Form 0920-1011 Patient Screening Questionnaire

Appendix 1: Questionnaire

Updated: August 28, 2018

Survey ID __________________________

Section 1: Questions about travel to Mexico and the southwest United States
Yes	No
		Did you attend a service trip to the Tijuana area of Mexico at any time during July 2018? (Note that the Tijuana area is directly south of the San Diego metro area. For purposes of this survey, please consider nearby towns, including Rosarito and La Joya as part of the Tijuana area.)
If Q1 is “No”, END survey. Thank you for participating in the survey.
When did you arrive in Mexico for this trip? (If you don’t know, check the box for “don’t know” and record your best guess) __ __ / __ __ / __ __ __ __ Don’t know M M D D Y Y Y Y
When did you leave Mexico at the end of this trip? (If you don’t know, check the box for “don’t know” and record your best guess) __ __ / __ __ / __ __ __ __ Don’t know M M D D Y Y Y Y
Yes	No
		As part of this trip, did you travel anywhere else in Mexico before arriving in the Tijuana area?
SKIP if Q4 is No		If yes, specify_______________________
Yes	No
		As part of this trip, did you travel anywhere else in Mexico after leaving the Tijuana area?
SKIP if Q6 is No		If yes, specify_______________________
Yes	No
		As part of this trip, did you spend time in California or Arizona? (Please don’t count travel directly between the San Diego airport and the Mexico border)
SKIP if Q8 is No		If yes, specify location(s) ______________________ Specify amount of time___________________
Yes	No	Don’t Know
			Before this service trip, had you previously traveled to the Tijuana area or other parts of northwestern Mexico (i.e., the states of Baja California and Sonora)?
SKIP if Q11 is No or don’t know			If yes, in which years? Specify_______________ (If you don’t remember exactly, please use your best guess)
Yes	No	Don’t Know
			Before this service trip, had you previously traveled to southern California or Arizona?
SKIP if Q13 is No or don’t know			If yes, in which years? Specify________________(If you don’t remember exactly, please use your best guess)

Section 2: Questions about your activities during travel to Mexico
Yes	No		Don’t Know
				Did you help build houses during the 2018 service trip?
How many houses did you work on during this trip? 1 2 3 4 5 or more
We would like to know which houses you worked on and what type of soil-related activities you did each day of your trip. We have provided pictures of the houses along with their location names to help you identify them as best you can. Please answer as best you can remember, even if you’re not sure.
House A (Castores) Next to a school, and view of a valley at the end of the street.
House B (Rosarito) Urban nice neighborhood.
House C (Cumbres) Top of a hill with breezy ocean view.
On Monday, which house did you work at? House A House B House C Other. Specify_____________ (describe the house the best you can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban location, whether it was next to a school, whether there were many stray dogs, and whether you saw a valley or an ocean)
As best you can recall, did you do the following activity?						Yes	No	Don’t Know	For about how many hours total?
Digging trenches or holes									_______hours
Shoveling or wheelbarrowing dirt/soil									_______hours
Mixing/making cement from dry ingredients (sand and gravel)									_______hours
Filling or passing buckets with sand or soil									_______hours
Filling or passing buckets with cement									_______hours
Passing empty buckets									_______hours
Backfilling the trench (putting dirt back into the foundation of the house)									_______hours
Compacting dirt/soil in the trench									_______hours
Cutting and bending rebar									_______hours
Tying rebar for the floor or the roof									_______hours
Laying blocks in the trench to make walls									_______hours
Building the roof									_______hours
Other activities, specify__________									_______hours
Other activities, specify__________									_______hours
Did you use any of the following tools this day? (check all that apply) Shovel Pick Electric tamper/soil compactor Manual tamper/soil compactor Wheelbarrow Other, specify ____________
How much of the time while you were working on the house this day was there dust in the air you were breathing? All of the time Most of the time Some of the time Rarely Never Don’t know
During times when you could see dust in the air, did you wear any type of covering over your mouth and nose at any time this day? No Bandanna Dust mask Respirator (e.g., N-95) Other, specify __________________
Yes		No	Don’t Know
					Did you notice dust on your clothes at the end of this day?
Skip if Q49 is No or Don’t know					If yes, how dusty was your clothes? Extremely dusty Very dusty Mildly dusty Just a little bit of dust
Skip if Q49 is No or Don’t know					As best as you can recall, what was the color of the dust? Black Tan brown Mustard yellow Other. Specify______
Skip if Q49 is No or Don’t know					Where did you shake off your dusty clothes at the end of the day? Specify______________
Yes		No	Don’t Know
					Were you near someone moving or digging dirt?
Skip if Q53 is No or Don’t know					If yes, what do you consider near? Specify ________feet
On Tuesday, which house did you work at? House A House B House C Other. Specify_____________ (describe the house the best you can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban location, whether it was next to a school, whether there were many stray dogs, and whether you saw a valley or an ocean)
As best you can recall, did you do the following activity?						Yes	No	Don’t Know	For about how many hours total?
Digging trenches or holes									_______hours
Shoveling or wheelbarrowing dirt/soil									_______hours
Mixing/making cement from dry ingredients (sand and gravel)									_______hours
Filling or passing buckets with sand or soil									_______hours
Filling or passing buckets with cement									_______hours
Passing empty buckets									_______hours
Backfilling the trench (putting dirt back into the foundation of the house)									_______hours
Compacting dirt/soil in the trench									_______hours
Cutting and bending rebar									_______hours
Tying rebar for the floor or the roof									_______hours
Laying blocks in the trench to make walls									_______hours
Building the roof									_______hours
Other activities, specify__________									_______hours
Other activities, specify__________									_______hours
Did you use any of the following tools this day? (check all that apply) Shovel Pick Electric tamper/soil compactor Manual tamper/soil compactor Wheelbarrow Other, specify ____________
How much of the time while you were working on the house this day was there dust in the air you were breathing? All of the time Most of the time Some of the time Rarely Never Don’t know
During times when you could see dust in the air, did you wear any type of covering over your mouth and nose at any time this day? No Bandanna Dust mask Respirator (e.g., N-95) Other, specify __________________
Yes		No	Don’t Know
					Did you notice dust on your clothes at the end of this day?
Skip if Q87 is No or Don’t know					If yes, how dusty was your clothes? Extremely dusty Very dusty Mildly dusty Just a little bit of dust
Skip if Q87 is No or Don’t know					As best as you can recall, what was the color of the dust? Black Tan brown Mustard yellow Other. Specify______
Skip if Q87 is No or Don’t know					Where did you shake off your dusty clothes at the end of the day? Specify______________
Yes		No	Don’t Know
					Were you near someone moving or digging dirt?
Skip if Q91 is No or Don’t know					If yes, what do you consider near? Specify ________feet
On Wednesday, which house did you work at? House A House B House C Other. Specify_____________ (describe the house the best you can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban location, whether it was next to a school, whether there were many stray dogs, and whether you saw a valley or an ocean)
As best you can recall, did you do the following activity?						Yes	No	Don’t Know	For about how many hours total?
Digging trenches or holes									_______hours
Shoveling or wheelbarrowing dirt/soil									_______hours
Mixing/making cement from dry ingredients (sand and gravel)									_______hours
Filling or passing buckets with sand or soil									_______hours
Filling or passing buckets with cement									_______hours
Passing empty buckets									_______hours
Backfilling the trench (putting dirt back into the foundation of the house)									_______hours
Compacting dirt/soil in the trench									_______hours
Cutting and bending rebar									_______hours
Tying rebar for the floor or the roof									_______hours
Laying blocks in the trench to make walls									_______hours
Building the roof									_______hours
Other activities, specify__________									_______hours
Other activities, specify__________									_______hours
Did you use any of the following tools this day? (check all that apply) Shovel Pick Electric tamper/soil compactor Manual tamper/soil compactor Wheelbarrow Other, specify ____________
How much of the time while you were working on the house this day was there dust in the air you were breathing? All of the time Most of the time Some of the time Rarely Never Don’t know
During times when you could see dust in the air, did you wear any type of covering over your mouth and nose at any time this day? No Bandanna Dust mask Respirator (e.g., N-95) Other, specify __________________
Yes		No	Don’t Know
					Did you notice dust on your clothes at the end of this day?
Skip if Q125 is No or Don’t know					If yes, how dusty was your clothes? Extremely dusty Very dusty Mildly dusty Just a little bit of dust
Skip if Q125 is No or Don’t know					As best as you can recall, what was the color of the dust? Black Tan brown Mustard yellow Other. Specify______
Skip if Q125 is No or Don’t know					Where did you shake off your dusty clothes at the end of the day? Specify______________
Yes		No	Don’t Know
					Were you near someone moving or digging dirt?
Skip if Q129 is No or Don’t know					If yes, what do you consider near? Specify ________feet
On Thursday, which house did you work at? House A House B House C Other. Specify_____________ (describe the house the best you can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban location, whether it was next to a school, whether there were many stray dogs, and whether you saw a valley or an ocean)
As best you can recall, did you do the following activity?						Yes	No	Don’t Know	For about how many hours total?
Digging trenches or holes									_______hours
Shoveling or wheelbarrowing dirt/soil									_______hours
Mixing/making cement from dry ingredients (sand and gravel)									_______hours
Filling or passing buckets with sand or soil									_______hours
Filling or passing buckets with cement									_______hours
Passing empty buckets									_______hours
Backfilling the trench (putting dirt back into the foundation of the house)									_______hours
Compacting dirt/soil in the trench									_______hours
Cutting and bending rebar									_______hours
Tying rebar for the floor or the roof									_______hours
Laying blocks in the trench to make walls									_______hours
Building the roof									_______hours
Other activities, specify__________									_______hours
Other activities, specify__________									_______hours
Did you use any of the following tools this day? (check all that apply) Shovel Pick Electric tamper/soil compactor Manual tamper/soil compactor Wheelbarrow Other, specify ____________
How much of the time while you were working on the house this day was there dust in the air you were breathing? All of the time Most of the time Some of the time Rarely Never Don’t know
During times when you could see dust in the air, did you wear any type of covering over your mouth and nose at any time this day? No Bandanna Dust mask Respirator (e.g., N-95) Other, specify __________________
Yes		No	Don’t Know
					Did you notice dust on your clothes at the end of this day?
Skip if Q163 is No or Don’t know					If yes, how dusty was your clothes? Extremely dusty Very dusty Mildly dusty Just a little bit of dust
Skip if Q163 is No or Don’t know					As best as you can recall, what was the color of the dust? Black Tan brown Mustard yellow Other. Specify______
Skip if Q163 is No or Don’t know					Where did you shake off your dusty clothes at the end of the day? Specify______________
Yes		No	Don’t Know
					Were you near someone moving or digging dirt?
Skip if Q167 is No or Don’t know					If yes, what do you consider near? Specify ________feet
On Friday, which house did you work at? House A House B House C Other. Specify_____________ (describe the house the best you can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban location, whether it was next to a school, whether there were many stray dogs, and whether you saw a valley or an ocean)
As best you can recall, did you do the following activity?						Yes	No	Don’t Know	For about how many hours total?
Digging trenches or holes									_______hours
Shoveling or wheelbarrowing dirt/soil									_______hours
Mixing/making cement from dry ingredients (sand and gravel)									_______hours
Filling or passing buckets with sand or soil									_______hours
Filling or passing buckets with cement									_______hours
Passing empty buckets									_______hours
Backfilling the trench (putting dirt back into the foundation of the house)									_______hours
Compacting dirt/soil in the trench									_______hours
Cutting and bending rebar									_______hours
Tying rebar for the floor or the roof									_______hours
Laying blocks in the trench to make walls									_______hours
Building the roof									_______hours
Other activities, specify__________									_______hours
Other activities, specify__________									_______hours
Did you use any of the following tools this day? (check all that apply) Shovel Pick Electric tamper/soil compactor Manual tamper/soil compactor Wheelbarrow Other, specify ____________
How much of the time while you were working on the house this day was there dust in the air you were breathing? All of the time Most of the time Some of the time Rarely Never Don’t know
During times when you could see dust in the air, did you wear any type of covering over your mouth and nose at any time this day? No Bandanna Dust mask Respirator (e.g., N-95) Other, specify __________________
Yes		No	Don’t Know
					Did you notice dust on your clothes at the end of this day?
Skip if Q201 is No or Don’t know					If yes, how dusty was your clothes? Extremely dusty Very dusty Mildly dusty Just a little bit of dust
Skip if Q201 is No or Don’t know					As best as you can recall, what was the color of the dust? Black Tan brown Mustard yellow Other. Specify______
Skip if Q201 is No or Don’t know					Where did you shake off your dusty clothes at the end of the day? Specify______________
Yes		No	Don’t Know
					Were you near someone moving or digging dirt?
Skip if Q205 is No or Don’t know					If yes, what do you consider near? Specify ________feet
Yes		No	Don’t Know
					Did you play volleyball at the Posada on this trip?
Skip if Q207 is No					If yes, how many times did you play at the volleyball court? Once Twice Three times More than three times
Please describe any other place that appeared very dusty. Specify__________________

Section 3: General Questions About Valley Fever This section includes questions about Valley fever and working in dusty places. Answers to these questions can help improve public communications to prevent the disease.
Yes	No
		Before August 2018, had you heard of Valley fever (coccidioidomycosis)?
Skip if Q210 is No		If yes, where or how had you heard of it? Specify______________
Yes	No
		Before August 2018, did you know that people can get fungal infections from breathing in dust in certain places?
		Did you take any special efforts to reduce the amount of dust that was created?
Skip if Q213 is No		If yes, specify_______________
What are ways that people can minimize the amount of dust they breathe when doing construction work? Specify _________________________________
Yes	No
		Did you take any special efforts to reduce the amount of dust that you inhaled?
Skip if Q216 is No		If yes, specify_______________

Section 4: Questions About Your Experience After Returning from Mexico
Yes	No	Don’t Know	Did you experience any of the following during or in the 4 weeks after your volunteer service trip to Mexico?
			Fever
			Fatigue
			Chest pain
			Chills
			Painful joints
			Painful muscles
			Cough
			Shortness of breath
			Any rashes? (painful or itchy red lumps on skin)
			Night sweats
			Headache
			Weight loss
			Do you still have any of these symptoms?
Did you have any other symptoms? Specify ____________
Did you have any other symptoms? Specify ____________
Yes	No	Don’t Know
			Did you have any respiratory symptoms or fever (for example, like from a cold or flu) that started during your recent travel to Mexico or in the four weeks after returning?
Skip to Q245 if Q233 is No or Don’t know			If yes, what date did you first feel sick? (If you don’t know, check the box for “don’t know” and record your best guess) __ __ / __ __ / __ __ __ __ Don’t know M M D D Y Y Y Y
Skip to Q245 if Q233 is No or Don’t know			If yes, how many days did your illness last? Specify__________
			Yes	No
Skip if Q233 is No or Don’t know					Were you unable to do your normal activities because of this illness?
Skip if Q236 is No			If yes, how many days? Specify___________________
			Yes	No
Skip if Q233 is No or Don’t know					Did you visit the emergency room for this respiratory illness in July or August 2018?
Skip if Q233 is No or Don’t know					Were you hospitalized for this illness in July or August 2018?
Skip if Q239 is No			If yes, how many days were you hospitalized in July or August 2018? Specify______________
			Yes	No
Skip if Q239 is No					If yes to hospitalized, were you put on a ventilator (breathing machine) in July or August 2018?
Skip if Q241 is No			If yes, how many days were you on a ventilator in July or August 2018? Specify__________
			Yes	No
Skip if Q239 is No					If yes to hospitalized, were you in the intensive care unit in July or August 2018?
Skip if Q243 is No			If yes, how many days were you in the intensive care unit in July or August 2018? Specify________________
Yes	No	Don’t Know
			Did you see a healthcare provider during your recent travel to Mexico or in the four weeks after returning to the United States?
Skip if Q245 is No			If yes to healthcare provider, what was the reason for visiting a healthcare provider? Specify ___________________
Skip if Q245 is No			If yes to healthcare provider, how many times did you visit a healthcare provider during this period? once twice three times four times five times or more
			Yes	No
Skip if Q245 is No					If yes to healthcare provider, was this for any type of respiratory symptoms or fever (for example, like from a cold or flu)?
Skip if Q248 is No			If yes to respiratory symptoms, what did the healthcare provider tell you was the cause of your illness? Specify ___________________ Don’t know
			Yes	No	Don’t Know
Skip if Q245 is No or Don’t know						Did you receive a chest x-ray in July or August 2018?
Skip if Q245 is No or Don’t know						Were you given any medication for this respiratory illness in July or August 2018?
Skip if Q245 is No or Don’t know						Did you take anti-fungal medication (Examples: Amphotericin B, Ambisome, Diflucan, Fluconazole, Itraconazole, Voriconazole, Posaconazole)?
Skip if Q245 is No or Don’t know						Did you take antibiotic medication (Example: amoxicillin, doxycycline, cephalexin, ciprofloxacin, clindamycin, metronidazole, azithromycin, sulfamethoxazole/trimethoprim)?
Yes	No	Don’t Know
			Did you take anything over the counter (without prescription)?
Skip if Q254 is No or Don’t know			If yes to over the counter, specify medication________________
Yes	No	Don’t Know
			Were you ever diagnosed with Valley fever before traveling to Mexico in summer 2018?
			Were you diagnosed with Valley fever after returning from Mexico in summer 2018?
			Did you take a corticosteroid (for example, prednisone) in the 4 weeks before your recent travel to Mexico?
			Do you have diabetes?
			Do you have lung disease such as COPD, asthma, or emphysema?
			Do you have any condition that weakens your immune system (for example, cancer, HIV, transplant, or medication that weakens your immune system)?
Skip if Q261 is No or Don’t know			If yes, specify ___________________

Section 5: Demographic Questions
Which State and city do you reside in?	State _____ City ____________
Age________	Sex: Male Female
How do you describe your race? (select all that apply) White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander
How do you describe your ethnicity? Hispanic Non-Hispanic
What is your occupation? Student Faculty Other. Specify_______________
What is the name of the school you attend or teach at? Specify________________

Section 6: Comments

If there is any other information you would like to share about your travel or Valley fever?