Form 0920-1170 Site Enrollment Questionnaire

FForm Approved

OMB No. 0920-1170

Expires 03/31/2019

Enrollment Questionnaire for Clinics and Shelters

Project Name: Canine Leptospirosis Surveillance in Puerto Rico, 2016

This form will provide project coordinators with background information on your facility. Please provide the information as accurately and completely as possible.

GENERAL INFORMATION

Name of Facility: ____________________________________________ Type of Facility: ☐ Clinic ☐ Shelter

Street Address: ______________________________________________________________________________________

City: __________________________ Municipality: _____________________________ Zip: _____________________

Point of Contact Name: ________________________________________ Job Title: _______________________________

Phone Number: _______________________________ Email Address: ______________________________________

Does your facility have a computer that can be used to record patient test results?: ☐ Yes ☐ No

If a computer is available, what software is available? Check all that apply.

☐ Microsoft Word ☐ Microsoft Excel ☐ Microsoft Access ☐ Microsoft PowerPoint

Does your facility have a fax machine? ☐ Yes ☐ No

Does your facility have internet access? ☐ Yes ☐ No

Do you vaccinate dogs for leptospirosis? ☐ Yes, name of vaccine(s): ____________________________________ ☐ No

For clinics, approximately how many dogs does your clinic see? _____________ per ☐ week ☐ month

How many dogs with febrile illness of unknown cause does your facility see? ____________ per ☐ week ☐ month

How many dogs diagnosed as or suspected to have leptospirosis does your facility see? _________ per ☐ week ☐month

QUESTIONS FOR SHELTERS ONLY

Size and Activity Level:

Shelter capacity (# of dogs it can house): _________________ Average # of new dogs each week: __________________

How often is the shelter full? ☐ Most of the time ☐ Sometimes ☐ Rarely ☐ Never

Origin of dogs (provide percentage where appropriate)

Are dogs: ☐ Surrendered by owner: ____ % ☐ Transferred from other facilities: ____ %

☐ Picked up in the community: ____ % ☐ Other, specify ____________________, ____ %

From which communities do most dogs originate? If possible, specify name of area and an approximate percentage.

1. ____________________________________________________________ ______ %

2. ____________________________________________________________ ______ %

3. ____________________________________________________________ ______ %

What is the most remote distance and community from which you receive animals? ______________________________

Veterinary Care:

Is veterinary care provided by: ☐ a full-time onsite vet ☐ a part-time onsite vet, how often/week? _____________

☐ a separate veterinary clinic

If a separate veterinary clinic provides care:

Clinic Name: _______________________________________________ Phone No: __________________________

Street Address: ________________________________________ City: _____________________ Zip: ___________

In what capacity does the veterinarian work with your shelter? Check all that apply.

☐ Euthanasia ☐ Consultation ☐ Spay/neuter ☐ Treatment of sick/injured ☐ Preventive (vaccination, deworming)

Send a copy of this form by fax to 404-471-8642 OR by email to study coordinators. Thank you!

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 (0920-1170).