ZEN Colombia: Infant Symptoms - English

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

Att B6_Infant Symptoms_071317_CLEAN.DOCX

Pregnant Women - Infant Symptoms Questionnaire

OMB: 0920-1190

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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.


Page 1 of 12

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).


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