99

d. In-home babysitter

1

2

77

99

e. Other

f. Specify:

1

2

77

99

B9. In the month before illness, did you have contact with any children in diapers?


YES.......................................... 1

NO........................................... 2 (GO TO B11)

UNKNOWN............................... 77 (GO TO B11)

REFUSED........................... 99 (GO TO B11)

B10. If yes, in the month before illness, did you change any diapers?

YES.................................................................... 1

NO...................................................................... 2 UNKNOWN......................................................... 77

REFUSED..................................................... 99


B11. In the month before you became ill, did you come in contact with anyone who had diarrhea?


YES.................................................... 1

NO...................................................... 2 (GO TO SECTION C)

UNKNOWN.......................................77 (GO TO SECTION C)

REFUSED..................................... 99 (GO TO SECTION C)


B12. IF YES, did they include:

[Read THE LIST. cIRCLE ALL THAT APPLY]


YES

NO

UNKNOWN

REFUSED

a. Children < 3 years of age

1

2

99

77

b. Children 4 to <13 years of age

1

2

99

77

c. Teenagers >13 to <18 years

1

2

99

77

d. Adults 18 years or older

1

2

99

77

B13. Did you provide direct care to a person with diarrhea?


YES............................................. 1

NO............................................... 2

UNKNOWN.................................... 77

REFUSED................................. 99




SECTION C. DIETARY EXPOSURES


I WOULD LIKE TO TALK ABOUT YOUR DIET DURING THE TWO WEEKS BEFORE YOUR DIARRHEA BEGAN (QUESTION A2), THAT WOULD BE THE PERIOD FROM /___/___/___/ TO /___/___/___/.


C1. In the month before your diarrhea began, did you eat any of the following food items? [READ THE LIST. ENTER ALL THAT APPLY]


FOOD

Y

N

U

R

a. Lettuce or garden salad

1

2

77

99

b. Cold cuts, chicken salad, egg salad, or tuna salad

1

2

77

99

c. Other cold salads such as

coleslaw, potato salad, or pasta salad

1

2

77

99

d. Raw vegetables such as

carrots, tomatoes, cucumbers, green onions

1

2

77

99

e. Raw berries (e.g. strawberries and raspberries)

1

2

77

99

f. Raw fruits with skin/peel (e.g., melons, apples)

1

2

77

99

g. Cider or juice

1

2

77

99

h. Raw shellfish

1

2

77

99

i. Cooked shellfish

1

2

77

99


C2. In the month before your diarrhea began, did you consume any of the following unpasteurized foods or drinks? This may include products supplied from health food stores, local farms, or imported from other countries.

[Read THE LIST. ENTER ALL THAT APPLY]


FOOD

YES

NO

UNKNOWN

REFUSED

a. Unpasteurized milk

1

2

77

99

b. Unpasteurized apple juice/cider

1

2

77

99

c. Other unpasteurized juices

1

2

77

99

d. Unpasteurized cheese

(e.g. goat cheese, farmer’s cheese, queso fresco)

1

2

77

99

e. Other

Specify:

1

2

77

99

SECTION D. DRINKING WATER EXPOSURES


I WOULD LIKE TO TALK ABOUT YOUR EXPOSURE TO DRINKING WATER IN THE MONTH BEFORE YOUR DIARRHEA BEGAN (QUESTION A2), THAT WOULD BE THE PERIOD FROM /___/___/___/ TO /___/___/___/.


D1 In the month before your diarrhea began, what were your sources of drinking water at home? [Read THE LIST. ENTER ALL THAT APPLY]

QUESTION

YES

NO

UNKNOWN

REFUSED

a. Does not drink water at home

1

2

77

99

b. Municipal or city water direct from tap

1

2

77

99

c. Municipal or city water with additional filtration or treatment

1

2

77

99

d. Refrigerator dispenser

1

2

77

99

e. Private well water

1

2

77

99

f. Private well water with additional filtration or treatment

1

2

77

99

g. Commercially bottled water

1

2

77

99

h. Other

Specify:

1

2

77

99

D2. In the month before your diarrhea began, what were your sources of drinking water outside the home, for example, at school or work?

[Read THE LIST. ENTER ALL THAT APPLY.]


QUESTION

YES

NO

UNKNOWN

REFUSED

a. Does not drink water outside the home

1

2

77

99

b. Municipal or city water direct from tap (including a water fountain)

1

2

77

99

c. Municipal or city water with additional filtration or treatment

1

2

77

99

d. Refrigerator dispenser

1

2

77

99

e. Private well water

1

2

77

99

f. Private well water with additional filtration or treatment

1

2

77

99

g. Commercially bottled water

1

2

77

99

i. Other Specify:

1

2

77

99



D3. What was your usual source of ice in the month before your diarrhea began?


[Read THE LIST. ENTER ALL THAT APPLY]


SOURCE

YES

NO

UNKNOWN

REFUSED

a. Do not use ice

1

2

77

99

b. From your home

1

2

77

99

c. From outside your home

1

2

77

99



D4. In the month before your diarrhea began, did you drink any untreated water from a lake, river or stream?


YES............................................ 1

NO............................................ 2

UNKNOWN...............................77

REFUSED...................................99


SECTION E: RECREATIONAL WATER EXPOSURE


I WOULD LIKE TO TALK ABOUT YOUR EXPOSURE TO RECREATIONAL WATER. WE WILL FIRST FOCUS ON THE PERIOD IN THE MONTH BEFORE YOUR DIARRHEA BEGAN (QUESTION A2, /___/___/___/ TO /___/___/___/).


E1. During the in the month before your diarrhea began, did you swim or enter recreational water (which means other than in a bathtub or shower)?


YES...............................................1

NO................................................2 (GO TO E4)

UNKNOWN................................77 (GO TO E4)

REFUSED…................................99 (GO TO E4)


E2. During the in the month before the diarrhea began, which recreational water settings did you swim in, wade in, or enter? [Read THE LIST. enter ALL THAT APPLY]

IF YES, on how many days did you swim or enter the water in the two weeks before you became ill?

IF YES, did you put your face under the water?


Setting

Y N U R

Number of days?

1 2-5 6-10 >11 U R

Y N U R


a. Lake, Pond, River or Stream


1 2 77 99


1 2 3 4 77 99


1 2 77 99

b. Hot Tub, Spa, Whirlpool, Jacuzzi


1 2 77 99


1 2 3 4 77 99


1 2 77 99

c. Recreational Water Park other than swimming pools (such as The Beach, Soak City, or Wyandot Lake)

1 2 77 99

1 2 3 4 77 99

1 2 77 99



E3. During the in the month before your diarrhea began, did you swim, wade in or enter a swimming pool?


YES...............................................1

NO................................................2

UNKNOWN................................77

REFUSED…................................99


read: THE FOLLOWING QUESTIONS ASK ABOUT TYPICAL SWIMMING ACTIVITIES DURING VISITS TO POOLS


E4. On a typical visit during the in the month before your diarrhea began, did you usually wade or play in the water without swimming?


YES………………....1

NO………………….2

UNKNOWN.............77

REFUSED….............99


E5. On a typical visit during the in the month before your diarrhea began, did you get water splashed in your face?

YES………………....1

NO………………….2

UNKNOWN.............77

REFUSED….............99


E6. On a typical visit during the in the month before your diarrhea began, did you put your face in the water?


YES………………....1

NO………………….2

UNKNOWN.............77

REFUSED….............99


E7. On a typical visit in the month before your diarrhea began, did you get any water in your mouth?

YES…………………1

NO……..…………...2 (GO TO E9)

UNKNOWN…........77 (GO TO E9)

REFUSED….…...... 99 (GO TO E9)


E8. On a typical visit during the in the month before your diarrhea began, did you swallow any of this water?

YES…………………..1

NO……..…………….2

UNKNOWN…..........77

REFUSED…..………99


E9. On a typical visit during the in the month before your diarrhea began, did you dive or jump into the water?

YES………………....1

NO………………….2

UNKNOWN.............77

REFUSED….............99


E10. On a typical visit in the month before your diarrhea began, did you use a slide to enter the water?

YES………………....1

NO………………….2

UNKNOWN.............77

REFUSED….............99


E11. During the in the month before your diarrhea began, please list the swimming pools that you swam in or entered [ENTER ALL THAT APPLY]


IF YES, on how many days in the month before you became ill?


IF YES, please list dates

(IF CANNOT RECALL EXACT DATES, prompt for week of swimming in that location and enter date of Wednesday of that week


IF YES, did you put your face under

the water?


Name

Y N U R

Number of days?

1 2-5 6-10 >11 U R

List dates (MM/DD/YY)

List dates (MM/DD/YY)

Y N U R


1 2 77 99


1 2 3 4 77 99



1 2 77 99


1 2 77 99


1 2 3 4 77 99



1 2 77 99


1 2 77 99

1 2 3 4 77 99



1 2 77 99


1 2 77 99

1 2 3 4 77 99



1 2 77 99


1 2 77 99

1 2 3 4 77 99



1 2 77 99


1 2 77 99

1 2 3 4 77 99



1 2 77 99


1 2 77 99

1 2 3 4 77 99



1 2 77 99



SECTION F. EVENTS

NOW I WOULD LIKE TO TALK TO YOU ABOUT THE EVENTS THAT YOU ATTENDED DURING X


F1. During the months of X before your diarrhea began, did you attend any large social gatherings with 50 or more persons present such as picnics, county fairs or other events?


YES............................................ 1

NO............................................…2

UNKNOWN................................77

REFUSED....................................99




F2. IF YES, please name the events/parties/potlucks and tell us when

Name Date (MM/DD/YY)




SECTION G. TRAVEL HISTORY

NOW I WOULD LIKE TO TALK TO YOU ABOUT YOUR TRAVEL HISTORY IN THE MONTH BEFORE YOUR DIARRHEA BEGAN

(QUESTION A2, /___/___/___/ TO /___/___/___/).


G1. In the month before your diarrhea began did you travel outside Michigan?


YES...............................................1

NO............................................…2

UNKNOWN................................77

REFUSED....................................99


G2. If yes please specify where and when _____________________________

SECTION H : DEMOGRAPHIC INFORMATION


CASE ID: A |__|__|__|



H1. What is your ZIP code? |__|__|__|__|__|

UNKNOWN…………77777

REFUSED…………... 99999



H2. What is your age?

|___|___|

Age



H3. What is your gender?


MALE ……….…… 1

FEMALE ………… 2

UNKNOWN……....77

REFUSED………....99



H4. What district do you live in? ________________________________


IF RESPONDENT ANSWERS “DON’T KNOW”, ASK:


H4a. What city do you live in?__________________________________



END OF QUESTIONNAIRE: This concludes our questionnaire. I would like to thank you very much for your time, patience, and cooperation in answering our questions. I would be happy to answer any questions you may have at this point.


If you have any questions in the future please contact X.






Public reporting burden of this collection of information is estimated to 40 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)

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