Data Collection Forms 01OCT2018 - 31DEC2018

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Patient Screening Questionnaire

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)

Patient ID ____ ____ - ____
Answers are being provided on behalf of:
□ Self
□ Child
Please answer the questions to the best of your ability. It is ok to say you don’t know.
1. Our records show that you (your child) was diagnosed with RMSF in ___________(mm/yyyy). Is this correct?
Yes
/
No
/
Don’t know
--If no, please provide us with the approximate date in which you (your child) had RMSF:
__________(mm/yyyy)
2. Our records also show that you (your child) left the hospital on __________________(MM/DD/YYY). Is this
correct?
Yes
/
No
/
Don’t know
3. After you left the hospital, where did you (your child) go?
□ Home
□ Another hospital
□ Nursing home

□ Rehabilita5on facility

□ Other
□ Don’t remember
Name of facility:

_______________________________________________________

How long were you there?

____________________

4. On a scale of 1 to 5 how would you rate your (your child’s) overall ability to function before your RMSF illness?
(Unable to function in my daily life) 1 — 2 — 3 — 4 — 5 (perfectly able to function)
5.

Do you feel like you (your child) has recovered fully from your RMSF illness?
Yes
/
No
/
Don’t know
--If yes:
how long did it take to get back to normal?

___________________

--If no:
have your (your child’s) symptoms improved over time?
Yes
/
No
/
Don’t know
what symptoms are you (your child) still experiencing?

_____________________________

______________________________________________________________________________
--If don’t know, proceed to next question.
6. On a scale of 1 to 5 how would you rate your (your child’s) overall ability to function since your (their) RMSF
illness?
(Unable to function in my daily life) 1 — 2 — 3 — 4 — 5 (perfectly able to function)

Patient ID ____ ____ - ____

7. Have you (your child) been diagnosed with neurologic illness since your (their) RMSF illness (such as a stroke,
dementia, Parkinson’s Disease, etc.)
Yes
/
No
/
Don’t know
--If yes:
what was the illness? __________________________________
when was it diagnosed? ________________________________

8. Are there any activities which you (your child) used to do before your RMSF illness that you (they) are unable to
do at this time?
Yes
/
No
/
Don’t know
--If yes:
please list which activities:
_____________________________________________________________________________________
_______________________________________________________________________
do you think this change is due to your (their) RMSF illness?
Yes

/

No

/

Don’t know

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Neurologic Exam Form
Final

Public reporting burden of this collection of information is estimated to average 40 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 (0920-1011)

NEUROLOGIC EXAM FORM
Patient data (remove top page following exam)
Patient’s Name:

PATIENT ID ___ ___ ___ ___
First Name

Last Name
Date of Birth:

_______/_______/_______
MM

Tribal community:

DD

Gender:

M

YYYY

Tribal affiliation:

FINAL

F

NEUROLOGIC EXAM FORM
PATIENT ID ___ ___ ___ ___

Date of RMSF onset:

Age at illness (years):______

_______/_______/_______
MM

DD

Neurologic exam completed?
If yes,

Yes

Date of exam:

If no, why not?

Deceased

I. Altered mental status

Current age (years): _____

YYYY

No

_______/_______/_______
MM

DD

Lost to follow up

Altered

Did not consent

Normal

Provider performing exam: __________________________________

YYYY

Other, describe: _______________________________________________________

Unknown/Unable to determine

(If altered or unknown, proceed to II. Mental status examination, otherwise skip to III. Language)

II. Mental status (8 years and older) (as determined by the healthcare provider using the Montreal Cognitive Assessment (MOCA))
(If less than 8 years skip to section IV, cranial nerve assessment.)
Visuospatial/executive:

(5)

Attention:

(6)

Abstraction:

(2)

Orientation

(6)

Naming:

(3)

Language:

(3)

Delayed recall

(5)

TOTAL:

(30)

III. Language (8 years and older)
Normal

Expressive aphasia

Global aphasia

Receptive aphasia

Dysarthria

Description of difficulty:

IV. Cranial nerves
CN I

Normal

Abnormal, describe: __________________________________

CN II
Pupil exam

Normal

Abnormal, describe: ____________________

Accommodation

Normal

Abnormal, describe: ____________________

Visual field

Normal

Visual acuity
Fundoscopic exam

CN VI

Normal

Abnormal, describe: __________________________________

CN VII

Normal

Abnormal, describe: ___________________________________

CN VIII

Normal

Abnormal, describe: __________________________________

Abnormal, describe: ____________________

CN IX

Normal

Abnormal, describe: __________________________________

Normal

Abnormal, describe: ____________________

CN X

Normal

Abnormal, describe: __________________________________

Normal

Abnormal, describe: ____________________

CN XI

Normal

Abnormal, describe: __________________________________

CN XII

Normal

Abnormal, describe: __________________________________

CN III

Normal

Abnormal, describe: __________________________________

CN IV

Normal

Abnormal, describe: __________________________________

CN V

Normal

Abnormal, describe: __________________________________

V. Sensory
Upper extremities

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

Lower extremities

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

Core

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

Face

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

VI. Motor
A. Abnormal movements
Fasiculations

Yes

No

Comments: ___________________________________________________

Tremor

Yes

No

Comments: ___________________________________________________

Chorea/dyskinesias

Yes

No

Comments: ___________________________________________________

Myoclonus

Yes

No

Comments: ___________________________________________________

B. Bulk
Atrophy

Yes

No

Comments: ___________________________________________________

Upper extremities

Normal

Increased (spastic or rigid)

Decreased

Comments: ___________________________________________________

Lower extremities

Normal

Increased (spastic or rigid)

Decreased

Comments: ___________________________________________________

Core

Normal

Increased (spastic or rigid)

Decreased

Comments: ___________________________________________________

C. Tone

D. Other upper motor neuro signs
R

L

Pronator drift

Yes

No

Yes

No

Comments: ___________________________________________________

Finger tap speed

Normal

Slow

Normal

Slow

Comments: ___________________________________________________

Foot tap speed

Normal

Slow

Normal

Slow

Comments: ___________________________________________________

NEUROLOGIC EXAM FORM
PATIENT ID ___ ___ ___ ___
E. Strength (0 = No movement; 1 = Barely discernable movement; 2 = Movement along plane of gravity; 3 = Movement against gravity; 4 = Movement against
resistance; 5 = Normal)

Neck flexors
Neck extensors

Lower extremity:
R

_______________

L
Hip flexors

_______________

Hip extensors

Upper extremity:
R

L

Hip abduction

Deltoids

Hip adduction

Biceps

Quadriceps

Triceps

Hamstrings

Wrist extensors

Plantarflexors

Wrist flexors

Dorsiflexors

Finger extensors

Foot evertors

Finger flexors

Foot invertors

Abductor pollicis brevis

Extensor hallucis longus

Opponens pollicis

Toe flexors

Interossei

Toe extensors

VII. Reflexes (0 = Absent; 1 = Decreased; 2 = Normal; 3 = Increased/hyperactive; 4 = sustained clonus)
R

L
Excessive jaw jerk

Brachioradialis

Yes

Biceps

No

R

Triceps

Sustained ankle clonus

Patellar

Plantar response
(Babinski)

Yes
Up

L

No
Down

│
Unclear │

Yes
Up

No

Down

Unclear

Ankle jerk

VIII. Coordination

R

Comments:

L

Finger-to-nose

Normal

Dysmetric

Other

Normal

Dysmetric

Other

______________________________________

Heel-knee-shin

Normal

Dysmetric

Other

Normal

Dysmetric

Other

______________________________________

Past-pointing

Normal

Overshoot

Other

Normal

Overshoot

Other

______________________________________

Check reflex

Normal

Loss of check reflex

Normal

Loss of check relfex

Other

Other ______________________________________

IX. Gait and station
Spontaneous gait

Normal

Hemiplegic

Able to walk on toes

Yes

No

Able to walk on heels

Yes

No

Able to tandem

Yes

No

Romberg

Positive

Negative

Steppage

Shuffling

Other, describe: _______________________________________________________

Unable to assess

X. Additional narrative/comments:

Modified Rankin Scale (Determined by healthcare provider at exam)
Use pediatric modified Rankin for children less than 8 years of age (appendix A)
0 = No symptoms at all
1 = No significant disability despite symptoms; able to carry our all usual duties and activities
2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
3 = Moderate disability; requiring some help, but able to walk without assistance
4 = Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5 = Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 = Dead

SCORE (0 – 6):

_____________

NEUROLOGIC EXAM FORM
PATIENT ID ___ ___ ___ ___

Appendix A: Modified Rankin Scale for children

Appendix 1: Questionnaire
Updated: August 28, 2018

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Survey ID __________________________

Section 1: Questions about travel to Mexico and the southwest
United States
Yes

No
1.

Did you attend a service trip to the Tijuana area of Mexico at any time during July 2018?
(Note that the Tijuana area is directly south of the San Diego metro area. For purposes of
this survey, please consider nearby towns, including Rosarito and La Joya as part of the
Tijuana area.)

If Q1 is “No”, END survey. Thank you for participating in the survey.
2.

3.

Yes

When did you arrive in Mexico for this trip?
(If you don’t know, check the box for “don’t know” and record your best guess)
__ __ / __ __ / __ __ __ __
Don’t know
MM D D
Y Y Y Y
When did you leave Mexico at the end of this trip?
(If you don’t know, check the box for “don’t know” and record your best guess)
__ __ / __ __ / __ __ __ __
Don’t know
MM D D
Y Y Y Y
No

 SKIP if
Q4 is No
Yes

As part of this trip, did you travel anywhere else in Mexico before arriving in the Tijuana
area?

5.

If yes, specify_______________________

6.

As part of this trip, did you travel anywhere else in Mexico after leaving the Tijuana area?

7.

If yes, specify_______________________

No

 SKIP if
Q6 is No
Yes

4.

No
8.

As part of this trip, did you spend time in California or Arizona? (Please don’t count travel
directly between the San Diego airport and the Mexico border)
 SKIP if
9. If yes, specify location(s) ______________________
Q8 is No 10. Specify amount of time___________________
Don’t
Yes
No
Know
11. Before this service trip, had you previously traveled to the Tijuana area or other
parts of northwestern Mexico (i.e., the states of Baja California and Sonora)?
 SKIP if Q11 is No or 12. If yes, in which years? Specify_______________ (If you don’t remember exactly,
don’t know
please use your best guess)
Don’t
Yes
No
Know
13. Before this service trip, had you previously traveled to southern California or
Arizona?
 SKIP if Q13 is No or 14. If yes, in which years? Specify________________(If you don’t remember exactly,
don’t know
please use your best guess)
Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Section 2: Questions about your activities during travel to Mexico
Yes

No

Don’t
Know

15. Did you help build houses during the 2018 service trip?
16. How many houses did you work on during this trip?
1
2
3
4
5 or more
We would like to know which houses you worked on and what type of soil-related activities you did each day of
your trip. We have provided pictures of the houses along with their location names to help you identify them as
best you can. Please answer as best you can remember, even if you’re not sure.
House A (Castores) Next to a school, and view of a valley at the end of the street.
House B (Rosarito) Urban nice neighborhood.
House C (Cumbres) Top of a hill with breezy ocean view.
17. On Monday, which house did you work at?
House A
House B
House C
Other. Specify_____________ (describe the house the best you
can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban location,
whether it was next to a school, whether there were many stray dogs, and whether you saw a valley or an
ocean)
Don’t For about how
As best you can recall, did you do the following activity?
Yes
No
Know many hours total?
19. _______hours
18. Digging trenches or holes
21. _______hours
20. Shoveling or wheelbarrowing dirt/soil
22. Mixing/making cement from dry ingredients (sand and
23. _______hours
gravel)
25. _______hours
24. Filling or passing buckets with sand or soil
27. _______hours
26. Filling or passing buckets with cement
29. _______hours
28. Passing empty buckets
30. Backfilling the trench (putting dirt back into the foundation of
31. _______hours
the house)
33. _______hours
32. Compacting dirt/soil in the trench
35. _______hours
34. Cutting and bending rebar
37. _______hours
36. Tying rebar for the floor or the roof
39. _______hours
38. Laying blocks in the trench to make walls
41. _______hours
40. Building the roof
43. _______hours
42. Other activities, specify__________
45. _______hours
44. Other activities, specify__________
46. Did you use any of the following tools this day? (check all that apply)
Shovel
Pick
Electric tamper/soil compactor
Manual tamper/soil compactor
Wheelbarrow
Other, specify ____________
47. How much of the time while you were working on the house this day was there dust in the air you were
breathing?
All of the time
Most of the time
Some of the time
Rarely
Never
Don’t know
Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
48. During times when you could see dust in the air, did you wear any type of covering over your mouth and
nose at any time this day?
No
Bandanna
Dust mask
Respirator (e.g., N-95)
Other, specify __________________
Don’t
Yes
No
Know
49. Did you notice dust on your clothes at the end of this day?
 Skip if Q49 is No or 50. If yes, how dusty was your clothes?
Don’t know
Extremely dusty
Very dusty
Mildly dusty
Just a little bit of dust
 Skip if Q49 is No or 51. As best as you can recall, what was the color of the dust?
Don’t know
Black
Tan brown
Mustard yellow
Other. Specify______
 Skip if Q49 is No or 52. Where did you shake off your dusty clothes at the end of the day?
Don’t know
Specify______________
Don’t
Yes
No
Know
53. Were you near someone moving or digging dirt?
 Skip if Q53 is No or
54. If yes, what do you consider near? Specify ________feet
Don’t know
55. On Tuesday, which house did you work at?
House A
House B
House C
Other. Specify_____________ (describe the house the best you
can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban
location, whether it was next to a school, whether there were many stray dogs, and whether you saw a
valley or an ocean)
Don’t For about how
As best you can recall, did you do the following activity?
Yes
No
Know many hours total?
57. _______hours
56. Digging trenches or holes
59. _______hours
58. Shoveling or wheelbarrowing dirt/soil
60. Mixing/making cement from dry ingredients (sand and
61. _______hours
gravel)
63. _______hours
62. Filling or passing buckets with sand or soil
65. _______hours
64. Filling or passing buckets with cement
67. _______hours
66. Passing empty buckets
68. Backfilling the trench (putting dirt back into the foundation of
69. _______hours
the house)
71. _______hours
70. Compacting dirt/soil in the trench
73. _______hours
72. Cutting and bending rebar
75. _______hours
74. Tying rebar for the floor or the roof
77. _______hours
76. Laying blocks in the trench to make walls
79. _______hours
78. Building the roof
81. _______hours
80. Other activities, specify__________
83. _______hours
82. Other activities, specify__________
84. Did you use any of the following tools this day? (check all that apply)
Shovel
Pick
Electric tamper/soil compactor
Manual tamper/soil compactor
Wheelbarrow
Other, specify ____________
Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
85. How much of the time while you were working on the house this day was there dust in the air you were
breathing?
All of the time
Most of the time
Some of the time
Rarely
Never
Don’t know
86. During times when you could see dust in the air, did you wear any type of covering over your mouth and
nose at any time this day?
No
Bandanna
Dust mask
Respirator (e.g., N-95)
Other, specify __________________
Don’t
Yes
No
Know
87. Did you notice dust on your clothes at the end of this day?
 Skip if Q87 is No or 88. If yes, how dusty was your clothes?
Don’t know
Extremely dusty
Very dusty
Mildly dusty
Just a little bit of dust
 Skip if Q87 is No or 89. As best as you can recall, what was the color of the dust?
Don’t know
Black
Tan brown
Mustard yellow
Other. Specify______
 Skip if Q87 is No or 90. Where did you shake off your dusty clothes at the end of the day?
Don’t know
Specify______________
Don’t
Yes
No
Know
91. Were you near someone moving or digging dirt?
 Skip if Q91 is No or
92. If yes, what do you consider near? Specify ________feet
Don’t know
93. On Wednesday, which house did you work at?
House A
House B
House C
Other. Specify_____________ (describe the house the best you
can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban
location, whether it was next to a school, whether there were many stray dogs, and whether you saw a
valley or an ocean)
Don’t For about how
As best you can recall, did you do the following activity?
Yes
No
Know many hours total?
95. _______hours
94. Digging trenches or holes
97. _______hours
96. Shoveling or wheelbarrowing dirt/soil
98. Mixing/making cement from dry ingredients (sand and
99. _______hours
gravel)
101._______hours
100.Filling or passing buckets with sand or soil
103._______hours
102.Filling or passing buckets with cement
105._______hours
104.Passing empty buckets
106.Backfilling the trench (putting dirt back into the foundation of
107._______hours
the house)
109._______hours
108.Compacting dirt/soil in the trench
111._______hours
110.Cutting and bending rebar
113._______hours
112.Tying rebar for the floor or the roof
115._______hours
114.Laying blocks in the trench to make walls
117._______hours
116.Building the roof
119._______hours
118.Other activities, specify__________
121._______hours
120.Other activities, specify__________
Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
122.Did you use any of the following tools this day? (check all that apply)
Shovel
Pick
Electric tamper/soil compactor
Manual tamper/soil compactor
Wheelbarrow
Other, specify ____________
123.How much of the time while you were working on the house this day was there dust in the air you were
breathing?
All of the time
Most of the time
Some of the time
Rarely
Never
Don’t know
124.During times when you could see dust in the air, did you wear any type of covering over your mouth and
nose at any time this day?
No
Bandanna
Dust mask
Respirator (e.g., N-95)
Other, specify __________________
Don’t
Yes
No
Know
125.Did you notice dust on your clothes at the end of this day?
 Skip if Q125 is No
126.If yes, how dusty was your clothes?
or Don’t know
Extremely dusty
Very dusty
Mildly dusty
Just a little bit of dust
 Skip if Q125 is No
127.As best as you can recall, what was the color of the dust?
or Don’t know
Black
Tan brown
Mustard yellow
Other. Specify______
 Skip if Q125 is No
128.Where did you shake off your dusty clothes at the end of the day?
or Don’t know
Specify______________
Don’t
Yes
No
Know
129.Were you near someone moving or digging dirt?
 Skip if Q129 is No
130.If yes, what do you consider near? Specify ________feet
or Don’t know
131.On Thursday, which house did you work at?
House A
House B
House C
Other. Specify_____________ (describe the house the best you
can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban
location, whether it was next to a school, whether there were many stray dogs, and whether you saw a
valley or an ocean)
Don’t For about how
As best you can recall, did you do the following activity?
Yes
No
Know many hours total?
133._______hours
132.Digging trenches or holes
135._______hours
134.Shoveling or wheelbarrowing dirt/soil
136.Mixing/making cement from dry ingredients (sand and
137._______hours
gravel)
139._______hours
138.Filling or passing buckets with sand or soil
141._______hours
140.Filling or passing buckets with cement
143._______hours
142.Passing empty buckets
144.Backfilling the trench (putting dirt back into the foundation of
145._______hours
the house)
147._______hours
146.Compacting dirt/soil in the trench
149._______hours
148.Cutting and bending rebar
151._______hours
150.Tying rebar for the floor or the roof
153._______hours
152.Laying blocks in the trench to make walls
155._______hours
154.Building the roof
Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
157._______hours
159._______hours

156.Other activities, specify__________
158.Other activities, specify__________
160.Did you use any of the following tools this day? (check all that apply)
Shovel
Pick
Electric tamper/soil compactor
Manual tamper/soil compactor
Wheelbarrow
Other, specify ____________
161.How much of the time while you were working on the house this day was there dust in the air you were
breathing?
All of the time
Most of the time
Some of the time
Rarely
Never
Don’t know
162.During times when you could see dust in the air, did you wear any type of covering over your mouth and
nose at any time this day?
No
Bandanna
Dust mask
Respirator (e.g., N-95)
Other, specify __________________
Don’t
Yes
No
Know
163.Did you notice dust on your clothes at the end of this day?
 Skip if Q163 is No
164.If yes, how dusty was your clothes?
or Don’t know
Extremely dusty
Very dusty
Mildly dusty
Just a little bit of dust
 Skip if Q163 is No
165.As best as you can recall, what was the color of the dust?
or Don’t know
Black
Tan brown
Mustard yellow
Other. Specify______
 Skip if Q163 is No
166.Where did you shake off your dusty clothes at the end of the day?
or Don’t know
Specify______________
Don’t
Yes
No
Know
167.Were you near someone moving or digging dirt?
 Skip if Q167 is No
168.If yes, what do you consider near? Specify ________feet
or Don’t know
169.On Friday, which house did you work at?
House A
House B
House C
Other. Specify_____________ (describe the house the best you
can such as how far it was from the Posada, whether it was paved road, whether it was rural or urban
location, whether it was next to a school, whether there were many stray dogs, and whether you saw a
valley or an ocean)
Don’t For about how
As best you can recall, did you do the following activity?
Yes
No
Know many hours total?
171._______hours
170.Digging trenches or holes
173._______hours
172.Shoveling or wheelbarrowing dirt/soil
174.Mixing/making cement from dry ingredients (sand and
175._______hours
gravel)
177._______hours
176.Filling or passing buckets with sand or soil
179._______hours
178.Filling or passing buckets with cement
181._______hours
180.Passing empty buckets
182.Backfilling the trench (putting dirt back into the foundation of
183._______hours
the house)
185._______hours
184.Compacting dirt/soil in the trench
187._______hours
186.Cutting and bending rebar
189._______hours
188.Tying rebar for the floor or the roof

Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
191._______hours
193._______hours
195._______hours
197._______hours

190.Laying blocks in the trench to make walls
192.Building the roof
194.Other activities, specify__________
196.Other activities, specify__________
198.Did you use any of the following tools this day? (check all that apply)
Shovel
Pick
Electric tamper/soil compactor
Manual tamper/soil compactor
Wheelbarrow
Other, specify ____________
199.How much of the time while you were working on the house this day was there dust in the air you were
breathing?
All of the time
Most of the time
Some of the time
Rarely
Never
Don’t know
200.During times when you could see dust in the air, did you wear any type of covering over your mouth and
nose at any time this day?
No
Bandanna
Dust mask
Respirator (e.g., N-95)
Other, specify __________________
Don’t
Yes
No
Know
201.Did you notice dust on your clothes at the end of this day?
 Skip if Q201 is No
202.If yes, how dusty was your clothes?
or Don’t know
Extremely dusty
Very dusty
Mildly dusty
Just a little bit of dust
 Skip if Q201 is No
203.As best as you can recall, what was the color of the dust?
or Don’t know
Black
Tan brown
Mustard yellow
Other. Specify______
 Skip if Q201 is No
204.Where did you shake off your dusty clothes at the end of the day?
or Don’t know
Specify______________
Don’t
Yes
No
Know
205.Were you near someone moving or digging dirt?
 Skip if Q205 is No
206.If yes, what do you consider near? Specify ________feet
or Don’t know
Don’t
Yes
No
Know
207.Did you play volleyball at the Posada on this trip?
208. If yes, how many times did you play at the volleyball court?
 Skip if Q207 is No
Once
Twice
Three times
More than three times
209.Please describe any other place that appeared very dusty. Specify__________________

Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Section 3: General Questions About Valley Fever
This section includes questions about Valley fever and working in dusty places. Answers to these
questions can help improve public communications to prevent the disease.
Yes

No
210.Before August 2018, had you heard of Valley fever (coccidioidomycosis)?

 Skip if
Q210 is
No
Yes
No

211.If yes, where or how had you heard of it? Specify______________

212.Before August 2018, did you know that people can get fungal infections from breathing in
dust in certain places?
213.Did you take any special efforts to reduce the amount of dust that was created?

 Skip if
Q213 is
214.If yes, specify_______________
No
215.What are ways that people can minimize the amount of dust they breathe when doing construction work?
Specify _________________________________
Yes
No
216.Did you take any special efforts to reduce the amount of dust that you inhaled?
 Skip if
Q216 is
217.If yes, specify_______________
No

Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Section 4: Questions About Your Experience After Returning from
Mexico
Don’t
Know

Did you experience any of the following during or in the 4 weeks after your volunteer
service trip to Mexico?
218.Fever
219.Fatigue
220.Chest pain
221.Chills
222.Painful joints
223.Painful muscles
224.Cough
225.Shortness of breath
226.Any rashes? (painful or itchy red lumps on skin)
227.Night sweats
228.Headache
229.Weight loss
230.Do you still have any of these symptoms?
231.Did you have any other symptoms? Specify ____________
232.Did you have any other symptoms? Specify ____________
Don’t
Yes
No
Know
233.Did you have any respiratory symptoms or fever (for example, like from a cold or
flu) that started during your recent travel to Mexico or in the four weeks after
returning?
234.If yes, what date did you first feel sick? (If you don’t know, check the box for “don’t
 Skip to Q245 if
know” and record your best guess)
Q233 is No or
__ __ / __ __ / __ __ __ __
Don’t know
Don’t know
M M D D Y Y Y Y
 Skip to Q245 if
Q233 is No or
235.If yes, how many days did your illness last? Specify__________
Don’t know
Yes
No
 Skip if Q233 is
236.Were you unable to do your normal activities because of this
No or Don’t
illness?
know
 Skip if Q236 is
237.If yes, how many days? Specify___________________
No
Yes
No
 Skip if Q233 is
238.Did you visit the emergency room for this respiratory illness
No or Don’t
in July or August 2018?
know
 Skip if Q233 is
No or Don’t
239.Were you hospitalized for this illness in July or August 2018?
know
 Skip if Q239 is
240.If yes, how many days were you hospitalized in July or August 2018?
No
Specify______________
Yes

No

Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
 Skip if Q239 is
No
 Skip if Q241 is
No
 Skip if Q239 is
No
 Skip if Q243 is
No
Don’t
Yes
No
Know
 Skip if Q245 is
No
 Skip if Q245 is
No

 Skip if Q245 is
No
 Skip if Q248 is
No
 Skip if Q245 is
No or Don’t
know
 Skip if Q245 is
No or Don’t
know
 Skip if Q245 is
No or Don’t
know
 Skip if Q245 is
No or Don’t
know
Yes

No

Don’t
Know

 Skip if Q254 is
No or Don’t
know
Don’t
Yes
No
Know

Yes

No

241.If yes to hospitalized, were you put on a ventilator (breathing
machine) in July or August 2018?
242.If yes, how many days were you on a ventilator in July or August 2018?
Specify__________
Yes
No
243.If yes to hospitalized, were you in the intensive care unit in
July or August 2018?
244.If yes, how many days were you in the intensive care unit in July or August 2018?
Specify________________
245.Did you see a healthcare provider during your recent travel to Mexico or in the four
weeks after returning to the United States?
246.If yes to healthcare provider, what was the reason for visiting a healthcare
provider? Specify ___________________
247.If yes to healthcare provider, how many times did you visit a healthcare provider
during this period?
once
twice
three times
four times
five
times or more
Yes
No
248.If yes to healthcare provider, was this for any type of
respiratory symptoms or fever (for example, like from a cold
or flu)?
249.If yes to respiratory symptoms, what did the healthcare provider tell you was the
cause of your illness? Specify ___________________
Don’t know
Yes
No
Don’t Know
250.Did you receive a chest x-ray in July or
August 2018?
251.Were you given any medication for this
respiratory illness in July or August 2018?
252.Did you take anti-fungal medication
(Examples: Amphotericin B, Ambisome,
Diflucan, Fluconazole, Itraconazole,
Voriconazole, Posaconazole)?
253.Did you take antibiotic medication
(Example: amoxicillin, doxycycline,
cephalexin, ciprofloxacin, clindamycin,
metronidazole, azithromycin,
sulfamethoxazole/trimethoprim)?

254.Did you take anything over the counter (without prescription)?
255.If yes to over the counter, specify medication________________

Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)

 Skip if Q261 is
No or Don’t
know

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020
256.Were you ever diagnosed with Valley fever before traveling to Mexico in summer
2018?
257.Were you diagnosed with Valley fever after returning from Mexico in summer
2018?
258.Did you take a corticosteroid (for example, prednisone) in the 4 weeks before your
recent travel to Mexico?
259.Do you have diabetes?
260.Do you have lung disease such as COPD, asthma, or emphysema?
261.Do you have any condition that weakens your immune system (for example, cancer,
HIV, transplant, or medication that weakens your immune system)?
262.If yes, specify ___________________

Section 5: Demographic Questions
263.Which State and city do you reside in?

State _____

City ____________

264.Age________
265.Sex:
Male
266.How do you describe your race? (select all that apply)
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
267.How do you describe your ethnicity?
Hispanic
Non-Hispanic
268.What is your occupation?

Student

Faculty

Female
Asian

Other. Specify_______________

269.What is the name of the school you attend or teach at? Specify________________

Section 6: COMMENTS
If there is any other information you would like to share about your travel or Valley fever?

Public reporting burden of this collection of information is estimated to average 20 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 (0920-1011)