ZEN Colombia: Infant Symptoms - English

STUDY ID: __________ -___-______________________ Form Approved

OMB No. 0920-1190

Date: __ __/__ __ __ /__ __ __ __ Exp. Date 07/31/2019

D D M M M Y Y Y Y

Staff Administered: ___________________________

INFANT Symptoms Questionnaire

City: ______________________________________________

Clinic: _____________________________________________

• Interviewer instructions: If this is the first study visit, say “Since your baby was born” instead of “Since your baby’s first study visit”.

Let’s first update your baby’s insurance information.

1. What type of health insurance does your baby 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 baby’s health insurance provider?

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

Now we have some questions about feeding your baby.

3. How are you currently feeding your baby?

Breast milk at the breast	1 Yes 0 No 77 Don’t know 88 Refused
Breast milk from a bottle	1 Yes 0 No 77 Don’t know 88 Refused
Infant formula from a bottle	1 Yes 0 No 77 Don’t know 88 Refused
Solid foods	1 Yes 0 No 77 Don’t know 88 Refused
Milk or other nutrition through a feeding tube or intravenously	1 Yes 0 No 77 Don’t know 88 Refused

4. Have you noticed your baby having any difficulty related to feeding?

Excessive spitting up	1 Yes 0 No 77 Don’t know 88 Refused
Excessive drooling	1 Yes 0 No 77 Don’t know 88 Refused
Gagging/retching/coughing	1 Yes 0 No 77 Don’t know 88 Refused
Difficulty swallowing	1 Yes 0 No 77 Don’t know 88 Refused
Difficulty latching to the breast	1 Yes 0 No 77 Don’t know 88 Refused 99 Not Applicable
Difficulty sucking at the breast or bottle	1 Yes 0 No 77 Don’t know 88 Refused 99 Not Applicable
Arching back/squirming away	1 Yes 0 No 77 Don’t know 88 Refused
Other: _______________________	1 Yes 0 No 77 Don’t know 88 Refused

5. How many hours per day would you say your baby cries, on average:

₀ <1 hour ₁ 1-3 hours ₂ 3-6 hours ₃ 6-9 hours ₄ 9-12 hours ₅ >12 hours

₇₇ Don’t know ₈₈ Refused

6. Since your baby’s last study visit, did you seek medical care for your baby at a health facility other than [study health facility name]?

₁ Yes  Go to question #6a

₀ No  Go to question #7

₇₇ Don’t know  Go to question #7

₈₈ Refused  Go to question #7

6a. If YES, fill in the table below:
Reason		Date of visit
Because your baby was sick (for example, a fever, rash, etc.)	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Tests
Cranial ultrasound	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
MRI	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
CAT scan	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Hearing screening	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Vision screening	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Other:_____________	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Providers
Pediatrician	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Occupation/physical therapy	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Neurologist	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Gastroenterologist	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Other:______________	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	__ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
Hospitalization	1 Yes (Clinic name:__________________) 0 No 77 Don’t know 88 Refused	Date of admission: __ __/__ __ __ /__ __ __ __ D D M M M Y Y Y Y 77 Don’t know 88 Refused
6b. If YES, did a medical provider tell you that your baby might have any of the following?
Zika virus	1 Yes 0 No 77 Don’t know 88 Refused
Dengue	1 Yes 0 No 77 Don’t know 88 Refused
Chikungunya	1 Yes 0 No 77 Don’t know 88 Refused
Mayaro	1 Yes 0 No 77 Don’t know 88 Refused
Yellow Fever	1 Yes 0 No 77 Don’t know 88 Refused
Cytomegalovirus	1 Yes 0 No 77 Don’t know 88 Refused
Rubella	1 Yes 0 No 77 Don’t know 88 Refused
Toxoplasmosis	1 Yes 0 No 77 Don’t know 88 Refused
Syphilis	1 Yes 0 No 77 Don’t know 88 Refused
Chicken Pox	1 Yes 0 No 77 Don’t know 88 Refused
Parvovirus	1 Yes 0 No 77 Don’t know 88 Refused
Herpes	1 Yes 0 No 77 Don’t know 88 Refused
Other	1 Yes, specify: ______________________ 0 No 77 Don’t know 88 Refused

7. Since your baby’s last study visit, has your baby had any of the following symptoms?

Fever	1 Yes 0 No 77 Don’t know 88 Refused
Rash (not a diaper rash)	1 Yes 0 No 77 Don’t know 88 Refused
Red eyes lasting more than 2 hours	1 Yes 0 No 77 Don’t know 88 Refused
Joint pain (difficulty in moving)	1 Yes 0 No 77 Don’t know 88 Refused
Vomiting	1 Yes 0 No 77 Don’t know 88 Refused
Coughing	1 Yes 0 No 77 Don’t know 88 Refused
Sneezing	1 Yes 0 No 77 Don’t know 88 Refused
Runny nose	1 Yes 0 No 77 Don’t know 88 Refused
Swollen lymph nodes	1 Yes 0 No 77 Don’t know 88 Refused
Sleeping more than usual	1 Yes 0 No 77 Don’t know 88 Refused
Not feeding as much as usual	1 Yes 0 No 77 Don’t know 88 Refused
Skin redness without a rash	1 Yes 0 No 77 Don’t know 88 Refused
Blood in the urine	1 Yes 0 No 77 Don’t know 88 Refused
Nosebleeds	1 Yes 0 No 77 Don’t know 88 Refused

• If the participant answered YES to fever, rash, red eyes, or joint pain go to question #8.

• If not, go to question #11.

8. If participant said “Yes” to fever in question # 7:

8a. When your baby had a fever, what was the highest temperature he/she had?	____________ degrees Celsius 77 Don’t know 88 Refused
8b. When did you first notice the fever?	__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused
8c. How many days did it last?	_________ days 66 Still ongoing 77 Don’t know 88 Refused

9. If participant said “Yes” to rash in question # 7:

9a. When your baby had a rash, did it seem itchy?	1 Yes 0 No 77 Don’t know 88 Refused
9b. Was the rash bumpy?	1 Yes 0 No 77 Don’t know 88 Refused
9c. Where did you first see the rash?
Face	1 Yes 0 No 77 Don’t know 88 Refused
Neck	1 Yes 0 No 77 Don’t know 88 Refused
Chest	1 Yes 0 No 77 Don’t know 88 Refused
Stomach	1 Yes 0 No 77 Don’t know 88 Refused
Arms	1 Yes 0 No 77 Don’t know 88 Refused
Hands	1 Yes 0 No 77 Don’t know 88 Refused
Back	1 Yes 0 No 77 Don’t know 88 Refused
Legs	1 Yes 0 No 77 Don’t know 88 Refused
Feet	1 Yes 0 No 77 Don’t know 88 Refused
Buttocks/genital area	1 Yes 0 No 77 Don’t know 88 Refused
9d. To which parts of the body did the rash spread?
Face	1 Yes 0 No 77 Don’t know 88 Refused
Neck	1 Yes 0 No 77 Don’t know 88 Refused
Chest	1 Yes 0 No 77 Don’t know 88 Refused
Stomach	1 Yes 0 No 77 Don’t know 88 Refused
Arms	1 Yes 0 No 77 Don’t know 88 Refused
Hands	1 Yes 0 No 77 Don’t know 88 Refused
Back	1 Yes 0 No 77 Don’t know 88 Refused
Legs	1 Yes 0 No 77 Don’t know 88 Refused
Feet	1 Yes 0 No 77 Don’t know 88 Refused
Buttocks/genital area	1 Yes 0 No 77 Don’t know 88 Refused
9d. When did you first notice the rash?	__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused
9e. How many days did it last?	_________ days 66 Still ongoing 77 Don’t know 88 Refused

10. If participant said “Yes” to red eyes in question #7:

10a. Were both eyes red or just one?	2 Both 1 Only one 77 Don’t know 88 Refused
10b. Was there any discharge? (Fluid or pus coming from the eye)	1 Yes 0 No 77 Don’t know 88 Refused
10c. When did you first notice your baby’s eyes were red?	__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused
10d. How many days did it last?	_________ days 66 Still ongoing 77 Don’t know 88 Refused

11. If participant said “Yes” to joint pain in question #7:

11a. When did you first notice the joint pain?	__ __/__ __ __ /__ __ __ __ 77 Don’t know D D M M M Y Y Y Y 88 Refused
11c. How many days did it last?	_________ days 66 Still ongoing 77 Don’t know 88 Refused
11d. Where did you notice the joint pain?
Arms	1 Yes 0 No 77 Don’t know 88 Refused
Legs	1 Yes 0 No 77 Don’t know 88 Refused
Other	1 Yes, specify: __________________________ 0 No 77 Don’t know 88 Refused

12. Since your baby’s last study visit, did your baby have any other unusual symptoms you would like to tell me about?

₁ Yes  What symptoms? _____________________________________________________

₀ No

₇₇ Don’t know

₈₈ Refused

13. Since your last study visit, have you or your baby enrolled in another Zika Virus study?

₁ Yes, I did  Which study? _______________________________________________

₂ Yes, my baby did  Which study? _______________________________________________

₃ Yes, my baby and I did  Which study? _____________________________________________

₀ No

₇₇ Don’t know

₈₈ Refused

Thank you for completing this questionnaire. Please let me know if you have any questions.

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Appendix F4, version 19/MAY/2017

CDC estimates the average public reporting burden for this collection of information as 10 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).