Appendix 4 - Example of Personal Interview Questionnaire

EEI GenICR 0920-13ZJ_App 4_Q Fever Person Interview Questionnaire_11-14-2013_Subm.docx

Emergency Epidemic Investigation Data Collections - Expedited Reviews (Y3Q4)

Appendix 4 - Example of Personal Interview Questionnaire

OMB: 0920-1011

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Appendix 4. Personal Interview Example Questionnaire – Q Fever


Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX













Q Fever Questionnaire























Public reporting burden of this collection of information is estimated to average XX minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Family ID: _______________ Participant ID: _____________ Interviewer Name: ____________________________________

Date of interview: ____________________________________ GPS coordinates: _____________________________________



Q Fever Questionnaire

Section I: Demographic and Contact Information


1. Name: ___________________________________________________________________


Shape4 2. DOB: ____/____/_______ 3. Sex: Male (1)

Shape5 Female (2)


Shape6 4. Are you Hispanic or Latino? Yes (1) No (2)


5. What is your race? (Select one or more responses.)

Shape7 American Indian or Alaska Native

Shape8

Asian

Shape9 Black or African American

Shape10 Native Hawaiian or Other Pacific Islander

Shape11 White


6. Street address:__________________________________________________________


7. City: ______________________ 8. State: ________ 9. Zip: ___________


10. Contact phone number : ________________________________


11. Email address: ________________________________________________





Section II: Exposure History

12a. Do you live on a property with animals? Yes (1) No (2)

If yes, complete this section; if no skip to question 13.


Which animals? Yes (1) No (2)

12b. Goats

12c. Cats

12d. Dogs

12e. Cows

12f. Sheep

12g. Horses

12h. Other, please specify: _________________________________________________________


13a. Do you work with animals in your profession? Yes (1) No (2)

If yes, complete this section; if no, skip to question 14.

13b. What is your profession? ________________________________________________________


Which animals? Yes (1) No (2)

12b. Goats

12c. Cats

12d. Dogs

12e. Cows

12f. Sheep

12g. Horses

12h. Other, please specify: _________________________________________________________


14. Is the place where you live within 1 mile of any livestock? Yes (1) No (2)

15. Is the place where you work within 1 mile of any livestock? Yes (1) No (2)

16. Have you been on any ranches or farms since [INSERT DATE]? Yes (1) No (2)

If yes, complete this section: if no skip to question 19.


17. Location of ranches or farms? ___________________________________________________________

____________________________________________________________________________________

_____________________________________________________________________________________


18. While you were on a ranch or farm did you have contact with any of the following animals? Yes (1) No (2)

18a. Goats

18b. Cats

18c. Dogs

18d. Cows

18e. Sheep

18f. Horses

18g. Other, please specify: _________________________________________________________



For each animal type in the following questions, try to recall any type of contact/activity with the animal since September 1, 2010. Include any contact/activity, even if you mentioned it already.

19a. Goats Yes (1) No (2)

If yes, complete this section: if no, skip to question 20.


Daily(1)

Several times/ week (2)

Several times/ month (3)

Hardly ever (4)

Never (5)

19b.

Near vicinity(same premises, but not close proximity)






19c.

Close proximity (within 6 feet)






19d.

Direct contact (touching/ handling)






19e.

Feed






19f.

Groom






19g.

Clean animal holding area






19h.

Remove manure






19i.

Replace bedding






19j.

Slaughter






19k.

Vaccinate or give medicine






19l.

Help or observe a birth






19m.

Direct contact with a newborn






19n.

Direct contact with a dead animal






19o.

Direct contact with afterbirth or birth products








Shape12 Shape13 20. Cows Yes (1) No (2)

If yes, complete this section; if no, skip to question 21.


Daily(1)

Several times/ week (2)

Several times/ month (3)

Hardly ever (4)

Never (5)

20b.

Near vicinity(same premises, but not close proximity)






20c.

Close proximity (within 6 feet)






20d.

Direct contact (touching/ handling)






20e.

Feed






20f.

Groom






20g.

Clean animal holding area






20h.

Remove manure






20i.

Replace bedding






20j.

Slaughter






20k.

Vaccinate or give medicine






20l.

Help or observe a birth






20m.

Direct contact with a newborn






20n.

Direct contact with a dead animal






20o.

Direct contact with afterbirth or birth products







Shape14 Shape15 21a. Sheep Yes (1) No (2)

If yes, complete this section; if no, skip to question 22.



Daily(1)

Several times/ week (2)

Several times/ month (3)

Hardly ever (4)

Never (5)

21b.

Near vicinity(same premises, but not close proximity)






21c.

Close proximity (within 6 feet)






21d.

Direct contact (touching/ handling)






21e.

Feed






21f.

Groom






21g.

Clean animal holding area






21h.

Remove manure






21i.

Replace bedding






21j.

Slaughter






21k.

Vaccinate or give medicine






21l.

Help or observe a birth






21m.

Direct contact with a newborn






21n.

Direct contact with a dead animal






21o.

Direct contact with afterbirth or birth products







22. Have any animals that you have been exposed to since [INSERT DATE] been ill with any of the following symptoms?

Shape16 Shape17 22a. Abortion Yes (1) No (2) 22b. If yes, what animals(s)? ___________ 22c. Newborn death Yes (1) No (2) 22d. If yes, what animals(s)? ___________

22e. Poor doer Yes (1) No (2) 22f. If yes, what animals (s)? ___________

22g.Weak newborn Yes (1) No (2) 22h. If yes, what animals (s)? ___________

22i. Decreased fertility Yes (1) No (2) 22j. If yes, what animals (s)? ___________


23. What time of year do the livestock you been exposed to give birth?


N/A

(1)

Dec-Feb

(2)

Mar-May

(3)

Jun-Aug

(4)

Sep-Nov

(5)

All Year

(6)

Unk

(9)

23a. Goats








23a. Cows








23a. Sheep









24a. How do you dispose of dead goats, cows, or sheep (including dead fetuses or newborn)?

Compost (1) Incinerate (2) Burial (3) Other (4) N/A (5)


24b. If other, please describe: ________________________________________________________


25a. Do you clean/disinfect an area after an animal has given birth? Yes (1) No (2)

25b. If yes, please explain: _______________________________________________________________


26. What is done with the manure (animal waste) from the livestock you care for?

  • Nothing- don’t pick it up (1)

  • Spread in fields (2)

  • Spread in garden (3)

  • Sell it/give it away (4)

  • N/A (5)




Section III: Medical History


27a. Do you recall having an illness with fever since [INSERT DATE]? Yes (1) No (2)

If yes, complete this section; if no, skip to questions 28

27b. When approximately did this illness begin? _____________________ Don’t remember (99)

27c. How many days did the illness last? ____________________________ Don’t remember (99)

27d. Did you miss work due to Illness? Yes (1) No (2)

27e. If yes, how many days were you out? ___________________________

27f. Did you seek medical attention for this illness? Yes (1) No (2)

27g. Physician’s name: ______________________________________________________________ Unk (9)

27h. Visit date: _____/_____/______ (Unk) 9

27i. Were you hospitalized due to this illness? Yes (1) No (2)

If yes, complete this section; if no, skip to question 27m.

27j. Name of hospital: _______________________________________________________________ Unk (9)

27k. Admit date: ____/_____/_____ Unk (9)

27l. Discharge date ____/____/_____ Unk (9)

27m. What diagnosis did you receive for this illness? ________________________________________________


28. Since [INSERT DATE], have you experienced/were you told by your doctor you had any of the following symptoms/ conditions?



Yes

(1)

No

(2)

Unk

(9)



Yes

(1)

No

(2)

Unk

(9)

28n.

Fever




28o.

Joint Pain




28p.

Chills




28q.

Back pain




28r.

Insomnia




28s.

Jaundice




28t.

Cough




28u.

Myocarditis




28v.

Nausea




28w.

Osteomyelitis




28x.

Anorexia




28y.

General fatigue




28z.

Stiff neck




28aa.

Night sweats




28bb.

Hepatitis




28cc.

Weight loss




28dd.

Pneumonia




28ee.

Shortness of breath




28ff.

Endocarditis




28gg.

Diarrhea




28hh.

Meningitis




28ii.

Muscle pain




28jj.

Headache




28kk.

Abdominal pain




28ll.

Rigors




28mm.

Hepatomegaly




28nn.

Rash




28oo.

Miscarriage




28pp.

Chest pain




28qq.

Guillain-Barre




28rr.

Vomiting










28ss. Is there anything else you would like to share about your illness?

29a. Do you have any history of heart problems? Yes (1) No (2)

29b. if yes, please explain: ______________________________________________________

30. Do you currently smoke or have you smokes since [INSERT DATE]?

Yes (1) No (2)

31. Since [INSERT DATE], have you consumed raw (unpasteurized) dairy products, such as goat cheese?

Yes (1) No (2)







Section IV: Human Lab Data

Serum specimen 1

32. Sample date: ____/___/_____

33. IgG Phase I: _________________ 34. IgG Phase II: __________________________

34. IgM Phase I: _________________ 36. IgM Phase II: __________________________


Serum specimen 2

37. Sample date: ____/___/_____

38. IgG Phase I: __________________ 39. IgG Phase II: ____________________________

40. IgM Phase I: __________________ 40. IgM Phase II: ____________________________


42a. Category of analysis: Case (1) Control (2)

42b. if case’ Probable (1) Confirmed (2)

2



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