Zika Investigation - Household Interview Form ENGLISH

Form Approved

OMB Control No. 0920-XXXX

Exp. Date: XX/XX/XXXX

ZIKA INVESTIGATION — HOUSEHOLD INTERVIEW FORM

TEAM #: ________________ DATE: ______/_______/_________ Household ID (e.g., S-1-A): _______-______-_____

GPS Coordinates (decimals): _____.____________ , ______.______________ SANID of lab-positive case: ______________

How many people live in this house? _______________people

List all members of household below put yourself first.

Head of household contact number/email to facilitate return of test results:___________________________________________

	Name (First, Paternal, Maternal)	Age	Gender	Present?	If yes, agreed to participate?	Place sticker here
1			M / F	Yes / No	Yes / No
2			M / F	Yes / No	Yes / No
3			M / F	Yes / No	Yes / No
4			M / F	Yes / No	Yes / No
5			M / F	Yes / No	Yes / No
6			M / F	Yes / No	Yes / No
7			M / F	Yes / No	Yes / No
8			M / F	Yes / No	Yes / No

Household Characteristics

Housing type (check only one): □ One story house □ Two story house □ Apartment/condo building □Other

Has anyone in your household been acutely ill in the past 3 months? □ Yes □ No □ Don’t recall

How many of your windows and doors have intact screens? □ All □ Some □ None □ Don’t know

Do you use air conditioning in your home? □Yes, in all rooms □Yes, but only in the bedroom at night □ Other □ No

Do you regularly leave your doors or windows open? □ Daytime only □ Night-time only □ Always □ Never

Do you use mosquito coils in your house or patio to keep mosquitos away? □ Yes □ No

Do you use citronela in your house or patio to keep mosquitoes away? □ Yes □ No

What is your approximate annual household income? □ < $25,000 □ $26,000–$50,000 □ $51,000–$75,000 □ > $76,000

□ Decline to answer

Do you have one or more AGO mosquito traps in your home or yard? □ Yes □ No □ Don’t know

If so, compared to before the trap was present, would you say that the number of mosquitos in your home has:

□ Increased □ Decreased □ Not changed □ Do not know □ No trap in yard

Notes: