Form noen Monthly Tick Encounter Survey

June 2017 Monthly Tick Encounter Survey

* 1. Please enter your BITM Study ID number. If you do not know your BITM Study ID number, please
contact your state BITM Study Coordinator (for CT: Rayda Krell, [email protected], or for RI:
Steve Engborg, [email protected]), or enter your street address and state.

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June 2017 Monthly Tick Encounter Survey

* 2. In the past month, has anyone living in your household (including yourself) found tickscrawling (but
NOT ATTACHED) on their body? (Note: this question does include ticks found on pets. There is a separate
question about pets.)
Yes
No

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June 2017 Monthly Tick Encounter Survey

3. How many household members (including you) found ticks crawling on their body?

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June 2017 Monthly Tick Encounter Survey

* 22. For the first member in your household who found at least one crawling tick, please provide his/her
initials and age (Example: JD, 24).

23. In the past month, how many ticks were found crawling on this household member?

24. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected "Other," please specify.

25. For the second member in your household who found at least one crawling tick, please provide his/her
initials and age.

26. In the past month, how many ticks were found crawling on this household member?

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27. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected "Other," please specify.

28. For the third member in your household who found at least one crawling tick, please provide his/her
initials and age.

29. In the past month, how many ticks were found crawling on this household member?

30. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected "Other," please specify.

31. For the fourth member in your household who found at least one crawling tick, please provide his/her
initials and age.

32. In the past month, how many ticks were found crawling on this household member?

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33. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected "Other," please specify.

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198. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected "Other," please specify.

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June 2017 Monthly Tick Encounter Survey

199. In the past month, has anyone living in your household (including yourself) found ticksattached to
their body?
Yes
No

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June 2017 Monthly Tick Encounter Survey

200. How many household members (including you) found ticks attached to their body?

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June 2017 Monthly Tick Encounter Survey

* 219. For the first member in your household who found at least one attached tick, please provide his/her
initials and age?

220. In the past month, how many ticks were found attached on this household member?

221. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected, "Other," please specify.

* 222. For the second member in your household who found at least one attached tick, please provide
his/her initials and age?

223. In the past month, how many ticks were found attached on this household member?

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224. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected, "Other," please specify.

* 225. For the third member in your household who found at least one attached tick, please provide his/her
initials and age?

226. In the past month, how many ticks were found attached on this household member?

227. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected, "Other," please specify.

* 228. For the fourth member in your household who found at least one attached tick, please provide his/her
initials and age?

229. In the past month, how many ticks were found attached on this household member?

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230. Where do you think this person picked up the tick(s)?
My yard
Another yard
Recreational area (e.g., park, golf course, hiking trail, recreational area, camp site, etc.)
Don't know
Prefer not to answer
Other
If you selected, "Other," please specify.

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June 2017 Monthly Tick Encounter Survey

396. In the past month, have you found any ticks crawling (but NOT ATTACHED) on your pets (dogs or
cats)?
Yes
No
I do not have a pet.
Don't know
Prefer not to answer

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June 2017 Monthly Tick Encounter Survey

397. How many total ticks were found crawling on your pet/s?

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June 2017 Monthly Tick Encounter Survey

398. In the past month have you found any attached, ticks on your pet/s (dogs or cats)?
Yes
No
Don't know
Prefer not to answer

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June 2017 Monthly Tick Encounter Survey

399. How many total ticks were found attached to your pet/s?

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June 2017 Monthly Tick Encounter Survey

400. If you indicated that you, someone in your household, or a pet had ticks crawling on, or attached to
their body in the past month did you submit a photo of the tick(s) to Tickspotters (tickspotters.org/BITM)?
Yes
No
Did not find any ticks on people or pets

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June 2017 Monthly Tick Encounter Survey

401. How many ticks did you report on tickspotters?

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June 2017 Monthly Tick Encounter Survey

402. To help us better understand any issues with using the Tickspotters website, please indicate why you did not submit a tick
photo on Tickspotters.

Other (please specify)

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June 2017 Monthly Tick Encounter Survey

403. In the past month, have you, or any members of your household, been diagnosed with a tickborne
illness?
Yes
No
Don't know
Prefer not to answer

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June 2017 Monthly Tick Encounter Survey

404. What disease was diagnosed?
I don't know
Lyme
Babesiosis
Anaplasmosis
Ehrlichiosis
Or, please specify if another disease or multiple diseases were diagnosed.

405. Please provide the initials and age for each person in your household diagnosed with a tickborne
illness in the past month. (Example: JD, 24).
Person 1
Person 2
Person 3
Person 4
Person 5

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406. Is there anything else you would like to tell us about your experience with ticks this month?

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June 2017 Monthly Tick Encounter Survey

Thank you so much for your time in completing this survey. If you have questions,
please contact your state coordinator, for CT: Rayda Krell,
[email protected], or for RI: Steve Engborg, [email protected],
or visit the study website, www.backyardtickstudy.org.

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