Baseline and Follow-Up Questionnaire - English

Form Approved

OMB Control No. 0920-1140

Exp. Date: 10/31/2017

Attachment H. Baseline and follow-up questionnaires

#	Question	Options	Skip
Section A. Visit information Interviewer: Answer A1-A4. Do not read.
A1	ZIP#	_ _ _ _ - _ _
A2	Date	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
A3	Visit code	V01 V02 V03 V04 S06 M02 S10 S12 S14 M04 S18 S20 S22 S24 M06	If (A3 ne V01) skip to B2. If A3=V01, continue to A4a.
A4	Interviewer: do not read question; answer it yourself. Is this a household contact?	0, No 1, Yes	If no (0), skip to A6. If yes (1), continue to A4a.
Household contacts INTERVIEWER: If household contact ask A4a. Otherwise, go to A5.
A5	What is your relationship with the person who gave you a coupon?	1, Spouse, significant other, or partner. 2, Parent. 3, Son/daughter. 4, Sibling 5, Grandmother/grandfather 6, Other. 7, Someone who lives with me but we are not family. 99, Do not know 77, Refused to answer	If 1, continue to A5a. Else, skip to A6.
A5a	Have you had sex with this person in the last 30 days?	0, No 1, Yes 99, Do not know 77, Refused to answer
INTERVIEWER: If V01 continue to A6. Other, go to B2. Participant information
A6	Age INTERVIEWER: If age <1 years enter “0”.	___ [0-100]
A7	What is your date of birth?	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
A8	What is your sex?	1, Male 2, Female 99, Do not know 77, Refused to answer	If male (1) or <14, skip to A9. Else, continue to A8a.
A9	Have you visited the United States or another country in the last 30 days?	0, No 1, Yes 99, Do not know 77, Refused to answer	If yes (1), continue to A9a. Else, skip to B1.
A9a	City	______________
A9b	Country	______________
A9c	Start Date	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
A9d	End date	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
A10	2nd city	_______________	If 2nd city, continue to A10a. Else, skip to B1.
A10a	2nd country	_______________
A10b	2nd Start Date	_ _ / _ _ / _ _ _ _ dd/mm/ yyyy
A10c	2nd End date	_ _ / _ _ / _ _ _ _ dd/mm/y yyyy
A11	3rd city	_______________	If 3rd city, continue to A11a. Else, skip to B1.
A11a	3rd country	_______________
A11b	3rd Start Date	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
A11c	3rd End date	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
Section B. Clinical Information
B1	Since November 2015 have you had any of the following? Rash, fever, arthralgia and conjunctivitis INTERVIEWER: Read all the options, except 99 and 77	0, No 1, Yes 99, Do not know 77, Refused to answer	If B1=0 (no) and A2=V01, skip to C1. If B1=0 (no) and A2 not V01, end survey. Else, continue to B2.
B2	Do you have any of these symptoms now?	0, No 1, Yes 99, Do not know 77, Refused to answer	If (A2 ne V01 or B1=0) and B2=0, skip to D4. Else, continue to B3.
B3	Which was your first symptom? INTERVIEWER: Read all the options, except 99 and 77	1, Fever 2, Rash 3, Arthralgia 4, Conjunctivitis 5, Other 99, Do not know 77, Refused to answer
B3a	Date you had the first symptom	_ _ / _ _ / _ _ _ _ dd/mm/yyyy
INTERVIEWER: READ: “Now I'll ask you about a list of symptoms. Tell me if you have had these symptoms since his illness began on the date he gave me. If you have any of these symptoms, I will ask for how many days you have had the symptom.”
B4	Fever	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B5. Else, continue to B4a.
B4a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B5	Rash	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B6. Else, continue to B5a.
B5a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B5b	Type INTERVIEWER: Do not read choices. Show flashcard B5 and enter the number with the corresponding picture.	1, Maculopapular 2, Petechial 3, Purpura 4, Other	If other (4), continue to B5c. Else, skip to B6.
B5c	Other rash description:	______________
B6	Eye pain	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B7. Else, continue to B6a.
B6a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B7	Cough	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B8. Else, continue to B7a.
B7a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B8	Red eye	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B9. Else, continue to B8a.
B8a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B9	Headache	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B10. Else, continue to B9a.
B9a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B10	Intolerance to light	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B11. Else, continue to B10a.
B10a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B11	Yellow eyes or skin	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B12. Else, continue to B11a.
B11a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B12	Enlarged lymph nodes INTERVIEWER: Flashcard GANGLIOS.	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B13. Else, continue to B12a.
B12a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B13	Diarrhea	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B14. Else, continue to B13a.
B13a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B14	Nausea	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B15. Else, continue to B14a.
B14a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B15	Vomiting	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B16. Else, continue to B15a.
B15a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B16	Itching	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B17. Else, continue to B16a.
B16a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B17	Swelling	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B18. Else, continue to B17a.
B17a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B18	Pain or burning with urination	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B19. Else, continue to B18a.
B18a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B19	Difficulty urinating	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B20. Else, continue to B19a.
B19a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B20	Pelvic or groin pain	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B21. Else, continue to B20a.
B20a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B21	Abdomen/lower back pain	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B22. Else, continue to B21a.
B21a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B22	Blood in urine	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B23. Else, continue to B22a.
B22a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B23	Blood in stool	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0) AND age ≥13 (A6 ≥13) AND male (A8=1), skip to B24. If Yes (1), continue to B23a. Else, skip to B27.
B23a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)	If no (0) AND age ≥13 (A6 ≥13) AND male (A8=1), continue to B24. Else, skip to B27.
B24	Painful ejaculation	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B25. Else, continue to B24a.
B24a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B25	Penile discharge	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B26. Else, continue to B25a.
B25a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B26	Blood in semen	0, No 1, Yes 99, Do not know 77, Refused to answer	If no (0), skip to B27. Else, continue to B26a.
B26a	Duration in days INTERVIEWER: if symptom started the day of the interview, enter “0”.	__ (0-100)
B27	Other INTERVIEWER: write in any other symptoms	Testicular Pain _ 0, No 1, Yes 99, Do not know 77, Refused to answer Other:______________________
INTERVIEWER: If V01 (baseline) continue a C1. Other go to D1. Section C. Demographics and household
C1	What is your current marital status? Choose one. INTERVIEWER: Read all the options, except 99 and 77	1, N/A (e.g. child) 2, Married 3, Living together as married 4, Separated 5, Divorced 6, Widowed 7, Never married 99, Do not know 77, Refused to answer
C2	What is the highest level of education you completed? INTERVIEWER: Read all the options, except 99 and 77	0, No school 1, Grades 1 through 5 2, Grades 6 through 8 3, Grades 9 through 12 4, High school diploma / GED 5, Some college, Associate’s or Technical Degree 6, Bachelor’s Degree 7, Any post graduate studies 99, Do not know 77, Refused to answer
C3	What best describes your employment status? Are you: INTERVIEWER: Read all the options, except 99 and 77	0, N/A (child) 1, Employed full-time 2, Employed part-time 3, Informal or casual work 4, A homemaker 5, A full-time student 6, Retired 7, Unable to work for health reasons 8. Unemployed 9. Other 99, Do not know 77, Refused to answer
C4	How much time during the day do you spend outdoors? INTERVIEWER: Read all the options, except 99 and 77	0, Very little to none 1, Many hours 2, All day 99, Do not know 77, Refused to answer	If contact (A4=1), skip to C7. Else, continue to C5.
C5	What was your household income last year from all sources before taxes? INTERVIEWER: Use flashcard.	1, $0 – $9,999 2, $10,000 – $19,999 3, $20,000 – $29,999 4, $30,000 – $39,999 5, $40,000 – $49,999 6, $50,000 – $59,999 7, $60,000 – $79,999 8, $80,000 or more 99, Do not know 77, Refused to answer
C6	How many people live in your household, including yourself? Household means all of the people that you live with.	__
C7	Do you currently have health insurance or health care coverage?	1, Yes 0, No 99, Do not know 77, Refused to answer	If contact (A4=1), skip to C12. Else, continue to C8.
C8	How many of the windows in your house have intact screens? INTERVIEWER: Read all the options, except 99 and 77	1, None 2, Some 3, All 99, Do not know 77, Refused to answer
C9	Do you use air conditioning in your home? INTERVIEWER: Read all the options, except 99 and 77	0, No 1, Yes, in all the rooms 2, Yes, only in the bedrooms 99, Do not know 77, Refused to answer
C10	How often do you leave your doors or windows open? INTERVIEWER: Read all the options, except 99 and 77	Never Daytime only Night-time only Always Other 99, Do not know 77, Refused to answer
C11	In the past 30 days, have you used mosquito coils (e.g., Cobra, espiral, caracol) OR natural repellents in your house or patio to keep mosquitoes away?	0, No 1, Yes 99, Do not know 77, Refused to answer
C12	In the past 30 days, how often have you used mosquito repellent?	0, Never 1, Every now and then 2, A few times a week 3, Daily 4, Always 99, Do not know 77, Refused to answer
Section D. Adults and emancipated minors
INTERVIEWER: If adult or emancipated minor, continue to D4, else end the interview. I will ask you some questions about sexual and injection risk. You may refuse to answer any question.
D4	In the past 7 days, with how many different persons have you had oral, vaginal or anal sex?	____ [0-1000]	If 0 and male, skip to D7. Else, skip to D8.
D5	In the past 7 days, how many times have you had vaginal or anal sex?	____ [0-1000]	If 0 and male, skip to D7. Else, skip to D8.
D6	Of the [fill with “# of times engaged in sex” (q14)] times you had anal or vaginal sex, how many times did you or your partner use a condom?	____ [0-1000]	Continue to D6a.
D6a	In the past 7 days, how many times have you had oral sex without using a condom?	____ [0-1000]	If male, continue to D7. Else, skip to D8.
D7	For men only: In the past 7 days how many times have you ejaculated (had an orgasm) during sex or masturbation?	____ [0-1000]
D8	Have you ever in your life shot up or injected any drugs other than those prescribed for you? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.	0, No 1, Yes 99, Do not know 77, Refused to answer	If yes (1), continue to D9. Else, end survey.
D9	When was the last time you injected any drug? That is, how many days or months or years ago did you last inject? [Interviewer: Enter the number below. If today, enter "000" ]	0, Today 1, Last week 2, Last month 3, Last 6 months 4, Last year 5, More than a year ago 99, Do not know 77, Refused to answer
END OF SURVEY INTERVIEWER: Thanks for your time; we have finished the interview.
NOTAS

ZIPER Pregnancy Questions

V01 Pregnancy Section For all adult women and emancipated female minors, go to pregnancy section after last question in core survey.
#	Question	Choices	Skip
P1	Have you been pregnant since November 2015? This includes if you are currently pregnant, any live births, still births, miscarriage, fetal death, tubal pregnancies, and induced abortions. Miscarriage: refers to a pregnancy that terminates naturally during the first 5 months (20 weeks) of pregnancy. Stillbirth: Refers to a baby that is born dead after 6 or more months (>20 weeks). Tubal pregnancy: Refers to a pregnancy that occurs in the fallopian tube. Induced abortion: Refers to a pregnancy that is terminated during the first 6 months using induced methods.	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If NO (0), END SECTION. Else, continue to P2.
P2	Are you pregnant right now?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If NO, DON’T KNOW, or REFUSE (0, 77, 99), SKIP to P7. Else, continue to P3.
Currently pregnant only
P3	What was the first day of your last menstrual period?	DATE Don’t know 77 Refuse to answer 99
P4	How many weeks pregnant are you?	NUMBER Don’t know 77 Refuse to answer 99
P5	Doctor’s information Name, office, phone number	Name: Office: Tel: Any other notes:
P5	Have you been pregnant any other time since November 2015?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If NO, DON’T KNOW, or REFUSE (0, 77, 99), END pregnancy section. If YES (1), continue to P7.
Ever pregnant
P7	How many times have you been pregnant since November 2015? (If you are currently pregnant, do not include now.)	NUMBER Don’t know 77 Refuse to answer 99	If 0, check skip pattern and confirm. If 1, continue. If >1, say, “I am going to ask you about each pregnancy since November. The first time I ask you these questions, please answer based on the first time you were pregnant in that period. The second time, please answer based on the second time you were pregnant in that period. [Add third, fourth, etc. as needed.]” INTERVIEWER: Repeat “past pregnancy” the number of times.
Past pregnancy INTERVIEWER: If you are repeating this section, say, “Now we are going to talk about the first (second, third, fourth, etc.) time you were pregnant between November 2015 and now.”
P8	What was the outcome of the pregnancy? Miscarriage: refers to a pregnancy that terminates naturally during the first 5 months (20 weeks) of pregnancy. Stillbirth: Refers to a baby that is born dead after 6 or more months (>20 weeks). Tubal pregnancy: Refers to a pregnancy that occurs in the fallopian tube. Induced abortion: Refers to a pregnancy that is terminated during the first 6 months using induced methods.	Live birth 1 Still birth, miscarriage, or fetal death (baby died before being born) 2 Ectopic / tubal 3 Induced abortion 4 Other (describe) 5 Don’t know 77 Refuse to answer 99	If 1, skip to P11. If 2, “I am so sorry for your loss.” Skip to P10. If 3 or 4, skip to P10. If 5, continue to P9.
P9	Other (describe)
P10	How long did that pregnancy last?	__ __ number of weeks Don’t know 77 Refuse to answer 99	If repeat, go back to P8. Else, end survey.
P11	Are you lactating?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If yes (1), participant will be asked to give breastmilk.
P12	Are you currently breastfeeding?	No 0 Yes 1 Don’t know 77 Refuse to answer 99
	END SECTION Thank you for your time.

Follow-up visits

Follow-up Pregnancy Section For all adult women and emancipated female minors, go to pregnancy section after last question in core survey.
#	Question	Choices	Skip
PF1	Were you pregnant at our last visit?	No 0 Yes 1 Don’t know 77 Refuse to answer 99
PF2	Are you pregnant right now?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If PF1 = YES (1) and PF2 = YES (1), END SECTION. If PF1 = YES (1) and PF2 = NO (1), skip to ## (Outcomes). If PF1 = NO (0) and PF2 = YES (1), skip to PF4 (New pregnancy). IF PF1 = NO (0) and PF2 = NO (0), continue to PF3.
PF3	Were you pregnant between our last visit and now?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If YES (1), skip to ## (Outcomes). Else, END SECTION.
New pregnancy only
PF4	What was the first day of your last menstrual period?	DATE Don’t know 77 Refuse to answer 99
PF5	How many weeks pregnant are you?	NUMBER Don’t know 77 Refuse to answer 99
PF6	Doctor’s information Name, office, phone number	Name: Office: Tel: Any other notes:	END SECTION.
Outcomes
PF7	What was the outcome of the pregnancy?	Live birth 1 Still birth, miscarriage, or fetal death (baby died before being born) 2 Ectopic / tubal 3 Induced abortion 4 Other (describe) 5 Don’t know 77 Refuse to answer 99	If LIVE BIRTH (1), skip to PF10. If 2, “I am so sorry for your loss.” Skip to PF9. If 3 or 4, skip to PF9. If 5, continue to PF8.
PF8	Other (describe)		END SECTION. Thank you for your time.
PF9	How long did that pregnancy last?	Less than 20 weeks (less than 4 months) 1 20 to 28 weeks (4 to 6 months) 2 More than 28 weeks (more than 6 months) 3 Don’t know 77 Refuse to answer 99	END SECTION. Thank you for your time.
PF10	Are you lactating?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If yes (1), participant will be asked to give breastmilk.
PF11	Are you currently breastfeeding?	No 0 Yes 1 Don’t know 77 Refuse to answer 99
	END SECTION Thank you for your time.

Public reporting burden of this collection of information is estimated to average 10 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 0920-1140