Example Questionnaire - Acute Gastroenteritis

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

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	___________________________________

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