Form 0920-1011 Acute Flaccid Myelitis Case Questionnaire - English

Emergency Epidemic Investigation Data Collections - Expedited Reviews (Y3Q4)

Appendix 1. Questionnaire - English

Undetermined cause of Acute Flaccid Myelitis, multiple states, United States, 2018

OMB: 0920-1011

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Form Approved

OMB No. 0920-1011

Exp. Date 01/31/2020


Acute Flaccid Myelitis Case Questionnaire

Section 1: Interviewer & Patient Information (Questions 1-10 to be completed by interviewer prior to questionnaire administration)

  1. CDC ID #: ______________________

  1. State/Local/Other ID #: _______________________

  1. Date of Interview:

__ __ /_ _ / __ __ __ __ (if Don’t know, enter 99/99/9999)

M M/D D/Y Y Y Y

  1. Interviewer Information Name: ______________________________________ Agency or Organization: _______________________________

  1. Interview conducted By Phone In Person

  1. State and county of residence? State _______ County ____________________

  1. Patient name_______________________

  1. Sex: Male Female Don’t know

  1. Date of Birth : __ __ /_ _ / __ __ __ __ (if Don’t know, enter 99/9999) or Age at limb weakness onset date __________________

M M/D D/Y Y Y Y

  1. Limb weakness onset date: __ __ /_ _ /__ __ __ __ (if Don’t know, enter 99/9999)



(Please remember to use the appropriate language if the interviewee is the patient (adult case) or the parent of a child. Please do not interview children under 18 years old. Text in italics is for your information only and not to be read to the interviewee.)

Hello, my name is_________, and I am a [insert title] that works for [insert health department name]. May I please speak to a parent or guardian of [name]?

(If parent not there) OK. Can you suggest a better time to call back to reach __________?

(If yes, parent/guardian) CDC has confirmed [name]‘s case of AFM. We’d like to learn more about your child’s illness with AFM. We hope to take about an hour of your time. Is this a good time to talk?

(If no) Is there a better time that I may call back? ___________________

Thank you. To start I just want to tell you a little bit about why we want to ask you these questions. We have learned a lot about AFM in the past few years and we think viruses likely play a role in AFM. We would like to go through the course of [name]’s illness with you to learn more about how [his/her/your] symptoms developed. And for completeness, we will also ask you some questions about other things like contact with animals, activities, travel, and household items that are often asked about when we are trying to learn more about an illness. Your answers may help us understand more about this illness, and in turn help [name] and others.

We want you to know that just because we ask a question about an activity or product does not mean that we believe it is harmful or causes AFM; these questions will help us focus future work to understand AFM. If there are any questions you don’t feel comfortable answering, please let me know and we will skip them and move on.

  1. Respondent was: Patient (>18 years old) Mother Father Other (specify):_______________

  2. Language interview conducted in English Spanish Other (specify):_______________

Patient Information

First, I’d like to confirm a few details about [name] with you.

  1. Date of Birth: __ __/_ _ /__ __ __ __ (if Don’t know, enter 99/9999)

M M/D D/Y Y Y Y

  1. Is [name] (are you) Hispanic or Latino?

☐ Hispanic or Latino Not Hispanic or Latino

  1. How would you describe [name]’s race? You can say yes to all that apply:

☐ American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

  1. Did [name] experience limb weakness during 2018?

☐ No Yes

(If yes) our records show that the weakness started on ___/___/____

Is this right? No Yes Don’t know (if no) record date on ___/___/____

  1. Did [name] receive a diagnosis of AFM from a doctor?

☐ Yes No Don’t know

If no, what was your (child’s) diagnosis(es)?___________________________________________________________________________________________

Interviewee information

  1. (If interviewing patient, skip to 18b) a. Does [name] live with you?

☐ No, Do not live together. (If interviewee is not the primary parent, please ask to speak to the primary parent or for their contact information)

☐ Yes, Live together, Full time (Please fill out b-c) Yes, Part time: describe______________(Please fill out b-d)



b. How many people lived with you at the time [name] got sick? ___________

c. Can you tell me their names and ages and relationship to [name], including yourself? If you don’t want to give names, we can do what you are comfortable with like use initials. (Please add this information to Household 1 table).

d. (For those who live part time) Can you tell me about {name]’s other household? How many people were living there when he/she/you got sick? __________ (Please mark this in Household 2)

Comments_______________________________________________________________________________________________________________________

HOUSEHOLD 1

Name/Initials

Age (at the time of AFM patient’s illness)

Relationship

Is relationship step, half, or full?



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full

HOUSEHOLD 2

Name/Initials

Age (at the time of AFM patient’s illness)

Relationship

Is relationship step, half, or full?



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Mother Father Sister Brother Grandmother Grandfather Other__________

Step Half Full



Medical history

Now I’d like you to think back to [name]’s (your) health before s/he developed AFM.

  1. Was [name] born full-term or preterm (less than 36 weeks)?

☐ Full-term (37-40+ weeks)

☐ Preterm (<36 weeks)

☐ Don’t know

  1. Before [name] got sick, what kinds of doctors did he/she see regularly?

☐ Pediatrician Neurologist, for ___________ Immunologist, for ____________ Dermatologist for ___________ Allergist, for _______________

☐ ENT, for _______________ Other, describe & for _______________

  1. Has [name] (Have you) ever been diagnosed with any of the following conditions or have any medical conditions for which s/he regularly visits the doctor or takes regular medication for prior to onset of AFM? (Please indicate for which condition medication is taken)

Condition

Did he/she take medication for this?

What kind of medication?

How often?

Comments

Atopy





Asthma

Yes No

Med name_____________

Steroid/prednisone

OTC Allergy medication Inhaler

Other __________

On a regular basis As needed


Eczema

Yes No

Med name_____________

Steroid/prednisone

OTC Allergy medication Inhaler Other _______

On a regular basis As needed




Condition

Did he/she take medication for this?

What kind of medication?

How often?

Comments

Allergies

If yes, what is the allergy to?

Seasonal allergy

Food

Medication

Bees

Other please describe________

Yes No

Med name_____________

Steroid/prednisone

Inhaler

Topical

Oral/pill

OTC Allergy medication

Inhaler Other____________

Does he/she get allergy shots?

Yes (currently)

Yes (past, no longer receiving) No

Don’t know

On a regular basis As needed


Immunodeficiency /weakened immune system (severe combined immunodeficiency (SCID), conditions requiring a stem cell transplant, antibody deficiency)

If yes, describe______________

Yes No

Med name_____________

Other ________________

On a regular basis As needed


Lyme disease

Yes No

Med name_____________

Steroid/prednisone

OTC Allergy medication

Other ________________

On a regular basis As needed


Malnourishment or vitamin/mineral deficiency

Yes No

Med name_____________

On a regular basis As needed


Eating disorder

Yes No

Med name_____________

On a regular basis As needed




Condition

Did he/she take medication for this?

What kind of medication?

How often?

Comments

Autoimmune conditions

Rheumatoid arthritis

Yes No

(Medication Name)_____________

Steroid/prednisone

Non-steroidal anti-inflammatory

( OTC RX)

Other ________________

Is this medication given Orally

Topical

Injection Other________

On a regular basis As needed


Inflammatory bowel disease (IBD) (eg Crohn’s and ulcerative colitis) Note: NOT IBS

Yes No

(Medication Name)_____________

Steroid/prednisone

☐ Non-steroidal anti-inflammatory

( OTC RX)

Other immunosuppressant, ____________

Other ________________

Is this medication given Orally

Topical

Injection Other________

On a regular basis As needed


Type 1 diabetes

Yes No

(Medication Name)_____________

Is this medication given

Orally

Injection Other________

On a regular basis As needed


Psoriasis

Yes No

(Medication Name)_____________

Steroid/prednisone

Non-steroidal anti-inflammatory

( OTC RX)

Other immunosuppressant, ____________

Other ________________

Is this medication given

Orally Inhaled

Topical

Injection Other________

On a regular basis As needed


Condition

Did he/she take medication for this?

What kind of medication?

How often?

Comments

Lupus

Yes No

(Medication Name)_____________

Steroid/prednisone

Non-steroidal anti-inflammatory

( OTC RX)

Other immunosuppressant, ____________

Other ________________

Is this medication given Orally

Other________

On a regular basis As needed


Thyroid disease (Hashimoto’s, Graves’)

Yes No

(Medication Name)_____________

On a regular basis As needed


Other autoimmune condition

Describe_____________

Yes No

(Medication Name)_____________

Steroid/prednisone

Non-steroidal anti-inflammatory

( OTC RX)

Other immunosuppressant, ____________

Other ________________


Is this medication given Orally Inhaled

Topical

Injection Other________

On a regular basis As needed


Congenital condition (e.g., conditions your child had at birth such as cleft palate and cleft lip, heart defects, spina bifida), describe,_______________

Yes No

(Medication Name)_____________

Is this medication given Orally Inhaled Topical

Injection Other________

On a regular basis As needed


Other condition describe,_______________

Yes No

(Medication Name)_____________

Is this medication given Orally Inhaled Topical

Injection Other________

On a regular basis As needed




Condition

Did he/she take medication for this?

What kind of medication?

How often?

Comments

Are there any other medications that s/he is taking routinely?

Yes No

(Medication Name)_____________

Is this medication given Orally Inhaled Topical

Injection Other________

On a regular basis As needed


No medical conditions reported

Don’t know






  1. Before [name] developed AFM— was [name] ever admitted to the hospital (stayed overnight) for any reason?

☐ Yes No Don’t know

If yes, How many times has [name] (have you) been hospitalized overnight? #_________

Hospitalization #

What was the date of hospitalization? (MM/YYYY)

What was the reason for hospitalization?

Briefly describe (presenting reason, cause (if applicable)

1


Illness Surgery

Trauma Other, describe_________________


2


Illness Surgery

Trauma Other, describe_________________


3


Illness Surgery

Trauma Other, describe_________________



  1. Next we’d like to know if [name] has any blood relatives that have been diagnosed with any of the following conditions:

(Please add comments as necessary; such as the interviewee’s level of certainty about a diagnosis or disease severity.)

Condition

Immediate Family

Maternal relatives

Paternal relatives

Comments

Asthma

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Eczema

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Allergies

Seasonal allergy Food

Medication Bees

Other________

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Immunodeficiency/weakened immune system (eg antibody deficiency, condition requiring a stem cell transplant)

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Lyme disease

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Autoimmune conditions

Rheumatoid arthritis

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Inflammatory bowel disease (IBD) (eg Crohn’s and ulcerative colitis)

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Type 1 diabetes

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Psoriasis

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Lupus

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Thyroid disease (Hashimoto’s, Graves’)

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Other autoimmune condition

Describe____________________

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Neurologic illness

Polio

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Transverse myelitis

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Guillain-Barre Syndrome

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Parkinson’s disease

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Epilepsy

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Dementias (eg Alzheimer’s)

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Multiple sclerosis

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


Other neurologic illness, describe__________

Mother Father

Sister Brother

Grandmother

Grandfather

Aunt

Uncle

Grandmother

Grandfather

Aunt

Uncle


No medical conditions

Do not know

Illness history (30 days)

Now I’d like to ask some questions about the time when [name] developed limb weakness. For many questions we are interested in the 30 days prior to limb weakness. It may be helpful to look at a calendar for these questions.

  1. As we discussed earlier, [name] first experienced limb weakness on ____/____/________ (MM/DD/YYYY)

Based on this information the 30 day period before [name]’s (your) limb weakness would be the period from ____/____/________ to ____/____/________.

  1. In the 30 days before limb weakness onset, did [name] have any medical or dental procedures (including dental work like a cavity filling, tonsillectomy, or ear tubes)?

☐ Yes No Don’t know

If yes, please describe: _________________________________________________________________________________ approximate date __/___/_____

  1. In the 30 days before limb weakness onset, did [name] experience any physical trauma? This may include experiences such as a broken bone, injury requiring stitches, animal bite, or concussion.

☐ Yes No Don’t know

If yes,

What was the approximate date? __/___/_____

What type of trauma? Broken bone injury requiring stitches Concussion Animal bite Other, describe______________________________

Where on the body was the trauma? Check all that apply.

☐ Head Neck Leg ( Left Right) Arm ( Left Right) Trunk Other, describe: _______________________________________________

  1. In the 30 days before limb weakness onset, did [name] receive any shots? This may include vaccinations, flu shots, steroid injection, allergy shots, antibiotics injection, vitamin injections, other medications, etc. Yes No Don’t know

If yes, please answer the following questions about each injection.



Type of injection?

Description of injection (name, reason)

Date (DD/MM/YYYY)

Reaction?

Location of injection


Routine childhood vaccination

Flu shot

Antibiotic

Steroid

Other medication

Allergy shot

Vitamin/supplement

Other


__/__/____

Soreness around injection site

Fever

Other

Upper arm

Right Left

Thigh

Right Left

Buttocks

Other, describe________

Routine childhood vaccination

Flu shot

Antibiotic

Steroid

Other medication

Allergy shot

Vitamin/supplement

Other


__/__/____

Soreness around injection site

Fever

Other

Upper arm

Right Left

Thigh

Right Left

Buttocks

Other, describe________

Routine childhood vaccination

Flu shot

Antibiotic

Steroid

Other medication

Allergy shot

Vitamin/supplement

Other


__/__/____

Soreness around injection site

Fever

Other

Upper arm

Right Left

Thigh

Right Left

Buttocks

Other, describe________

Routine childhood vaccination

Flu shot

Antibiotic

Steroid

Other medication

Allergy shot

Vitamin/supplement

Other


__/__/____

Soreness around injection site

Fever

Other

Upper arm

Right Left

Thigh

Right Left

Buttocks

Other, describe________




  1. In the 30 days before limb weakness onset, did [name] come down with symptoms of an illness? These may include cold, cough, stomach aches, vomiting or diarrhea, body aches, fever, or other symptoms. (Some symptoms like fever may go away and then reappear right before limb weakness. Please record symptoms that recur as a separate illness in the second illness section.)

☐ Yes No Don’t know (if no or Don’t know, skip to question 30)

Illness #1: Did s/he have any of the following symptoms?

Symptoms (check yes or no for each)

Approximate date (DD/MM/YYYY)

Days prior to limb weakness

Were these symptoms present when limb weakness developed?

Fever? Yes No

☐ If yes, what was the highest measured? _______

☐ Subjective (d/n measure)


_____days

☐ Don’t know

☐ Yes No

Cold symptoms? Yes No

☐ Cough

☐ Runny nose

☐ Congestion

☐ Sore throat


_____days

☐ Don’t know

☐ Yes No

Gastrointestinal symptoms? Yes No

☐ Vomiting

☐ Diarrhea

☐ Nausea

☐ Stomach pains


_____days

☐ Don’t know

☐ Yes No

Rashes/Sores? Yes No

☐ Rash/sores on the palms

☐ Rash/sores on the soles of the feet

☐ Rash/sores in the diaper/underwear region

☐ Sores in the mouth


_____days

☐ Don’t know

☐ Yes No

☐ Other Please specify _______________


_____days

☐ Don’t know

☐ Yes No




  1. In the 30 days before limb weakness onset, did s/he have any other episodes of illness?

☐ Yes No Don’t know (if no or Don’t know, skip to question 30)

Illness #2:

Symptoms (check yes or no for each)

Approximate date (DD/MM/YYYY)

Days prior to limb weakness

Were these symptoms present when limb weakness developed?

Fever? Yes No

☐ If yes, what was the highest measured? _______

☐ Subjective (d/n measure)


_____days

☐ Don’t know

☐ Yes No

Cold symptoms? Yes No

☐ Cough

☐ Runny nose

☐ Congestion

☐ Sore throat


_____days

☐ Don’t know

☐ Yes No

Gastrointestinal symptoms? Yes No

☐ Vomiting

☐ Diarrhea

☐ Nausea

☐ Stomach pains


_____days

☐ Don’t know

☐ Yes No

Rashes/Sores? Yes No

☐ Rash/sores on the palms

☐ Rash/sores on the soles of the feet

☐ Rash/sores in the diaper/underwear region

☐ Sores in the mouth


_____days

☐ Don’t know

☐ Yes No

☐ Other Please specify _______________


_____days

☐ Don’t know

☐ Yes No




  1. Were any household members sick in the 30 days before you or [name]’s limb weakness?

☐ Yes No Don’t know (if no or Don’t know, skip to question 31)

(If the interviewee doesn’t recall all of the details, please mark don’t know and add any additional comments at the end of the table.)

Household member (Relationship and age)

Symptoms (check yes or no for each)

Duration of illness (days)

Did they seek medical attention?

Did [this person] get sick before or after [name]?

Household member #1 (Relationship and age)

Fever? Yes No

If yes, what was the highest measured? _______

Subjective (d/n measure)

Cold symptoms? Yes No

Cough

Runny nose

Congestion?

Gastrointestinal symptoms? Yes No

Vomiting

Diarrhea

Nausea

Stomach pains

Rashes/Sores? Yes No

Rash/sores on the palms

Rash/sores on the soles of the feet

Rash/sores in the diaper/underwear region

Sores in the mouth

Other. Please specify _______________

_____days

Don’t know

Yes, _________

No

Don’t know

AFM patient did not have any illness before limb weakness

Before

After

Same time

Don’t know



Household member (Relationship and age)

Symptoms (check yes or no for each)

Duration of illness (days)

Did they seek medical attention?

Did [this person] get sick before or after [name]?

Household member #2 (Relationship and age)

Fever? Yes No

If yes, what was the highest measured? _______

Subjective (d/n measure)

Cold symptoms? Yes No

Cough

Runny nose

Congestion?

Gastrointestinal symptoms? Yes No

Vomiting

Diarrhea

Nausea

Stomach pains

Rashes/Sores? Yes No

Rash/sores on the palms

Rash/sores on the soles of the feet

Rash/sores in the diaper/underwear region

Sores in the mouth

Other. Please specify _______________

_____days

Don’t know

Yes, _________

No

Don’t know

AFM patient did not have any illness before limb weakness

Before

After

Same time

Don’t know

Household member #3 (Relationship and age)

Fever? Yes No

If yes, what was the highest measured? _______

Subjective (d/n measure)

Cold symptoms? Yes No

Cough

Runny nose

Congestion?

Gastrointestinal symptoms? Yes No

Vomiting

Diarrhea

Nausea

Stomach pains

Rashes/Sores? Yes No

Rash/sores on the palms

Rash/sores on the soles of the feet

Rash/sores in the diaper/underwear region

Sores in the mouth

Other. Please specify _______________

_____days

Don’t know

Yes, _________

No

Don’t know

AFM patient did not have any illness before limb weakness

Before

After

Same time

Don’t know

Household member (Relationship and age)

Symptoms (check yes or no for each)

Duration of illness (days)

Did they seek medical attention?

Did [this person] get sick before or after [name]?

Household member #4 (Relationship and age)

Fever? Yes No

If yes, what was the highest measured? _______

Subjective (d/n measure)

Cold symptoms? Yes No

Cough

Runny nose

Congestion?

Gastrointestinal symptoms? Yes No

Vomiting

Diarrhea

Nausea

Stomach pains

Rashes/Sores? Yes No

Rash/sores on the palms

Rash/sores on the soles of the feet

Rash/sores in the diaper/underwear region

Sores in the mouth

Other. Please specify _______________

_____days

Don’t know

Yes, _________

No

Don’t know

AFM patient did not have any illness before limb weakness

Before

After

Same time

Don’t know

Household member #5 (Relationship and age)

Fever? Yes No

If yes, what was the highest measured? _______

Subjective (d/n measure)

Cold symptoms? Yes No

Cough

Runny nose

Congestion?

Gastrointestinal symptoms? Yes No

Vomiting

Diarrhea

Nausea

Stomach pains

Rashes/Sores? Yes No

Rash/sores on the palms

Rash/sores on the soles of the feet

Rash/sores in the diaper/underwear region

Sores in the mouth

Other. Please specify _______________

_____days

Don’t know

Yes, _________

No

Don’t know

AFM patient did not have any illness before limb weakness

Before

After

Same time

Don’t know

(Please capture In what order did these family members (including [name]) got sick.)

Additional comments:

Care received

Now we’d like to hear about visits to the doctor from the 30 days before limb weakness onset to when [name] was admitted to the hospital.

  1. How many times did [name] see a doctor before hospitalization? #____________

  2. I’d like to ask you a few questions about each visit. Let’s start with the first time [name] saw a doctor.

(If limb weakness was the reason for the visit, please either put the date or ‘0’ days before limb weakness. All patients should have at least one entry for this table. If the patient was admitted to the hospital as a result of the first visit to a doctor or clinic, please record the details that led up to the hospitalization. We do not need information from after admittance)


Visit 1

Visit 2

Visit 3

Visit 4

Where was [name] seen?

Doctor’s office

Urgent care

Emergency room

Other, describe

____________

Doctor’s office

Urgent care

Emergency room

Other, describe

____________

Doctor’s office

Urgent care

Emergency room

Other, describe

____________

Doctor’s office

Urgent care

Emergency room

Other, describe

____________

Why did you take [name] to the doctor?





Number of days before or after limb weakness onset of limb weakness





Who saw [name]?

Nurse

Doctor (Ped/FP)

Specialist, specify________

Other, specify___________

Don’t know

Nurse

Doctor (Ped/FP)

Specialist, specify________

Other, specify___________

Don’t know

Nurse

Doctor (Ped/FP)

Specialist, specify________

Other, specify___________

Don’t know

Nurse

Doctor (Ped/FP)

Specialist, specify________

Other, specify___________

Don’t know

Did [name] receive a diagnosis?

Yes, specify___________

No

Don’t know

Yes, specify___________

No

Don’t know

Yes, specify___________

No

Don’t know

Yes, specify___________

No

Don’t know




Visit 1

Visit 2

Visit 3

Visit 4

Did the doctor recommend any medications or treatments?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

What medications were given/prescribed?

Steroids

Antibiotics

Other_____________

Steroids

Antibiotics

Other_____________

Steroids

Antibiotics

Other_____________

Steroids

Antibiotics

Other_____________

Did the medications result in any improvement?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Did the doctor decide to admit [name] to the hospital on this visit?

Yes

No

Yes

No

Yes

No

Yes

No

Comments:






  1. In the 30 days before limb weakness onset, did [name] take any prescription or over-the-counter medications or supplements? This could include antibiotics, medications for asthma or allergies, vitamins, herbal or homeopathic remedies, nutritional supplements, or topical treatments like vapor rubs. (If any medications were noted above, please repeat them here to confirm was taken in the 30 days prior to limb weakness.)

Medication (name)

Type of medication

Method of administration

Frequency


Steroid/prednisone

Antibiotic

Insulin

ADHD med

OTC pain med/fever reducer

OTC cold/cough

Herbal or homeopathic remedies

Vitamins or nutritional supplements

Topical treatments

Other ________________

Don’t know

Inhaler

Oral

Topical

Injection

Other

________________

On a regular basis

As needed

One time prescription



Medication (name)

Type of medication

Method of administration

Frequency


Steroid/prednisone

Antibiotic

Insulin

ADHD med

OTC pain med/fever reducer

OTC cold/cough

Herbal or homeopathic remedies

Vitamins or nutritional supplements

Topical treatments

Other ________________

Don’t know

Inhaler

Oral

Topical

Injection

Other

________________

On a regular basis

As needed

One time prescription


Steroid/prednisone

Antibiotic

Insulin

ADHD med

OTC pain med/fever reducer

OTC cold/cough

Herbal or homeopathic remedies

Vitamins or nutritional supplements

Topical treatments

Other ________________

Don’t know

Inhaler

Oral

Topical

Injection

Other

________________

On a regular basis

As needed

One time prescription



  1. In the 30 days prior to limb weakness, did [name] follow any of the following special or restricted diets? (if yes/maybe please check all that apply)

Kosher

Halal

Raw foods

Low carb

Paleo (high protein, low carb)

Vegetarian/Vegan

Dairy-free

Gluten-free

Weight loss/low fat

Other, please describe: ____________________________________




  1. In the 30 days before limb weakness, did [name] consumed any raw or unpasteurized dairy products from a cow or other animal source? These might include raw milk, or homemade, farm‐fresh, and door‐to‐door cheeses.

If yes, please specify: ____________________________________________________________________________________________________________

Contacts

In this section we’d like to learn more about who [name] interacted with in the 30 days prior to developing their limb weakness.

  1. In the 30 days before limb weakness onset, did [name] attend daycare or school?

☐ Yes No, did not attend daycare or school Don’t know

If yes, specify:

☐ Daycare/Preschool (exclude nanny) School (K-12) Home schooled

  1. In the 30 days before limb weakness onset, did [name] attend any of the following activities with other kids?

☐ Before- or After-school Care Dance/sports/music/art class Scouts Day camp

☐ Sleepaway camp Church/Religious school Other, describe: _______________________________ No, did not attend any activities

  1. In the 30 days before limb weakness onset, did [name]’s daycare or school report any of the following illnesses amongst students?

☐ Respiratory infections Hand-foot-mouth disease Meningitis Acute flaccid myelitis Don’t know No

  1. In the 30 days before illness onset, did [name] participate in any of the following recreational water activities (select all that apply):

☐ Water park

☐ Lake/River

☐ Beach

☐ Public pool

☐ Private residence pool

☐ Don’t know

☐ Splash pad

☐ Other__________

☐ No

  1. In the 30 days before illness onset, did [name] participate in any of the following outdoor activities (select all that apply):

☐ Camping

☐ Amusement park

☐ Gardening/raking/moving/digging in soil

☐ Playing in sandbox

☐ Going to a farm/petting zoo

☐ Fishing

☐ Hiking

☐ Eating or picking wild plants (fruit, seeds, etc.) or mushrooms

☐ Other, describe: ________________

☐ Don’t know

☐ No



Travel history

  1. In the 30 days before limb weakness onset, did [name] take any overnight, out-of-town trips in the US or internationally? (Photos and social media can help with remembering dates and places)

☐ Yes No Don’t know

If yes, please describe

City, State or

City, Country

When did s/he go? (DD/MM/YYYY)

When did s/he come back? (DD/MM/YYYY)

How did s/he get there?

Did [name] come into contact with anyone sick?


___/___/______ Don’t know

___/___/______ Don’t know

☐ Personal vehicle

☐ Airplane

☐ Train Bus

☐ Other, describe: _________________

☐ Yes

☐ No

☐ Don’t know

If yes, describe: __________________________


___/___/______ Don’t know

___/___/______ Don’t know

☐ Personal vehicle

☐ Airplane

☐ Train Bus

☐ Other, describe: _________________

☐ Yes

☐ No

☐ Don’t know

If yes, describe: __________________________

Household

Now I’d like to ask you some questions about the home where [name] lived in the 30 days before limb weakness onset.

  1. Please describe the setting of this home:

☐ Urban Suburban Rural Other, describe______________

  1. Please describe the type of housing:

☐ Apartment Duplex Townhouse Single family home Mobile home Other, describe________________

  1. When was your home or apartment built?

☐ Before 1980? After 1980 Don’t know

  1. Was there any remodeling or renovation work done inside or to the outside of your home during the 12 months before limb weakness? This might include new construction or remodeling portions of the home, painting or removing/scraping paint, removing or installing carpeting, etc.

☐ Yes, describe ________________ No Don’t know

  1. In the past 12 months has [name] ever lived next door to or very near any of the following (check all that apply)

□ Industrial plant □ Commercial business □ Waste dump site □ Non-residential property □ Farm □ Construction site

  1. In the 12 months prior to [name]’s illness, did anyone in the household have a job that involves industrial chemicals or pesticides (eg zinc smeltering, using or making pesticides, plastics, polymer, or other manufacturing) (check all that apply)

□ Industrial plant □ Commercial business □ Waste dump site □ Non-residential property □ Farm □ Construction site

  1. How often does anyone smoke (cigarettes, cigars, pipe tobacco, or marijuana) inside your home? Would you say daily, weekly, monthly, less than monthly, or never?

□ daily □ Weekly □ Monthly □ Less than monthly □ Never □ Don’t know

Specific Exposures: Vectors

  1. In the 30 days before limb weakness onset, was [name] ever in an environment where you or others saw mosquitoes?

□ Yes □ No □ Don’t know

If yes, was [name] bitten by a mosquito? □ Yes □ No □ Don’t know

  1. In the 30 days before limb weakness onset, did you see a tick on [name]?

□ Yes □ No □ Don’t know

If yes, was [name] bitten by a tick? □ Yes □ No □ Don’t know

Specific Exposures: Environment

***If the child lives in multiple homes, please consider all homes in your answers to the questions in this section.***

  1. In the 30 days before limb weakness onset, was [name] in direct contact with any of the following chemicals (eg helped apply the chemical, touched items with the chemical on it, chemical was applied in his/her room?)

Please select all that apply.

□ Indoor pesticides or animal poison, describe type of contact with [name]____

□ Outdoor pesticides or animal poison, describe type of contact with [name]____

□ Outdoor fertilizer □ Solvents (paint thinner, lighter fluid, varnishes)

□ Insect repellents □ Treatments for scabies

□ Other, specify____________

□ Indoor pesticides or animal poison, describe_______

□ Outdoor pesticides or animal poison, describe________

□ Outdoor fertilizer

Solvens

□ Indoor pesticides or animal poison

□ Outdoor pesticides or animal poison

□ Outdoor fertilizer

□ Solvents (paint thinner, lighter fluid, varnishes)

□ Other, specify____________


□ Solvents (paint thinner, lighter fluid, varnishes)

□ Other, specify____________

□ Insect repellents

□ Treatments for scabies

  1. In the past 12 months has [name] ever lived next door to or very near any of the following (check all that apply)

☐ Industrial plant Commercial business Waste dump site Non-residential property Farm Construction site

  1. In the 12 months prior to [name]’s illness, did anyone in the household have a job that involves industrial chemicals or pesticides (eg zinc smeltering, using or making pesticides, plastics, polymer, or other manufacturing) (check all that apply)

☐ Industrial plant Commercial business Waste dump site Non-residential property Farm Construction site

  1. How often does anyone smoke (cigarettes, cigars, pipe tobacco, or marijuana) inside your home? Would you say daily, weekly, monthly, less than monthly, or never?

☐ Daily Weekly Monthly Less than monthly Never Don’t know

Specific Exposures: Vectors

  1. In the 30 days before limb weakness onset, was [name] ever in an environment where you or others saw mosquitoes?

☐ Yes No Don’t know

If yes, was [name] bitten by a mosquito? Yes No Don’t know

  1. In the 30 days before limb weakness onset, did you see a tick on [name]?

☐ Yes No Don’t know

If yes, was [name] bitten by a tick? Yes No Don’t know

Specific Exposures: Environment

(If the child lives in multiple homes, please consider all homes in your answers to the questions in this section.)

  1. In the 30 days before limb weakness onset, was [name] in direct contact with any of the following chemicals (eg helped apply the chemical, touched items with the chemical on it, chemical was applied in his/her room?)

Please select all that apply.

☐ Indoor pesticides or animal poison, describe type of contact with [name]__________________________________________________________________

☐ Outdoor pesticides or animal poison, describe type of contact with [name]_________________________________________________________________

☐ Outdoor fertilizer □ Solvents (paint thinner, lighter fluid, varnishes)

☐ Insect repellents □ Treatments for scabies

☐ Other, specify__________________________________________________________________________________________________________________

□ Indoor pesticides or animal poison, describe_______

□ Outdoor pesticides or animal poison, describe________

□ Outdoor fertilizer

Solvens

□ Indoor pesticides or animal poison

□ Outdoor pesticides or animal poison

□ Outdoor fertilizer

□ Solvents (paint thinner, lighter fluid, varnishes)

□ Other, specify____________


□ Solvents (paint thinner, lighter fluid, varnishes)

□ Other, specify____________

□ insect repellents

□ treatments for scabies

  1. Were there any pets in [name]’s household in the 30 days before s/he got sick?

☐ Dog(s) Cat(s) Bird(s) Small mammals (hamster, guinea pig, rabbits, etc) Reptiles (snakes, lizards) Bird(s) Other ________________



  1. From where does [name] get drinking water? Please select all sources from which [name] has had water in the last 30 days before limb weakness onset. Municipal (Tap water) Private well Bottled Stream/River/Lake Other

If other, please describe: _____________________________________

  1. Do you treat your drinking water?

☐ Do not treat Boil Add bleach/chlorine Use a water filter Deionize Other

If yes OR other, please describe: _______________________________

A few last things

  1. Thanks for finishing the questionnaire….How is [name] doing? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  2. If you wish to share, what do you think caused you or [name]’s illness? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  3. Is there anything else you would like to share, or anything additional about you or [name] that you think we should know?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

That completes the interview. Thank you for taking the time to answer these questions. Your responses may be helpful in preventing others from becoming sick. If you have more questions about AFM please consult our website at: https://www.cdc.gov/acute-flaccid-myelitis

Public reporting burden of this collection of information is estimated to average 60 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)

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AuthorRose, Erica (CDC/DDID/NCIRD)
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