Form 0920-XXXX Dog Exposure Questionnaire

Enhanced surveillance for cases linked to a multistate outbreak of multidrug-resistant Campylobacter infections linked to contact with pet store puppies

3. Dog exposure questionnaire

DOG EXPOSURE QUESTIONNAIRE - State and Local Health Department Staff

OMB: 0920-1261

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Notes to Interviewer

Questionnaire to be used for individuals who have had an isolate with the multidrug-resistant pattern associated with the outbreak.

Epi Info ID


________

  • Instructions in italics are for interviewer only. Do not read italicized words to person being interviewed.

  • Administer questionnaire to the patient (or patient’s caregiver). Complete Section 1 before contacting the patient. Complete one form for every patient and complete as much information as possible. Thank you!

Shape1

Dog Exposure Questionnaire


Form Approved

OMB Control No.:0920-XXXX

Expiration date: XX/XX/XXXX





Read aloud before interview: My name is [name] and I’m with [organization]. We are investigating an outbreak of diarrhea caused by the Campylobacter germ. Your participation is completely voluntary, and you can quit at any time. Any data we collect will be kept confidential, and your participation may help in the response and control of the outbreak. Do you agree to participate?

Section 1: Interview information (Complete before administering questionnaire)


  1. PulseNet ID #: ___________________________

  1. State/Local/Other ID #: ______________________________


  1. Date of Interview: __ __ / __ __ / __ __ __ __ (If unknown, enter 99/99/9999)

M M D D Y Y Y Y


Interviewer information

  1. Name: 6.Contact phone number: (____) ______-_______


  1. Agency:


  1. Did the patient die? Yes No Don’t know

Shape2 7a: Date of death: __ __ / __ __ / __ __ __ __ (If unknown, enter 99/99/9999)

M M D D Y Y Y Y

7b: If the patient died, was it attributable to Campylobacter? Yes No Don’t know


  1. Respondent was: Patient Parent Other, name and explain relation________________________




Section 2: Demographic Data: I’d like to begin by asking a few questions about the patient and the patient’s household.


  1. What are your state, county, and zip code?

State abbr. _____ County ____________ Zip Code _____________


  1. Patient’s age ________ Years Months Days

  1. Sex: Male Female Unknown


  1. How do you describe your/your child’s race (may select more than one)?

White

Asian

Black/ African American Declined to answer

American Indian or Alaska Native

Native Hawaiian/Pacific Islander


  1. How do you describe your/your child’s ethnicity? Hispanic Non-Hispanic Unknown Declined to answer



  1. What is your/your child’s occupation or job? ________________________________________________________________






Public reporting burden of this collection of information is estimated to average 15 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX 







Section 3: Clinical Information: Now I have a few questions about your/your child’s illness.


  1. What date did you/your child first feel sick? I can wait while you get a calendar if you need to.

__ __ / __ __ / __ __ __ __

M M D D Y Y Y Y

Yes

Maybe

No

Don’t Know

Did you/your child or Were you/your child:


  1. Have any diarrhea?


  1. Hospitalized for this illness?


3a: If hospitalized, how many nights? ______



  1. How many days did your/your child’s illness last? _______ days Don’t know Still Ill





Section 4A: Dog Exposure Details (At Home):Now, I have a few questions about any interaction you/your child may have had with dogs/puppies at home in the 7 days before illness began, which is from ___ ___ / ___ ___ / ___ ___ ___ ___ (subtract 7 days from onset date) to __ __ / __ __ / __ ___ ___ __ (onset date).

Yes

Maybe

No

Don’t Know


  1. In the 7 days before you/your child became ill, did you/your child have a dog/puppy in the household? (If “no” or “don’t know” skip to Section 4B)

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  1. What was the age of the dog/puppy at the time of your/your child’s illness?

<6 months 6 months - <1 year >1 year Don’t know

  1. What is the breed or your/your child’s dog/puppy? Unknown

Breed 1:_________________ Breed 2:_________________ Breed 3:____________________

  1. In the 30 days before your/your child’s illness, was your/your child’s dog/puppy purchased from a pet store? (If “no” or “don’t know” skip to Section 4B)

Shape6 Shape5

  1. At what store did you purchase your dog? Don’t know

Store Name:__________________________

Location:_____________________________

  1. When did you purchase your dog? __ __ / __ __ / __ __ __ __ Don’t know

M M D D Y Y Y Y


Section 4B: Dog Exposure Details (Outside the Home): Just a few more questions about any interaction you/your child may have had with dogs/puppies outside of your home in the 7 days before illness began, which is from ___ ___ / ___ ___ / ___ _ (subtract 7 days from onset date) to __ __ / __ __ / __ ___ __(onset date).

Yes

Maybe

No

Don’t Know


  1. In the 7 days before your/your child’s illness began, did you/your child touch any dog/puppy in a pet store, at a friend’s house, or other location?

  1. In the 7 days before you/your child’s illness began, did you/your child touch any dog/puppy cages or other areas where dogs/puppies were present?

(If “no” or “don’t know” to Questions 1 and 2, skip to Section 5)

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  1. Where did you/your child have contact with a dog/puppy or its cages/areas in the 7 days before you/your child became ill? (check all that apply)

Another person’s home Pet Store Other:_________________ Don’t know

3a. If at a pet store, please provide more information.

Name of store: _____________________________

Address of store: ___________________________

  1. What was the age of the youngest dog/puppy you/your child were in contact with?

<6 months 6 months - <1 year >1 year Don’t know

  1. What is the breed or your/your child’s dog/puppy? Unknown

Breed 1:_________________ Breed 2:_________________ Breed 3:____________________

  1. Do you/your child work or volunteer in a location where dogs are present such as a pet store or dog shelter? Yes No


Section 5: Comments: Is there any other information you would like to share about this illness or about contact with dogs/puppies?
























That was my last interview question. Thank you very much for your time and assistance.






Please send completed questionnaires to CDC Enteric Diseases Epidemiology Branch, Attn: Dr. Mark Laughlin. Email: [email protected] Fax: 404-471-2620


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