ZEN Columbia - Male Partner Enrollment Questionnaire - E

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

Att B4 - Male Partner Enrollment_052517_CLEAN

Male Partners - Male 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: ___________________________


MALE PARTNER 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 0 None

77 Don’t know 88 Refused


3. 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


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


Name: ___________________________________________ 77 Don’t know 88 Refused


The next questions are about mosquito bites.


5. 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


6. 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 ankles and feet completely covered






Used mosquito repellant








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


7. 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


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


1 Yes 0 No 77 Don’t know 88 Refused


9. 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


10. How worried have you been about getting Zika virus during your partner’s current pregnancy?


3 Very worried 2 Somewhat worried 1 Not at all worried

77 Don’t know 88 Refused


11. 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 one of these means.



Very likely2

Somewhat likely1

Impossible0

Don’t know77

Refused88

Being bitten by an infected mosquito







Having vaginal sex with a woman 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







12. Momentarily, I will give you a number of statements about the possible 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 questions are about Zika symptoms you might have had.


13. 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?

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

D D M M M Y Y Y Y


14. 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


Next I’ll ask you some questions about your job.


15. 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

Shape4

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


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


Now I’ll ask you about your health.


16. Have you ever had…?


16a. Yellow fever


1 Yes 0 No 77 Don’t know 88 Refused

Shape5

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


16b. Dengue


1 Yes 0 No 77 Don’t know 88 Refused

Shape6

When?


Less than 3 months ago

Shape71 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

Shape81 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

Shape91 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

Shape101 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

Shape111 Yes

0 No

77 Don’t know

88 Refused

Was it hemorrhagic?


1 Yes 0 No 77 Don’t know 88 Refused


16c. Chikungunya


1 Yes 0 No 77 Don’t know 88 Refused

Shape12

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


17. Have you ever been vaccinated for yellow fever?


1 Yes 0 No 77 Don’t know 88 Refused


18. In the past 3 months, have you smoked cigarettes?


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.


19. In the past 3 months, how many women have you had sex with?


0 None End of questionnaire

1 1

2 2

3 3 or more

77 Don’t know End of questionnaire

88 Refused End of questionnaire


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


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

2 2-6 times a week

3 Once a week (4 times per month)

4 2-3 a month

5 Once a month

6 Less than once a month

0 Never Go to question #22

77 Don’t know Go to question #22

88 Refused Go to question #22


21. When you had vaginal sex in the past 3 months, how often have you used a condom?


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


22. 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


23. Since you found out that your partner was pregnant, have you changed how often you use condoms during sex with your partner?

1 Yes, I use them more often

2 Yes, I use them less often

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

4 No, we don’t use condoms

0 I haven’t had regular sex with my partner

77 Don’t know

88 Refused


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


Page 1 of 11

Appendix F5, version 19/MAY/2017


CDC estimates the average public reporting burden for this collection of information as 25 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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AuthorLisa Haddad
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