ZEN Columbia - Pregnant Woman Follow-Up Questionnaire -

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 FOLLOW-UP Questionnaire

City: _______________________________________________________

Clinic: ______________________________________________________

First, I will update our information on your health insurance.

1. 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

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

Name: ___________________________________________ ₇₇ Don’t know ₈₈ Refused

Next, I will ask you some questions about mosquito bites.

3. 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

4. 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

5. 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

6. 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

7. How many adults and children, aside from you, live in your household?

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

• If she is the only person living in her house, go to question #10.

The next questions are about Zika virus.

8. Since your last study clinic visit, 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

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? _____________________________________

9. Since your last study clinic visit, has a doctor or healthcare provider ever told anyone in your household, other than you, 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

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.

10. Since your last study clinic visit, have you changed jobs?

₁ Yes ₀ No, I am still at my previous job ₆₆ No, I do not have a job ₇₇ Don’t know ₈₈ Refused

Have any of your jobs since your last study clinic visit involved the following:

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, or 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 or your coworkers use mercury	1 Yes 0 No 77 Don’t know 88 Refused

• If, according to question #7, this participant lives alone in her house, go to question #12.

11. Since your last study clinic visit, 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, or 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

12. Since your last study clinic visit, 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

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

13. Since your last study clinic visit, 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

14. Since your last study clinic visit, 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

15. Since your last study clinic visit, have you taken folic acid?

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

Are you still taking it?

₁ Yes ₀ No ₇₇ 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.

16. Since your last study clinic visit, 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

₀ Never  Go to question #18

₇₇ Don’t know  Go to question #18

₈₈ Refused  Go to question #18

17. When you had vaginal sex since your last study clinic visit, how often has your male partner used a condom?

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

18. Since your last study clinic visit, 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

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

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Appendix F3, version 19/MAY/2017

CDC estimates the average public reporting burden for this collection of information as 15 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).