ZEN Columbia - Pregnant Woman Enrollment Questionnaire -

ZEN Colombia Study: Zika in Pregnant Women and Children in Colombia

Att B2 - Maternal Enrollment_052517_CLEAN

Pregnant Women - Pregnant Women Enrollment Questionnaire

OMB: 0920-1190

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STUDY ID: __________ -___-______________________ Form Approved

OMB No. 0920-XXXX

Date: __ __/__ __ __ /__ __ __ __ Exp. Date xx/xx/20xx


D D M M M Y Y Y Y


Staff Administered: ___________________________


PREGNANT WOMAN Enrollment Questionnaire



City: _______________________________________________________


Clinic: ______________________________________________________



First, I will start with some questions about you.


1. What is your birthdate?


__ __/__ __ __ /__ __ __ __ 77 Don’t know 88 Refused

D D M M M Y Y Y Y


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


1 Less than primary 2 Primary 3 Secondary 4 Technical 5 University or more 6 None

77 Don’t know 88 Refused


3. What is your household’s socioeconomic stratum?


1 1 2 2 3 3 4 4 5 5 6 6 77 Don’t know 88 Refused


4. What type of health insurance do you have?


1 Contributory 2 Subsidized 3 Not insured 4 Specialized 5 Exception

6 Indeterminate / independent 77 Don’t know 88 Refused


5. What is the name of your health insurance provider?


Name: ___________________________________________ 77 Don’t know 88 Refused


6. How many adults and children live in your household, including yourself?


______ adults (18+ years) ______ children (<18 years) 77 Don’t know 88 Refused


7. What is your marital status?


1 Married 2 Free Union 3 Single, divorced, or widowed 4 Other, specify: ______________

77 Don’t know 88 Refused


8. Do you live in the same household as your husband or male partner?


1 Yes 0 No 66 I don’t have a husband or a male partner 77 Don’t know 88 Refused



The next questions are about mosquito bites.


9. 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


10. In the past 7 days, how often have you done the following things? Response options include never, some of the time, or always.



Never0

Some of the time1

Always2

Don’t know77

Refused88

Worn long pants that covered your legs







Worn shirts or jackets with long sleeves that covered your arms






Kept your feet and ankles completely covered






Used mosquito repellant








11. 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 Always 0 I don’t have air conditioning

77 Don’t know 88 Refused


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


2 Yes, on all windows and doors 1 Some 0 None 77 Don’t know 88 Refused


The next questions are about what you might have heard about Zika virus.


13. Do you think it’s possible for a person to get Zika virus in your community?


1 Yes 0 No 77 Don’t know 88 Refused


14. Do you think that everybody with Zika virus has symptoms?


1 Yes 0 No 77 Don’t know 88 Refused


15. Do you know anyone who has had Zika virus?


1 Yes 0 No 77 Don’t know 88 Refused

Shape1

Have you had Zika virus?


1 Yes 0 No 77 Don’t know 88 Refused


16. How worried have you been about getting Zika virus during this pregnancy?

3Very worried 2 Somewhat worried 1 Not at all worried

77 Don’t know 88 Refused

17. Momentarily, I will give you a number of statements about Zika virus; we ask that you respond if you consider it to be “very likely”, “somewhat likely”, or “impossible” that Zika can be transmitted by any of these means.



Very likely2

Somewhat likely1

Impossible0

Don’t know77

Refused88

Being bitten by an infected mosquito







Having vaginal sex with a man who has Zika without using a condom






Kissing someone on the mouth who has Zika







Shaking hands with someone who has Zika







Being coughed or sneezed on by someone who has Zika






Receiving a blood transfusion with Zika in it







Being in utero if a mother has Zika during pregnancy







18. Momentarily, I will give you a number of statements about the possible side effects on a baby if their mother was infected with Zika during her pregnancy; we ask that you respond if you consider it to be “very likely”, “somewhat likely”, or “impossible” that a baby could be born with the following conditions:



Very likely2

Somewhat likely1

Impossible0

Don’t know77

Refused88

Microcephaly (a small sized head)






Other birth defects






Intrauterine growth restriction (small baby)






Miscarriages/stillbirths







The next few questions are about Zika symptoms that you or your family might have had.


19. In the past 3 months, have you had symptoms of Zika virus? Symptoms of Zika virus means being sick with 2 or more of fever, rash, red eyes, and joint pain that are not explained by other causes.


1 Yes 0 No 77 Don’t know 88 Refused

Shape2

When did these symptoms first start?


__ __/__ __ __ /__ __ __ __ 77 Don’t know 88 Refused

D D M M M Y Y Y Y


20. At any time, has a doctor or healthcare provider ever told you that you might have Zika virus?


1 Yes 0 No 77 Don’t know 88 Refused

Shape3

When?

__ __/__ __ __ /__ __ __ __ 77 Don’t know 88 Refused

D D M M M Y Y Y Y


  • If according to question #6, this participant lives alone in her house, go to question #23.


21. In the past 3 months, 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 77 Don’t know 88 Refused

Shape4

Was it…


Your husband or partner?

1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused

Your child?

1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused

Another person in the household?

1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused


If yes:,Who was it? _____________________________________


22. 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 77 Don’t know 88 Refused

Shape5

Was it…


Your husband or partner?

1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused

Your child?

1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused

Another person in the household?

1 Yes 0 No 66 Not applicable 77 Don’t know 88 Refused


If yes:,Who was it? _____________________________________


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


23. Where do you usually get your drinking water? (Select all that apply.)

Public or private water utility

1 Yes 0 No 77 Don’t know 88 Refused

Well

1 Yes 0 No 77 Don’t know 88 Refused

Cistern or tank

1 Yes 0 No 77 Don’t know 88 Refused

Bottled water

1 Yes 0 No 77 Don’t know 88 Refused

Lake, river, or other natural source

1 Yes 0 No 77 Don’t know 88 Refused

Another water source, specify:




24. In the past 3 months, have you worked at a job? Include jobs in which you don’t have a formal employer, such as selling goods or providing services.


1 Yes 0 No 77 Don’t know 88 Refused

Shape6

Have any of your jobs in the past 3 months involved:

X-rays

1 Yes 0 No 77 Don’t know 88 Refused

Contact with body fluids such as urine, saliva, or blood

1 Yes 0 No 77 Don’t know 88 Refused

Applying pesticides, insecticides, or rat poison

1 Yes 0 No 77 Don’t know 88 Refused

Battery manufacturing or battery recycling

1 Yes 0 No 77 Don’t know 88 Refused

Electronic waste recycling

1 Yes 0 No 77 Don’t know 88 Refused

Gold mining or gold processing

1 Yes 0 No 77 Don’t know 88 Refused

Other metal mining (for example: uranium, nickel, cobalt)

1 Yes 0 No 77 Don’t know 88 Refused

A job in which you or your coworkers use lead

1 Yes 0 No 77 Don’t know 88 Refused

A job in which you your coworkers use mercury

1 Yes 0 No 77 Don’t know 88 Refused


  • If according to question #6, this participant lives alone in her house, go to question #26.


25. In the past 3 months, has anyone in your household other than yourself worked in the following jobs?


Battery manufacturing or battery recycling

1 Yes 0 No 77 Don’t know 88 Refused

Electronic waste recycling

1 Yes 0 No 77 Don’t know 88 Refused

Gold mining or gold processing

1 Yes 0 No 77 Don’t know 88 Refused

Other metal mining (for example: uranium, nickel, cobalt)

1 Yes 0 No 77 Don’t know 88 Refused

A job in which they or their coworkers use lead

1 Yes 0 No 77 Don’t know 88 Refused

A job in which they or their coworkers use mercury

1 Yes 0 No 77 Don’t know 88 Refused


26. In the past 3 months, have you or your household members used any pesticides, insecticides, or rat poison in or around your home?


1 Yes 0 No 77 Don’t know 88 Refused



Now I’ll ask you about medical conditions you might have had.


27. Have you ever had…?


27a. Yellow fever


1 Yes 0 No 77 Don’t know 88 Refused

Shape7

When?

Less than 3 months ago

1 Yes 0 No 77 Don’t know 88 Refused

Between 3-6 months ago

1 Yes 0 No 77 Don’t know 88 Refused

7-12 months ago

1 Yes 0 No 77 Don’t know 88 Refused

13 months-5 years ago

1 Yes 0 No 77 Don’t know 88 Refused

More than 5 years ago

1 Yes 0 No 77 Don’t know 88 Refused

27b. Dengue


1 Yes 0 No 77 Don’t know 88 Refused

Shape8

When?


Less than 3 months ago

Shape91 Yes

0 No

77 Don’t know

88 Refused

Was it hemorrhagic?


1 Yes 0 No 77 Don’t know 88 Refused

Between 3-6 months ago

Shape101 Yes

0 No

77 Don’t know

88 Refused

Was it hemorrhagic?


1 Yes 0 No 77 Don’t know 88 Refused

7-12 months ago

Shape111 Yes

0 No

77 Don’t know

88 Refused

Was it hemorrhagic?


1 Yes 0 No 77 Don’t know 88 Refused

13 months-5 years ago

Shape121 Yes

0 No

77 Don’t know

88 Refused

Was it hemorrhagic?


1 Yes 0 No 77 Don’t know 88 Refused

More than 5 years ago

Shape131 Yes

0 No

77 Don’t know

88 Refused

Was it hemorrhagic?


1 Yes 0 No 77 Don’t know 88 Refused



27c. Chikungunya


1 Yes 0 No 77 Don’t know 88 Refused

Shape14

When?

Less than 3 months ago

1 Yes 0 No 77 Don’t know 88 Refused

Between 3-6 months ago

1 Yes 0 No 77 Don’t know 88 Refused

7-12 months ago

1 Yes 0 No 77 Don’t know 88 Refused

13 months-5 years ago

1 Yes 0 No 77 Don’t know 88 Refused

More than 5 years ago

1 Yes 0 No 77 Don’t know 88 Refused


28. Have you ever been vaccinated for yellow fever?


1 Yes 0 No 77 Don’t know 88 Refused


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


29. In the past 3 months, 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

1 Yes 0 No 77 Don’t know 88 Refused


30. In the past 3 months, how many alcoholic drinks (such as beer, wine, or others) have you had in an average week?


6 I drank, but I don’t know how much

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


31. In the past 3 months, have you taken folic acid?


1 Yes 0 No 77 Don’t know 88 Refused

Shape15

31a. When did you start taking it?


1 Before I found out I was pregnant

0 After I found out I was pregnant

77 Don’t know

88 Refused


31b. Are you currently taking folic acid?


1 Yes 0 No 77 Don’t know 88 Refused

The next questions are about your pregnancies.


32. What was your weight when you got pregnant?


_______ kg 77 Don’t know 88 Refused


33. What is your height?


________cm 77 Don’t know 88 Refused


34. How many total pregnancies have you had (not including this pregnancy)? (All previous pregnancies, including miscarriages):


_________ number of pregnancies 77 Don’t know 88 Refused


  • If participant responds “zero”, go to question #39.


35. Did any of these pregnancies have more than one fetus, such as twins or triplets?


1 Yes 0 No 77 Don’t know 88 Refused

Shape16

How many pregnancies had more than one fetus?


______ number of pregnancies 77 Don’t know 88 Refused


36. In how many of your previous pregnancies (not including this pregnancy) did you have…?

Live birth


________ number of live births
77 Don’t know 88 Refused

Miscarriage (loss before 20th week)


________ number of miscarriages (loss before 20th week)
77 Don’t know 88 Refused

Stillbirth (loss at or after the 20th week)


________ number of stillbirths (loss at or after the 20th week)
77 Don’t know 88 Refused

Abortion


________ number of abortions
77 Don’t know 88 Refused

Ectopic or molar pregnancy


________ number of ectopic or molar pregnancies
77 Don’t know 88 Refused


37. During your previous [pregnancy/pregnancies], in how many pregnancies (not including this pregnancy)…?


Did your doctor tell you that you had pre-eclampsia (high blood pressure in pregnancy)


__________ number of pregnancies with with pre-eclampsia

77 Don’t know 88 Refused

Did your doctor tell you that you had gestational diabetes (diabetes diagnosed in pregnancy)


__________ number of pregnancies with gestational diabetes

77 Don’t know 88 Refused

Did you have a premature birth (delivery before 37 weeks)


__________ number of premature births

77 Don’t know 88 Refused

Did you have a baby who was born weighing less than 2500g, or 2.5 kg


__________ number of babies with low birth weight

77 Don’t know 88 Refused

Did you have a Cesarean section


__________ number of Cesarean sections

77 Don’t know 88 Refused

Did you breastfeed your baby


__________ number of babies breastfed

77 Don’t know 88 Refused


38. When did your last pregnancy end?


__ __/__ __ __ /__ __ __ __ 77 Don’t know 88 Refused

D D M M M Y Y Y Y

39. For your current pregnancy, when was your last menstrual period?


__ __/__ __ __ /__ __ __ __ 77 Don’t know 88 Refused

D D M M M Y Y Y Y


Shape17

How sure are you about the date of your last menstrual period?


0 Not sure 1 Sure 77 Don’t know 88 Refused

40. Did you use any fertility treatments to help you get pregnant?


1 Yes 0 No 77 Don’t know 88 Refused

Shape18

Did you use…?


Medicine for ovarian stimulation, such as clomiphene citrate or Femara

1 Yes 0 No 77 Don’t know 88 Refused

Intrauterine insemination

1 Yes 0 No 77 Don’t know 88 Refused

In vitro fertilization (IVF)

1 Yes 0 No 77 Don’t know 88 Refused

Intracytoplasmic sperm injection

1 Yes 0 No 77 Don’t know 88 Refused


41. Thinking back to right before you became pregnant, which of these statements best describes how you felt about being pregnant?


4 I wanted to be pregnant sooner

3 I wanted to be pregnant later

2 I wanted to be pregnant then

1 I didn’t want to be pregnant then or at any time in the future

77 I don’t know

88 Refused


These next few questions are about your recent sexual experiences. You do not have to answer any questions if they make you uncomfortable.


42. In the past 3 months, how many men have you had sex with?


0 None This is the end of the questionnaire.

1 1

2 2
3 3 or more

77 Don’t know This is the end of the questionnaire.

88 Refused This is the end of the questionnaire.


43. In the past 3 months, how often have you had vaginal sex with a man? Choose the best answer.


1 Once a day or more (About 7 times or more per week)

2 2-6 times a week

3 Once a week (About 4 times per month)

4 2-3 a month

5 Once a month

6 Less than once a month

0 Never Go to question #46

77 Don’t know Go to question #46

88 Refused Go to the question #46


44. When you had vaginal sex in the past 3 months, how often has your male partner used a condom?


2 Always 1 Sometimes 0 Never 77 Don’t know 88 Refused


45. In the past 3 months, 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


46. Since you found out that you were pregnant, have you and your male partner changed how often you use condoms during sex?


1 Yes, we use them more often

2 Yes, we use them less often

3 No, we haven’t changed how often we use condoms

4 No, we don’t use condoms

0 I haven’t had regular sex with a male partner

77 Don’t know

88 Refused



Thank you for answering the questionnaire. Do you have any questions?



Page 1 of 21

Appendix F1, version 19/MAY/2017


CDC estimates the average public reporting burden for this collection of information as 35 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-XXXX).


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