Example Questionnaire - Acute Gastroenteritis

AttE1 AGE Example Questionnaire.docx

Emergency Cruise Ship Outbreak Investigations (CSOIs)

Example Questionnaire - Acute Gastroenteritis

OMB: 0920-1255

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Attachment E1. Acute Gastroenteritis (AGE) Example Questionnaire (Passenger or Crew)



Shape1

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX





[Ship Name]

Acute Gastroenteritis (AGE) Example Questionnaire (Passenger or Crew)


Q1

ID (CDC use only)

_________


Q2

Status (CDC use only)

I


W


U




I. Personal Information


Q3

Respondent was…

Self


Spouse


Parent


Other



Q4

Stateroom number _____________




Q6


Age (in years) ______________







Q5

Total number of people in your stateroom (including yourself) _____________


Q7

What is your Sex/Gender? (Check only one)


Male


Female


Q8

Are you...


Passenger


Crew member


Q9

If crew member, what is your position?


___________________________________________


Q10

In which country do you reside?

United States


Canada




Other country, specify

___________________________________




Shape2

CDC estimates the average public reporting burden for this collection of information as 15 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)






II. Medical/Health Information


Q11

Did you have DIARRHEA (e.g., loose stools) on this cruise?

Yes



No


Q12

If you selected "YES" to Question 9, what was the maximum number of diarrhea episodes you had in any 24-hour period. If you DID NOT have diarrhea, leave blank and proceed to Question 11.


_______________


Q13

Did you have VOMITING (other than seasickness) on this cruise?

Yes



No


Q14

If you selected "YES" to Question 11, what was the maximum number of vomiting episodes you had in any 24-hour period? If you DID NOT have vomiting, leave blank and proceed to Question 13.


_______________


Q15

Any food allergies or special diets for medical, religious or any other reason?


Yes




No


Q16

If yes, select the food allergy or special diet(s).


Vegetarian


Medical diet


No nuts


Kosher


Vegan


Lactose-free


No shellfish


No eggs


Weight loss


Gluten-free


Halal




Other, please specify

_______________________


Q17

Which of the following symptoms did you have? Please check "Yes" or "No" for each symptom.



Yes

No


Blood in stool


Fever (feeling warm or hot)


Stomach cramps or pain


Muscle aches (other than from excessive physical activity)


Headache


Q18

If you were ill with DIARRHEA or VOMITING, please indicate the date that your FIRST symptom began. (Please select one)


[date] (Two days before embarkation)


[date] (location)


[date] (Day before embarkation)


[date] (location)


*[date] (Embarkation day)


[date] (location)


[date] (location)


[date] (location)


[date] (location)


I was not ill with diarrhea/vomiting

Other (specify)

_______________________________________


Q19

If you were ill with diarrhea or vomiting, please indicate the time your FIRST symptom began (Please select one)


Midnight - 05:59am


06:00pm - 11:59pm


06:00am-11:59am


I was not ill with diarrhea or vomiting


Noon - 5:59pm





Q20

If you were ill with diarrhea or vomiting, did you report your illness to the Medical Center?


Yes




No


Q21

If you were ill with diarrhea or vomiting and you did not report your illness to the Medical Center, what was/were the reasons for not reporting? (Please check all that apply).


I have my own medication(s)


My ill stateroom mate already contacted the medical center and I knew what to do


I thought it would pass




Other, please specify

_____________________________________


Q22

Are you still ill with any of the symptoms?

Yes



No



I was not ill with diarrhea/vomiting


Q23

If you were ill with diarrhea or vomiting and your illness is over, how many hours did your illness last?

_________


Q24

Did you witness/see a diarrhea/vomiting event(s) in a public area?

Yes



No


Q25

If you answered "Yes" to Question 22, in which location did you witness/see the diarrhea or vomiting event(s) Please check all that apply.


Embarkation terminal (location)


Food outlet on ship (e.g., restaurant)


Private coach bus to terminal (location)


Theater on ship


Private vehicle


Lounge on ship


Public toilet room on ship


Other public area on ship


Q26

If you answered "Yes" to Question 22, did you come in contact with the diarrhea/vomit?

Yes



No



Don't know



III. Shipboard Activities


Q27

What time did you board the [ship name]?


I stayed on from the previous voyage


[date], between 1pm and 1:59pm


[date], between 11am and11:59am


[date], between 2pm and 2:59pm


[date], between Noon and 12:59pm


[date], 3pm or later


Q28

Please indicate which of the following activities in which you participated in on Embarkation day, [date]. Please select all that apply.


Group table games (i.e., Trivia)


Lecture/Demonstration


Group active games (i.e., Table tennis)


Dancing


Casino


Pool/Whirlpool


Vitality at Sea Spa/Fitness Center


Special event(s)


Religious service


I did not participate in any of these activities


Q29

If you selected "Special event" in Question 26 above, please specify the name(s) of the event(s).


_________________________________________________




IV. Food and Beverage Outlets


Q30

On Embarkation day, [date] (location), did you eat or drink anything at the following restaurants. Please select "Yes". "No" or "Don't know" for each food outlet



Yes

No

Don't know


location (deck)


location (deck)


location (deck)


location (deck)


Room Service


I did not eat/drink at any of these restaurants


Q31

On Embarkation day, [date] (location), did you eat or drink anything at the following venues. Please select "Yes", "No" or "Don't know" for each venue.



Yes

No

Don't know


location (deck)


location (deck)


location (deck)


location (deck)


location (deck)


I did not eat/drink at any of these venues




V. Food and Beverage History


Q32

Did you drink any of the following BEVERAGES on [date] (day of voyage)?



Yes

No

Don't know


Coffee


Tea


Hot chocolate


Milk/Cream


Fruit /Vegetable juice (e.g., Orange juice, Passionfruit)


Carbonated beverages (e.g., Sodas)


Fruit/Vegetable "Smoothies" or similar drinks


Lemonade


Bottled water


Unbottled water


Beverages containing alcohol


Beverages containing ice


Q33

Did you eat any of the following DAIRY or DAIRY-CONTAINING ITEMS on [date] (day of voyage)?



Yes

No

Don't know


Any "soft" cheese (e.g., Brie)


Any "hard" cheese (e.g., Cheddar)


Ice cream


Sour cream


Any other dairy items


Q34

Did you eat any of the following PASTA DISHES on [date] (day of voyage)?



Yes

No

Don't know


Seafood Spaghetti


Linguini Pomodoro


Crab Ravioli


Meat Lasagna


Potato Gnocchi


Long Pasta


Short Pasta


Rigatoni


Penne Pasta


Any other pasta dishes


Q35

Did you eat any of the following MEATS or POULTRY on [date] (day of voyage)?



Yes

No

Don't know


Hamburger/Beef sliders


Steak (beef)


Beef tenderloin


Other ground beef (e.g. tacos, burritos)


Any other beef (prime rib, ribs, stir-fry)


Pork chop


Sausage (e.g., Bratwurst, Kielbasa, Beef, Turkey)


Turkey


Chicken


Veal chops


Veal Meatballs


Lamb


Italian-style cured meats (e.g., Proscuitto, Capocollo)


Salami


Roast beef


Any other meats


Q36

Did you eat any of the following FISH or SEAFOOD on [date] (day of voyage)?



Yes

No

Don't know


Salmon


Smoked Fish Rillettes


Cod


Calamari


Snapper


Tuna


Lobster


Mussels


Shrimp/Prawns


Shrimp Cocktail


Surf and Turf


Escargots


Eel


Octopus


Squid


Amberjack


Sole


Crab


Scallops


Sushi


Any other fish or seafood


Q37

Did you eat any of the following FRESH or COOKED VEGETABLES on [date] (day of voyage)?



Yes

No

Don't know


Lettuce


Spinach


Bok Choi


Asparagus


Tomatoes


Eggplant


Potatoes


Lentils


Mushrooms


Onions


Corn


Green beans


Green peas


Carrots


Bean sprouts


Olives


Red/Green pepper


Any other vegetables


Q38

Did you eat any of the following PREPARED/DELI SALADS on [date] (day of voyage)?



Yes

No

Don't know


Caesar salad


Potato salad


Coleslaw


Pasta salad


Asian salad


Goat cheese salad


Mesclun salad


Greek salad


Garden salad


Fruit salad


Waldorf salad


Garbanzo bean salad


Seafood salad


Chicken salad


Crabstick salad


Spinach salad


Any other salad


Salad toppings


Q39

Did you eat any of the following FRESH and SLICED FRUITS on [date] (day of voyage)?



Yes

No

Don't know


Watermelon


Pineapple


Any berries (e.g., Strawberries, Blackberries)


Kiwi


Any other fresh/sliced fruit


Q40

Did you eat any of the following SOUPS and BROTHS on [date] (day of voyage)?



Yes

No

Don't know


Chicken noodle soup


Chicken and corn soup


Leek and potato soup


Asian coconut seafood soup


Vegetarian lentil and root vegetable soup


Seafood tomato stew


Mushroom soup


Onion soup


Any other soups or broths


Q41

Did you eat any of the following MISCELLANEOUS FOOD ITEMS on [date] (day of voyage)?



Yes

No

Don't know


Paella


Sashimi


Veggie burger


Steak sandwich


Deli-type sandwich or sub


Bacon


Barbecue (e.g., BBQ Chicken, BBQ Pork, BBQ Beef)


Burrito, (or similar item)


Tortilla


Focaccia bread (flat Italian bread)


Ricotta and spinach crepes


Egg or egg-containing dishes


Asian rice


Any stir-fry or similar dishes


Other Asian dishes


Cookie


Tarts


Cheesecake


Any other desserts

Thank you for your assistance

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