0920-1166 Follow-up questionnaire for individuals calling poison c

DATE

Attachment 3. Follow-up questionnaire for individuals calling poison control centers (PCCs) regarding exposures to harmful algal blooms (HABs) – adolescent

GenIC Name: Identifying Sources of and Risk Factors for Harmful Algal Bloom Exposures through Poison Control Center Follow-up Questionnaires – United States, 2019

ADOLESCENT QUESTIONNAIRE

CDC estimates the average public reporting burden for this collection of information as 40 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1166).

Form Approved

OMB No. 0920-1166

Exp. Date 02/29/2020

Date of the interview: ____/____/______ Name of interviewer: _______________________

Poison control center: _______________________

State call originated from: ____________________

Title of the investigation: ____________________

NPDS Case ID No. ____________________

I. Exposure and Health Effects Information

I am going to ask you a few questions about your exposure and the circumstances surrounding your exposure.

1. What were you exposed to that prompted the call to the poison control center?

     

Refuse to answer

Choose all that apply; ask follow up questions along the same row as reported exposure below	2. Location-related question	3. Appearance-related question	4. Symptom-related question	5. Symptom timing-related question
Ask questions along this row if the response to Q1 is related to shellfish	Where were you when you were exposed? __ Home __ Restaurant __ Other (describe) __ Don’t know __ Refused	Did the shellfish look normal? __ Yes __ No (describe) __ Don’t know __ Refused	What symptoms did you experience as a result of eating the shellfish? (choose all that apply) __ Nausea __ Vomiting __ Diarrhea __ Tingling in the extremities (fingers and toes, mouth) __ Numbness in the extremities (fingers, toes, mouth) __ Weakness __ Shortness of breath __ Confusion __ Memory loss __ Heart palpitations __ Other (describe)	How long was it between exposure to shellfish and onset of symptoms? __ Immediately to less than 6 hours __ 6 to 24 hours __ More than 24 hours
Ask questions along this row if the response to Q1 is related to bathing or swimming in a body of water	Where were you when you were exposed? __ Ocean __ Fresh water body __ Other (describe)	Did the water look unusually colored? __ Yes (describe) ____ __ No __ Don’t know __ Refused	What symptoms did you experience as a result of exposure to the body of water? (choose all that apply) __ Nausea __ Vomiting __ Diarrhea __ Rash __ Itchiness __ Burning sensation on the skin __ Blisters on skin __ Watery eyes __ Burning sensation in eyes __ Trouble breathing __ Asthma attack __ Respiratory irritation __ Other (describe)	How long was it between exposure to the body of water and onset of symptoms? __ Immediately to less than 6 hours __ 6 to 24 hours __ More than 24 hours
Ask questions along this row if the response to Q1 is related to being near a body of water	Where were you when you were exposed? __ Ocean __ Fresh water body __ Other (describe)	Did the water look unusually colored? __ Yes (describe) ____ __ No __ Don’t know __ Refused	What symptoms did you experience as a result of exposure to the body of water? (choose all that apply) __ Nausea __ Vomiting __ Diarrhea __ Rash __ Itchiness __ Burning sensation on the skin __ Blisters on skin __ Watery eyes __ Burning sensation in eyes __ Trouble breathing __ Asthma attack __ Respiratory irritation __ Other (describe)	How long was it between exposure to the body of water and onset of symptoms? __ Immediately to less than 6 hours __ 6 to 24 hours __ More than 24 hours
Ask questions along this row if the response to Q1 is related to drinking water	What was the source of the drinking water? __ Outside body of water (i.e., ocean, lake) __ Water from an indoor or outdoor faucet __ Other (describe)	Did the water look unusually colored? __ Yes (describe) ____ __ No __ Don’t know __ Refused	What symptoms did you experience as a result of exposure to the drinking water? (choose all that apply) __ Nausea __ Vomiting __ Diarrhea __ Rash __ Itchiness __ Burning sensation on the skin __ Other (describe)	How long was it between exposure to the drinking water and onset of symptoms? __ Immediately to less than 6 hours __ 6 to 24 hours __ More than 24 hours
Ask questions along this row if the response to Q1 is not related the options above	Where were you when you were exposed? (describe)		What symptoms did you experience as a result of the exposures? (describe)	How long was it between the exposure and onset of symptoms? __ Immediately to less than 6 hours __ 6 to 24 hours __ More than 24 hours
__ Do not know

II. Medical Treatment

Now I am going to ask you a few questions about the medical treatment received.

6. What was the reason for the call to the poison control center during or immediately after the exposure? (check all that apply)

Wanted information about the exposure

Worried about being exposed/Worried about child being exposed

Was feeling ill/Child was feeling ill

Smelled something

Other (describe):      

Refuse to answer

6. What action did the poison control center recommend? (please describe in detail)

     

Refuse to answer

6. Did you go to any kind of healthcare facility such as a doctor’s office, emergency room or urgent care center after your exposure? (choose one)

Yes Go to part b

No Go to next section (Health Messaging)

Do not know

Refuse to answer

b. What type of healthcare facility did you go to? (choose the initial facility visited)

Hospital emergency room

Doctor’s office

Urgent care center

Other (describe)      

Do not know

Refuse to answer

6. What kind of treatment did you receive while in the healthcare facility? (choose one)

Describe      

Do not know

None

Refuse to answer

6. Did a doctor place you on any medications as a result of this incident? (choose one)

Yes Go to part b

No

Do not know

Refuse to answer

b. If yes, which medications? (choose one)

Describe      

Do not know

Refuse to answer

6. What happened after the visit at the health care facility was completed?

Discharged

Admitted

Transferred/transported to other healthcare facility (specify)      

Other (describe)      

Do not know

Refuse to answer

III. Health Messaging

We are almost finished. The last few questions are about what you have heard regarding the exposure.

6. Just before or during the exposure, did you hear or read warnings about the danger of harmful algal blooms?

Yes Go to part b

No

Do not know

Refuse to answer

b. If so, where did you hear or read these warnings? (read all choices and check all that apply)

Newspapers/magazines

Pamphlet/fact sheet

Fire Department

Radio

Television

Friends or family

Salesman or store employee

Law enforcement

Utility workers

Signs posted near waterbodies

Information on recreational water or utility website

Other      

Do not know

Refuse to answer

6. Did you hear any communication messages prior to exposure? (Health alerts, evacuation orders, radio alerts, etc)

Yes (describe):       Go to part b

No

Do not know

Refuse to answer

b. Did you act upon those communication messages?

Yes

No

Do not know

Refuse to answer

6. What exposure prevention methods were in place prior to the exposure? (e.g., warning signs posted near water bodies)

Signs posted near waterbodies

Information on recreational water or utility website

Other (describe):      

Do not know

Refuse to answer

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