Canine Exposure Supplemental Questionnaire

CANINE EXPOSURE QUESTIONNAIRE
Epi Info ID

Notes to Interviewer:
Questionnaire to be used for individuals who have had exposure to a dog/puppies or a pet
store/environment.
• 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 one form for every patient and complete as much information as possible. Thank you!

_________

Section 1: Interview information (Complete before administering questionnaire)
1.

PulseNet ID #: ___________________________

3.

PulseNet cluster code: _____________________

4.

2. State/Local/Other ID #: ______________________________

3a. PFGE Pattern: ____________________________________
3b. Campylobacter Strain_______________________________
Date of Interview: __ __ / __ __ / __ __ __ __ (If unknown, enter 99/99/9999)
M

Interviewer information
8. Did the patient die?

M

D

D

Y

5.

Name:

6.

Agency:

Yes

Y

Y

Y

7. Contact phone number: (____) ______-_______

No

Don’t know

8a: Date of death: __ __ / __ __ / __ __ __ __ (If unknown, enter 99/99/9999)
M

M

D

D

Y

Y

Y

Y

8b: If the patient died, was it attributable to Campylobacter?
9. Respondent was:

Patient

Parent

Yes

No

Don’t know

Other, name and explain relation________________________

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. We believe you may have become sick with this germ, so I’d like to ask you a few
questions. Your participation is completely voluntary, and you can discontinue the interview 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 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?

2.

Patient’s age

4.

How do you describe your/your child’s race?
White
Asian
Black/ African American
Native American Indian/Alaska Native
Native Hawaiian/Pacific Islander (specify)

5.
6.

________

Years

State abbr. _____
Months

Days

3.

County ____________
Sex:

Zip Code _____________

Male

Female

Unknown

Other race: __________________
Unknown
Declined to answer

How do you describe your/your child’s ethnicity?
Hispanic
Non-Hispanic
Unknown
Declined to
answer
What is your/your child’s occupation or job? ________________________________________________________________

Section 3: CLINICAL INFORMATION
Now I have a few questions about your/your child’s illness.
1.
2.
Yes

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

How many days total did your/your child’s illness last? _______ days
Maybe

No

Don’t
Know

Y

Y

Don’t know

Y

Don’t know

Still Ill

Did you/your child or Were you/your child:
3.

Have any diarrhea (3 or more loose stools in 24 hours)?
3a: What day did the diarrhea start? __ __ / __ __ / __ __ __ __
M

M

D

D

Y

Y

Y

Don’t know

Y

3c. What was the highest number of loose stools you had in any 24 hours?
1
2
3
4
5
>5
Please send completed questionnaires to CDC Outbreak Response and Prevention Branch, Attn: Enteric Zoonoses Team Email: [email protected] Fax: 404-679-5073.

4.

Have any bloody diarrhea?
4a: What day did the bloody diarrhea start? __ __ / __ __ / __ __ __ __
M

M

D

D

Y

Y

Y

4b: What day did the bloody diarrhea end? __ __ / __ __ / __ __ __ __
M

5.

M

D

D

Y

Y

Y

Don’t know

Y

Y

Still have blood
Don’t know

Have any fever (temperature measured at 100.4 F or higher)?
5a: What day did the fever start?

__ __ / __ __ / __ __ __ __
M

5b: What day did the fever end?

M

D

D

Y

Y

Y

__ __ / __ __ / __ __ __ __
M

M

D

D

Y

Y

Y

Don’t know

Y

Y

Still have fever
Don’t know

6.

Did you/your child seek medical care for this illness?

7.

6a. Where did you seek medical care? Check all that apply.
Doctor’s office
Urgent care
Pharmacy clinic
Emergency department
Other: _____________________________________________________________
Hospitalized for this illness?
7a: If hospitalized, how many nights? ______

8.

Admitted to the intensive care unit (ICU) for this illness?
8a. If admitted to the ICU, how many nights? _______

9.

Develop serious complications from this illness?

10. Prescribed an antibiotic (or multiple antibiotics) for this illness? Provide information about each
course of antibiotics separately.
10a. Antibiotic #1 information
Name: _______________________________________
Don’t know
Start date: __ __ / __ __ / __ __ __ __
Length of treatment (# of days): _____
M

M

D

D

Y

Y

Y

Y

10b. Antibiotic #2 information
Name: _______________________________________
Don’t know
Start date: __ __ / __ __ / __ __ __ __
Length of treatment (# of days): _____
M

M

D

D

Y

Y

Y

Y

10c. Antibiotic #3 information
Name: _______________________________________
Don’t know
Start date: __ __ / __ __ / __ __ __ __
Length of treatment (# of days): _____
M

M

D

D

Y

Y

Y

Y

10d. Antibiotic #4 information
Name: _______________________________________
Don’t know
Start date: __ __ / __ __ / __ __ __ __
Length of treatment (# of days): _____
M

M

D

D

Y

Y

Y

Y

10e. Antibiotic #5 information
Name: _______________________________________
Don’t know
Start date: __ __ / __ __ / __ __ __ __
Length of treatment (# of days): _____
M

M

D

D

Y

Y

Y

Y

10f. Did your symptoms go away or get better after taking the antibiotics?
Yes
No
Don’t know
10g. Did your symptoms stay the same or get worse despite taking
antibiotics?
Stay same
Get worse
Don’t know
10h. Did you/your child return to the doctor because of
persistent symptoms?
Yes
No
Don’t know
10i. Did you/your child have a stool test return positive for Campylobacter after
completing a course of antibiotics?
Yes
No
Don’t know
11. Have any close contact with anyone with diarrhea or vomiting?
11a: When was the close contact ill?
during the 7 days before you got sick

more than 1 week before you got sick

Unknown

12. Have chronic diarrhea caused by a health condition or a medication before you got sick?

Please send completed questionnaires to CDC Outbreak Response and Prevention Branch, Attn: Enteric Zoonoses Team Email: [email protected] Fax: 404-679-5073.

13. Immune-compromised at the time of illness due to a health condtion or medication (e.g. cancer,
HIV, diabetes, chemotherapy)?
13a. Name of condition or medication: ______________________________________________
14. Did you take an antibiotic in the 30 days before you got sick?
14a. Antibiotic information
Name: _______________________________________
Don’t know
Start date: __ __ / __ __ / __ __ __ __
Length of treatment (# of days): _____
M

M

D

D

Y

Y

Y

Y

Reason for antibiotic: ____________________________

Section 4A: 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)

2.

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

3.

What is the breed of your/your child’s dog/puppy?

Unknown

Breed 1: ___________________ Breed 2:__________________ Breed3:______________________
4.

Did you/your child touch the dog/puppy?

5.

Did you/your child hold or snuggle the dog/puppy?
(If “no” or “don’t know” skip to Question 6)
5a. How often do you wash your hands/does your child wash his or her hands such as with soap
and water or hand sanitizer after touching the dog/puppy?
Always or almost always

Sometimes

Rarely

Never

5b. What do you/does your child use to wash your/his or her hands after touching the dog/puppy?
Soap and water

Alcohol-based hand sanitizer

Other

Nothing/Do not wash hands

6.

Did you/your child kiss the dog/puppy?

7.

Did you/your child ever feed or give water to the dog/puppy?

8.

Did you/your child ever touch the dog’s/puppy’s cage/enclosure?
Do not have cage/enclosure (If checked, skip to question 10)

9.

Did you/your child clean the dog’s/puppy’s cage/enclosure?
(If “no” or “don’t know” skip to Question 10)

Both

9a. How often do you wash your hands/does your child wash his or her hands such as with soap
and water or hand sanitizer after touching the cage/enclosure?
Always or almost always

Sometimes

Rarely

Never

9b. What do you/does your child use to wash your/his or her hands after touching the
cage/enclosure?
Soap and water

Alcohol-based hand sanitizer

Other

Nothing/Do not wash hands

Both

10. Did you/your child pick up the dog’s/puppy’s poop?
(If “no” or “don’t know” skip to Question 11)
10a. How often do you wash your hands/does your child wash his or her hands such as with soap
and water or hand sanitizer after picking up the poop?
Always or almost always

Sometimes

Rarely

Never

10b. What do you/does your child use to wash your/his or her hands after picking up the poop?
Soap and water

Alcohol-based hand sanitizer

Other

Nothing/Do not wash hands

Both

Please send completed questionnaires to CDC Outbreak Response and Prevention Branch, Attn: Enteric Zoonoses Team Email: [email protected] Fax: 404-679-5073.

11. In the 7 days before your/your child’s illness began, did the dog/puppy have diarrhea?
(If “no” or “don’t know” skip to Question 12)
11a. In the 7 days before your/your child’s illness began, did your/your child’s dog/puppy die?

12. 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)
13. At what store did you purchase your dog?

Don’t know

Store Name:__________________________
Location:_____________________________
14. When did you purchase your dog? __ __ / __ __ / __ __ __ __
M

M

D

D

Y

Y

Y

Don’t know

Y

15. Do you have a loyalty/shopper card for a pet store where a dog/puppy was purchased, and would
you be willing to provide us the number? We will use this number to help gather information about
dogs/puppies purchased.
Store name: ___________________________________________
Number: ______________________________________________
Store name: ___________________________________________
Number: ______________________________________________
16. Do you have the microchip number for your dog/puppy, and would you be willing to provide us the
number? We may use this number to help determine where the dog came from, such as breeder.
Microchip number: ___________________________________

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 dogs/puppies in
a pet store, at a friend’s house, or other location?

2.

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)

3.

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

Don’t know

Name of store: _____________________________
Address of store: ___________________________
4.

When did you/your child have contact with a dog/puppy outside your home?
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
M

M

D

D

Y

Y

Y

Y

M

M

D

D

Y

Y

Y

Don’t know

Y

5.

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

6.

What was (were) the breed(s) of dog/puppy you/your child had contact with?

Unknown

Breed 1: ___________________ Breed 2:__________________ Breed3:______________________
7.

Did you/your child hold or snuggle the dog/puppy?
(If “no” or “don’t know” skip to Question 8)
7a. How often do you wash your hands/does your child wash his or her hands such as with soap
and water or hand sanitizer after touching the dog/puppy?
Always or almost always

Sometimes

Rarely

Never

7b. What do you/does your child use to wash your/his or her hands after touching the dog/puppy?
Soap and water

Alcohol-based hand sanitizer

Other

Nothing/Do not wash hands

Both

Please send completed questionnaires to CDC Outbreak Response and Prevention Branch, Attn: Enteric Zoonoses Team Email: [email protected] Fax: 404-679-5073.

8.

Did you/your child kiss the dog/puppy?

9.

Did you/your child ever feed or give water to the dog/puppy?

10. Did you/your child ever touch the dog’s/puppy’s cage/enclosure?
11. Did you/your child clean the cage/enclosure?
(If “no” or “don’t know” skip to Question 12)
11a. How often do you wash your hands/does your child wash his or her hands such as with soap
and water or hand sanitizer after touching the cage/enclosure?
Always or almost always

Sometimes

Rarely

Never

11b. What do you/does your child use to wash your/his or her hands after touching the
cage/enclosure?
Soap and water

Alcohol-based hand sanitizer

Other

Nothing/Do not wash hands

Both

12. Did you/your child pick up the dog’s/puppy’s poop?
(If “no” or “don’t know” skip to Question 13)
12a. How often do you wash your hands/does your child wash his or her hands such as with soap
and water or hand sanitizer after picking up the poop?
Always or almost always

Sometimes

Rarely

Never

12b. What do you/does your child use to wash your/his or her hands after picking up the poop?
Soap and water
Other

Alcohol-based hand sanitizer

Both

Nothing/Do not wash hands

13. In the 7 days before your/your child’s illness began, did any of the dogs/puppies you/your child
had contact with have diarrhea?
(If “no” or “don’t know” skip to Section 5)
13a. How many of the dogs/puppies had diarrhea? ________
13b. Did any of the dogs/puppies die? (If “no” or “don’t know” skip to Section 5)
13c. (If yes) How many of the dogs/puppies died? ________

Section 5: OTHER ANIMAL EXPOSURE DETAILS
Now, I have a few questions about any interaction you/your child may have had with other animals in the 7 days before illness began.
Yes

Maybe

No

Don’t
Know

1.

In the 7 days before your/your child’s illness began, did you/your child have any contact with any
other animal?
(If “no” or “don’t know” skip to Question 2)
1a. Cat or kitten?
1b. Live poultry, such as chickens or ducks?
1c. Other birds, such as pet birds or wild birds, such as parrots or pigeons?
1d. Other animal: _________________________
1e. In the 7 days before your/your child’s illness began, did you/your child have any contact
with any animal that had diarrhea?

2.

In the 7 days before your/your child’s illness began, did you/your child work at any pet store?

3.

In the 7 days before your/your child’s illness began, did you/your child visit any pet store?

4.

In the 7 days before your/your child’s illness began, did you/your child work or visit a petting zoo,
fair, exhibit or trade show?

5.

In the 7 days before your/your child’s illness began, did you/your child work or visit a farm or
ranch with animals present?

Please send completed questionnaires to CDC Outbreak Response and Prevention Branch, Attn: Enteric Zoonoses Team Email: [email protected] Fax: 404-679-5073.

Section 6: AWARENESS AND EDUCATION
The final questions have to do with your awareness of the connection between dogs and Campylobacter.
Yes

Maybe

No

Don’t
Know

1.

Before this illness, were you aware of the connection between dogs/puppies and Campylobacter
infection?
1a: How did you find this information? (Check all that apply)
Magazine/newspaper
Website/blog
Employee at retail store
Sign at retail store
Friend/family
Television
Veterinarian
Healthcare Provider
Other:_______________________________

Section 7: 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 Outbreak Response and Prevention Branch, Attn: Enteric Zoonoses Team Email: [email protected] Fax: 404-679-5073.