PR- ____ ____ - ____
Case-Control Study Questionnaire for the Investigation of
Severe Neurologic Illness in Relation to Arboviral Infections
Public reporting burden of this collection of information is estimated to average 15 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-XXXX)
Study ID Number PR- ____ ____ - ____ □ Case □ Control
The ID number begins with the 2 digit case number (for example PR01) followed by an “A” for the case patient, a “B” for the first control, and a “C” for the second control. For example, the second control subject matched for case number 8 would be labeled “PR-08-C.”
Interviewer: _______________________________ Date of Interview: __ __ /__ __ /______ MM DD YYYY
Neuro Symptom Onset Date for Case __ __ /__ __ /______ MM DD YYYY
Insert onset date into questions 10 and 11.
This questionnaire was conducted on: □ Directly with case or control □ Indirectly
If indirectly, with whom? _______________
T
Background and Demographics
Name: _________________________________________________________________________
Name Initial Last Name Maiden Name
a) Date of birth : __ __ /__ __ /______ Place of Birth: ________________________
MM DD AAAA
Phone numbers : _______________________________________
¿Are you a minor? □ Yes □ No
If the answer is “Yes,” name of father or legal guardian:
________________________________________________________________________
Name Initial Last Name Maiden Name
Current Address: _______________________________________________________/_______________________/____________
(Street) (Municipality) (Zip Code)
Postal Address: _______________________________________________________/_______________________/____________
(Street) (Municipality) (Zip Code)
Onset Address: _________________________________/__________________/__________________/___________
(for cases only if different from above; where cases spent most nights in the 2 months prior to neuro onset)
GPS Coordinates (onset for cases; current for controls): __ __. __ __ __ __ __ N, __ __ __. __ __ __ __ __ W
Sex: □ Male □ Female
a) Are you of Hispanic or Latino ethnicity? □ Yes □ No □ Don’t know □ Decline to answer
b) Race: □ American Indian/Alaskan Native □ Asian □ Black □ Hawaiian/Pacific Islander □ White □ Other: ___________________________ □ Decline to answer
Age when case developed first neuro symptoms (or equivalent date for controls): ______ years
What is your occupation? ________________________________________________
What form of health insurance do you have? □ Reforma/SSS □ Private □ Veteran’s □ Other □ None
a) ¿Es usted de origen hispano o latino? □ Sí □ No □ No sabe □ Se niega a responder
b) Raza: □ Indoamericana/nativa de Alaska □ Asiática □ Negra
□ Hawaiana/isleña del Pacífico □ Blanca □ Otra: __________________________ □ Se niega a responder
Edad en la que el caso presentó los primeros síntomas neurológicos (o fecha equivalente para los controles)
__ __M /__ __ D/______A ______ años
¿En qué trabaja? ________________________________________________
¿Qué tipo de seguro médico tiene? □ Reforma/SSS □ Privado □ Veteranos □ Otro □ Ninguno
Medical History
Have you ever 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 □ Rheumatologic disease
□ Asthma □ Cancer □ Chronic obstructive pulmonary disease (COPD)
□ Surgery (within 2 months of date of symptom onset) □ Other neurologic illness:__________________________
Do you take any medication (e.g., prednisone) or have any condition that might impact your ability to fight infections (e.g., immunological disorder):
□ Yes □ No If yes, please list: ______________________________________________
a) In the 2 months prior to __ __ /__ __ / 2016 (neuro onset date for case), have YOU been sick at all?
□ Yes □ No □ Unknown
b) If so, when did you first feel sick? __ __ /__ __ /_____
MM DD YYYY
c) If so, what symptoms did you have (check all that apply)?
□ Fever □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Abnormally red eyes
□ Headache □ Pain behind eyes □ Stiff neck □ Confusion
□ Abdominal pain □ Coughing □ Runny nose □ Sore throat
□ Calf pain
d) If so, did you see a doctor or go to the hospital for this illness?
□ Yes □ No □ Unknown
Which doctor? ________________________ Which hospital? _____________________________
e) If so, did they draw any blood for testing? □ Yes □ No □ Unknown
f) If so, were any other body fluids tested? □ Yes □ No □ Unknown
If yes, which? □ Urine □ Saliva □ Other_______________
a) In the 2 months prior to __ __ /__ __ / 2016 (neuro onset date for case), has anyone in your HOUSEHOLD
been sick at all?
□ Yes □ No □ Unknown
b) If so, when did the first household member become sick? __ __ /__ __ /_____
MM DD YYYY
c) If so, what symptoms did this household member have (check all that apply)?
□ Fever □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pain □ Joint pain □ Skin rash □ Abnormally red eyes
□ Headache □ Pain behind eyes □ Stiff neck □ Confusion
□ Abdominal pain □ Coughing □ Runny nose □ Sore throat
□ Calf pain
I would like to ask you some questions about vaccination. Do you have a vaccination record available?
□ Yes and shown to interviewer □ Yes, but not shown □ Information provided verbally
Which vaccinations have you received and when?
a) In the last 2 months, did you receive the influenza vaccine? □ Yes □ No □ Unknown
If yes, when? __ __ / __ __ /______
MM DD YYYY
b) Which other vaccinations have you received and when? __ __ / __ __ /______
MM DD YYYY
□ Vacunas en la niñez (no recuerdo cuáles)
i.) MMR __ __/__ __/______ Additional doses: ____________________
ii.) Polio __ __/__ __/______ ____________________
iii.) Yellow fever __ __/__ __/______ ____________________
iv.) BCG __ __/__ __/______ ____________________
v.) DTaP __ __/__ __/______ ____________________
vi.) HIB __ __/__ __/______ ____________________
vii.) Pneumococcal __ __/__ __/______ ____________________
viii.) Meningitis __ __/__ __/______ ____________________
ix.) Hep B __ __/__ __/______ ____________________
x.) Zoster/Shingles __ __/__ __/______ ____________________
x.) Other vaccines (e.g. rabies, Japanese encephalitis, etc.):
Which? ________________________________ __ __/__ __/______
Behavior and Environmental Exposures
For the remaining questions, I will ask about practices and behaviors over the past two months. Please think back over the past 2 months when answering to them.
What pets or other animals (e.g., farm animals) have lived in your house or on your property (check all that apply)?
□ Dogs □ Cats □ Mice/rats □ Pet birds □ Reptiles/amphibians
□ Goats □ Sheep □ Cows □ Chickens □ Pigs
□ Other __________________________________________
How often have you gotten your drinking water from the tap?
□ Almost always (>75%) □ Often (25-75%) □ Rarely (<25%) □ Never (0%)
If ever, was the water boiled or treated? □ Yes □ No □ Unknown
How often have you gotten your drinking water from a well or river/stream/pond?
□ Almost always (>75%) □ Often (25–75%) □ Rarely (<25%) □ Never (0%)
If ever, was the water boiled or treated? □ Yes □ No □ Unknown
How often do you walk around barefoot outside?
□ Almost always (>75%) □ Often (25–75%) □ Rarely (<25%) □ Never (0%)
Have you swam or waded in a freshwater river, stream, or pond?
□ Daily □ Weekly □ Monthly □ Rarely (<once per month) □ Never
How much time do you spend outdoors each day?
□ <1 hour □ 1–4 hours □ 5–8 hours □ >8 hours
Do you recall being bitten by a mosquito? □ Yes □ No □ Unknown
Do you normally wear insect repellant when outside?
□ Almost always (>75%) □ Often (25–75%) □ Rarely (<25%) □ Never (0%)
Do you leave the windows open at your house?
□ Yes, during the day □ Yes, at night □ Yes, all times □ Windows are not left open at this
house
How many of your windows or doors have intact screens?
□ All of them □ Some of them □ None of them
Does your home use any of the following for air conditioning?
□ Central air conditioning □ Local air conditioning (1–2 room) □ None
How often do you have sources of standing water around the outside of your house (e.g. buckets, water storage/cistern, septic tank, pond)?
□ Daily □ 2–3 times/week □ Once/week □ Every other week □ Never
Have you slaughtered animals and/or handled any dead animals?
□ Yes □ No □ Unknown
If yes, which? ________________________
Have you eaten or drunk any of the following foods at least once per week (check all that apply)?
□ Beef □ Lamb □ Chicken □ Fish □ Shellfish
□ Milk □ Cheese □ Yogurt □ Fresh salad /uncooked greens
Did you eat any of the following foods raw or undercooked (check all that apply)?
□ Beef □ Lamb □ Chicken □ Shellfish □ Fish (including ceviche)
| File Type | application/msword |
| File Title | Emergency Epidemic Investigations |
| Author | lmp2 |
| Last Modified By | Zirger, Jeffrey (CDC/OD/OADS) |
| File Modified | 2016-10-14 |
| File Created | 2016-05-05 |