Maternal Follow-Up Questionnaire

STUDY ID: ___________________

ZEN COLOMBIA

Maternal Follow-Up Questionnaire

Study site: _______________________________________________________

The first questions are about mosquito bites.

1. On average, how many hours per day do you spend outside?

_______ hours/day ₇₇ Don’t know ₈₈ Refused

2. In the past 7 days, how many mosquito bites did you get?

₀ None ₁ Less than 20 ₂ 20 or more, or too many to count

₇₇ Don’t know ₈₈ Refused

3. In the past 7 days, how often have you…

	Never	Some of the time	Most of the time	Not applicable	Don’t know	Refused
Worn long pants that covered your legs
Worn shirts or jackets with long sleeves that covered your arms
Worn shoes with socks
Worn permethrin-treated clothing
Used mosquito repellant

4. In the past 7 days, when you were inside your home, how often was the air conditioner running?

₃ Never ₂ Some of the time ₁ Most of the time ₀ I don’t have air conditioning

₇₇ Don’t know ₈₈ Refused

5. Does your home have intact screens on all windows and doors that prevent mosquitos from entering?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused ₁ Not applicable

The next questions are about Zika virus.

6. In the past month, did anyone in your household other than you have symptoms of Zika? Symptoms of Zika means being sick with 2 or more of fever, rash, red eyes, or joint pain that are not explained by any other cause.

₁ Yes ₀ No ₇₈ I am the only person in the household

₇₇ Don’t know ₈₈ Refused

If yes: Who was it?

₃ Husband or partner ₂ Your child ₁ Another person in the household

₇₇ Don’t know ₈₈ Refused

7. In the past month, has a doctor or healthcare provider ever told anyone in your household, aside from yourself, that they might have Zika virus?

₁ Yes ₀ No ₇₈ I am the only person in the household

₇₇ Don’t know ₈₈ Refused

If yes: Who was it?

₃ Husband or partner ₂ Your child ₁ Another person in the household

₇₇ Don’t know ₈₈ Refused

Next I’ll ask you some questions about your home, community, and environment.

8. In the past month, have you traveled to another province or country?

₁ Yes ₁ No ₇₇ Don’t know ₈₈ Refused

If yes: Where did you travel?

a. Place: _________________________ # days: __________

b. Place: _________________________ # days: __________

c. Place: _________________________ # days: __________

9. In the past month, have you worked at a job? Include jobs in which you don’t have a formal employer, such as selling goods or providing services.

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

If yes: Have any of your jobs in the past month involved:

X-rays	0 No 1 Yes 77 Don’t know 88 Refused
Contact with body fluids	0 No 1 Yes 77 Don’t know 88 Refused
Applying pesticides, insecticides, or rat poison	0 No 1 Yes 77 Don’t know 88 Refused
Battery manufacturing or battery recycling	0 No 1 Yes 77 Don’t know 88 Refused
Electronic waste recycling	0 No 1 Yes 77 Don’t know 88 Refused
Gold mining or gold processing	0 No 1 Yes 77 Don’t know 88 Refused
A job in which you or other people around you use lead	0 No 1 Yes 77 Don’t know 88 Refused
A job in which you or other people around you use mercury	0 No 1 Yes 77 Don’t know 88 Refused

10. In the past month, has anyone in your household other than yourself worked in…

Battery manufacturing or battery recycling	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
Electronic waste recycling	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
Gold mining or gold processing	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
A job in which they or their coworkers use lead	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household
A job in which they or their coworkers use mercury	0 No 1 Yes 77 Don’t know 88 Refused 99 No one else in the household

11. In the past months, have you or your household members used any pesticides, insecticides, or rat poison in or around your home?

₀ No ₁ Yes ₇₇ Don’t know ₈₈ Refused

12. In the past month, have you had any of the following genital tract infections or problems…?

Genital herpes	1 Yes 0 No 77 Don’t know 88 Refused
Gonorrhea or chlamydia	1 Yes 0 No 77 Don’t know 88 Refused
Bacterial vaginosis	1 Yes 0 No 77 Don’t know 88 Refused
Trichomonas	1 Yes 0 No 77 Don’t know 88 Refused
Genital tract infection (diagnosis unknown)	1 Yes 0 No 77 Don’t know 88 Refused

The next questions are about smoking, drug use, alcohol, and vitamin use.

13. In the past month, have you …?

Smoked cigarettes	1 Yes 0 No 77 Don’t know 88 Refused
Smoked marijuana	1 Yes 0 No 77 Don’t know 88 Refused
Used drugs such as crack, cocaine, or heroin to get high	1 Yes 0 No 77 Don’t know 88 Refused

14. In the past month, how many alcoholic drinks (such as beer, wine, or spirits) have you had in an average week?

₅ 14 drinks or more a week

₄ 7–13 drinks a week

₃ 4-6 drinks a week

₂ 1–3 drinks a week

₁ Less than 1 drink a week

₀ None

₇₇ Don’t know

₈₈ Refused

15. In the past month, have you regularly taken any vitamin supplements with or without folic acid?

₃ Yes, vitamins with folic acid

₂ Yes, vitamins without folic acid

₁ I took vitamins but I don’t know if there was folic acid in them

₀ No

₇₇ Don’t know

₈₈ Refused

These next few questions are about your recent sexual experiences.

16. In the past month, how often have you had vaginal sex with a man? Choose the best answer.

₁ Once a day or more

₂ Two or more times a week

₃ Once a week

₄ A few times a month

₅ Once a month

₆ Less than once a month

₇ Never

₇₇ Don’t know

₈₈ Refused

17. When you had sex in the past month, how often has your male partner used a condom?

₂ Always ₁ Sometimes ₀ Never ₇₈ Did not have sex

₇₇ Don’t know ₈₈ Refused

18. In the past month, have you…?

Received oral sex from someone	1 Yes 0 No 77 Don’t know 88 Refused
Performed oral sex on someone	1 Yes 0 No 77 Don’t know 88 Refused
Had anal sex	1 Yes 0 No 77 Don’t know 88 Refused

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