Zika Investigation - Individual Interview Form ENGLISH

Form Approved

OMB No. 0920-1137

Expires 03/31/2017

ZIKA INVESTIGATION — INDIVIDUAL INTERVIEW FORM

Team #: _______ Interviewer: _________ Date of interview (MM/DD/YYYY): ___/___/____

Individual ID (e.g., S-1-A-1): ______-_____-_____-____

1. Name: _________________________________________________________________

First (given) Initial Paternal Maternal

2. Sex: □ Male □Female □Other □Refuse to answer

3. Date of Birth (MM/DD/YYYY): ____/_____/______

4. For females only: Are you currently pregnant (circle one) □Yes □No

4a. If yes, please provide name and contact information of your obstetrician (or general physician if you do not have an obstetrician yet).

Name _________________________

Phone _________________________

Address _________________________

City _________________________

5. How long have you been living in Puerto Rico? _______ years □ Refuse to answer

6. Have you been told by a clinician that you have any of the following medical conditions?

□ Diabetes □ High blood pressure □ Heart disease □ High cholesterol

□ Stroke □ Kidney disease □ Liver disease □ Thyroid disease

□ Asthma □ Lung disease □ Joint disease/arthritis □ Cancer

□ Lupus □ Other autoimmune disease (specify: ____________________________)

□ None of the above

□ Refuse to answer / Don’t know

7. Do you take any of the following medications daily:

□ NSAID (e.g., aspirin, Ibupofen) □ Corticosteroids □ Antibiotics

□ Other: __________________________

□ None

□ Refuse to answer / Don’t know

8. Have you had any new, acute illnesses in the past 6 months?

Note to interviewer: this should not include flare-ups of chronic illnesses.

□Yes □No □ Refuse to answer / Don’t recall

(If more than one illness episode, use additional copy of questions 8 – 8d-3 to record, and document each additional episode in Notes.)

8a. If yes, first day of illness (MM/DD/YYYY): ____/_______/_____________

Note to interviewer: ask for best guess of participant, even if they can remember only the week. Show calendar to participant to aid recall.

□ Refuse to answer / Don’t recall

8b. What symptoms did you have (check all that apply)?

□ Fever □ Skin rash □ Nausea/Vomiting □ Diarrhea

□ Muscle pain □ Joint pain □ Chills □ Red eyes

□ Headache □ Pain behind eyes □ Abdominal pain □ Cough

□ Runny nose □ Sore throat □ Calf pain □ Arthritis (red, swollen joints)

□ Minor bleeding (e.g., petechiae, gum bleeding, nosebleeds, bruising)

□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy menses)

□ Other (specify): _________________________________________________________

□ Don’t recall / Refuse to answer

8c. How long did this illness last? ______ days □ Don’t recall / Refuse to answer

8d. Did you go to the doctor because of this illness? □ Yes □ No

□ Don’t recall / Refuse to answer

8d-1. If yes, how many times did you seek medical attention for this illness?

__ times □ I don’t know □ Refuse to answer / Don’t recall

8d-2. What was the diagnosis? □Zika □Chikungunya □ Dengue

□ Viral syndrome, unspecified □ Other: ______________

□ Refuse to answer / Don’t know

8d-3. Were you hospitalized for this illness? □ Yes □ No

□ Refuse to answer / don’t recall

8d-4a. If yes, Hospital Name: ________________________________

8d-4b. Days in the hospital: _____ days

□ I don’t know □ Refuse to answer

9. During an average week from 7am–7pm, many hours are you at home or in this community on (maximum = 12)

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

□ Refuse to answer / Don’t know

Note to interviewer: ask the participant for their best guess.

10. How frequently do mosquitoes bite you? □ Daily □ At least once a week □ Rarely

□ Never □ Don’t know / Refuse to answer

11. When do mosquitoes usually bite you? (select all that apply) □ Morning □ Daytime □ Evening □ Night-time □Mosquitoes don’t bite me □ Refuse to answer / don’t know

12. Where do mosquitoes usually bite you? (select all that apply) □ Home □ Work/school □ Others’ homes inside my community □ Others’ homes outside my community

□ Elsewhere □ Mosquitoes don’t bite me □ Refuse to answer / don’t know

13. Have you used mosquito repellent in the past month?

□ Daily □ Weekly □ Never □ Refuse to answer / don’t know

14. Have you slept under a bednet in the past month? □ Yes □ No

□ Refuse to answer / don’t recall

15. What is the highest level of education that you have completed?

□ No school □ Grades 1 through 8 □ Grades 9 through 11 □ Grade 12 or GED

□ Some college, Associate’s, or Technical Degree □ Bachelor’s Degree

□ Any post graduate studies

□ Do not know / Refused to answer

NOTES:

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1137).