Appendix C - Survey Instrument 2

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Appendix C. Survey Instrument 2

The U.S. Centers for Disease Control and Prevention is doing a survey to investigate several cases of drug-resistant shigellosis in the United States. Shigellosis is a diarrheal illness caused by the bacteria Shigella. You are invited to take part in this survey because you recently had an illness caused by drug-resistant Shigella.

By taking part in this survey, you will help - us to learn how people became sick. This will help improve prevention efforts. Your participation is voluntary, and you may skip any question you do not want to answer.

The survey includes questions about recent activities and symptoms of your illness. Some of these questions are sensitive in nature, but your answers will be kept confidential and private. The survey will take about 10 minutes to complete.

Screening

1. Are you 18 years of age or older?

   1. Yes

   2. No (if no, end survey)

2. Have you completed this online survey before?

   1. Yes (if yes, end survey)

   2. No

SURVEY

1. What is your age in years?

   1. Fill in blank

2. What is your state (or territory) of residence?

   1. Drop Down

3. What is your zip code?

   1. Fill in blank

4. What is your first and last initial? (If you prefer not to answer, please type “NA” in both fields below)

   1. First initial

      1. Fill in blank

   2. Last initial

      1. Fill in blank

Section 2: CASE INFORMATION

1. What sex were you assigned at birth, on your original birth certificate?

   1. Female

   2. Male

2. Do you consider yourself to be Hispanic or Latino?

   1. Yes

   2. No

3. Which racial group or groups do you consider yourself to be in? [select all that apply]

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Pacific Islander

   5. White

   6. Other not listed here

Section 3: HOUSEHOLD INFORMATION

1. In the past 30 days, did you double up or stay overnight with friends, relatives, or someone you didn’t know well because you didn’t have a regular place to stay at night? ☐ Yes ☐ No ☐ Prefer not to answer ☐ Unknown

2. In the past 30 days, were you ever homeless? That is, were you living on the street, in a shelter, in a single room occupancy hotel, or in a car? ☐ Yes ☐ No ☐ Prefer not to answer ☐ Unknown

3. What is the water source at your primary place of residence?

☐ Municipal ☐ Well ☐ Unknown ☐ Other

4. How many people, including you, live in your primary place of residence? _______

Section 4: EXPOSURE INFORMATION
Yes	No	Don’t Know
☐	☐	☐	In the 7 days before your illness started, did you spend any time outside of your home state?
			If yes to 1, list all U.S. states where you traveled: _________________________________________________________
			If yes to 1, list all countries outside the United States where you traveled: __________________________________________________
			If yes to 1, did you travel on a cruise? Yes (specify)__________________ No
			In the 7 days before your illness started, did you attend, visit, work in, or volunteer at any of the following: [select all that apply]
☐	☐	☐	A religious gathering (such as church, mosque, or synagogue)?
☐	☐	☐	Camp?
☐	☐	☐	Conference or other large meeting?
☐	☐	☐	Festival, fair, play, or concert?
☐	☐	☐	Party, picnic, or barbeque?
☐	☐	☐	Sports practice, sports game, or exercise class?
☐	☐	☐	A place that serves food, such as a restaurant or cafeteria?
☐	☐	☐	A homeless shelter?
☐	☐	☐	A health care facility?
☐	☐	☐	A nursing home, long term care, or assisted living facility?
☐	☐	☐	Other gathering of people I did not ask about?
Yes	No	Don’t Know	In the 7 days before your illness started, did you do any of the following: [select all that apply]
☐	☐	☐	Drink water from an untreated source, such as lake, pond, or river?
☐	☐	☐	Eat any foods prepared by a friend, neighbor, or coworker in their home?
☐	☐	☐	Eat any foods prepared by a catering company? (such as food served at a wedding or conference?)
☐	☐	☐	Eat at a restaurant?
☐	☐	☐	Swim in treated water, such as a swimming pool?
☐	☐	☐	Swim in untreated water, such as a lake, river, or ocean?
☐	☐	☐	Play in an interactive water fountain, water table, children’s pool, kiddie pool, or baby pool?
☐	☐	☐	In the 7 days before your illness started, did you have contact with someone with diarrhea (at least 3 loose, watery stools in 24 hours) or symptoms like your symptoms?
☐	☐	☐	If yes to 4, was this person diagnosed with a Shigella infection?
☐	☐	☐	If yes to 4, was this person a member of your household?
			While you were sick with the Shigella infection, did you do any of the following:
☐	☐	☐	Prepare or handle food for other people?
☐	☐	☐	Go swimming or play in a swimming pool, baby pool, interactive fountain, or water table?
☐	☐	☐	Visit, work in, or volunteer at a healthcare facility?
☐	☐	☐	Visit, work in, or volunteer at a nursing home, long term care, or assisted living facility?
☐	☐	☐	Visit, work in, volunteer, or attend a school or childcare facility?
☐	☐	☐	Visit, work in, volunteer, or attend any gathering of people? For example, a picnic, party, concert, conference, or religious gathering.

Section 5: CHILD CARE AND SCHOOL INFORMATION
Yes	No	Don’t Know
☐	☐	☐	In the 7 days before your illness started, did you visit, work in, volunteer, or attend a child care center, daycare, or preschool?
			If yes to 1, what is the name of the facility? ______________________________
☐	☐	☐	If yes to 1, at this facility were there any other children or adults ill with diarrhea (at least 3 loose, watery stools in 24 hours) or symptoms like yours before you became ill?
☐	☐	☐	In the 7 days before your illness started, did you attend, visit, work in, or volunteer in a school (such as an elementary, middle, after school center, or other type of school)?
			If yes to 2, what is the name of the school? ______________________________
☐	☐	☐	If yes to 2, at this school were there any other children or adults ill with diarrhea (at least 3 loose, watery stools in 24 hours) or symptoms like yours before you became ill?

The next module asks about your recent sexual activity because Shigella can be spread through sexual contact. Your answers to these questions will be kept private and may help us to identify how you became sick with a Shigella infection. This will also help us to prevent others from getting sick.

Section 6: RECENT SEXUAL ACTIVITY
Which of the following best represents how you think of yourself? [select one] Gay (lesbian or gay) Straight, this is not gay (or lesbian or gay) Bisexual Something else I don’t know the answer
How do you describe your gender identity? [select one] Female Male Male-to-female transgender Female-to-male transgender Other gender identity (specify):)___________________
Yes	No	Don’t Know
☐	☐	☐	Are you currently sexually active? Sexual activity includes genital sex, anal sex, oral sex, or any other sexual contact.
☐	☐	☐	If yes to 3, in the 7 days before your illness started, did you have sexual contact with another person? Sexual contact would include genital sex, anal sex, oral sex, or any other sexual contact.
			If yes to 3a, were your sex partners (select all that apply): ☐ Female ☐ Male ☐ Transgender Woman ☐ Transgender Man ☐ Another ☐ Unknown ☐ Prefer Not to Answer
☐	☐	☐	If yes to 3a, in the 7 days before your illness started did any of your sex partners have diarrhea or symptoms like your own?
			If yes to 3a. In the 7 days before your illness started, what kind of sexual contact did you have? Oral sex (give) Oral sex (receive) Anal sex (give) Anal sex (receive) Vaginal sex Rimming (give) Rimming (receive) Fingering (give) Fingering (receive) Sharing sex toys Group sex (sex with more than 1 partner)
			If yes to 3a. In the 7 days before your illness, how many sex partners did you have? (specify):_________
☐	☐	☐	If yes to question 3aiv, were any of these partners new?
			If yes to 3a, in the 7 days before your illness started, did you meet your new sex partner(s) at any of the following places? (select all that apply) Bar, restaurant or club Bathhouse Bookstore Gym Park Social media site Dating or hookup site Party, conference, or other type of event Sex club or sex party Other location

3. In the 7 days before your illness started, how often did you engage in the following behaviors?

	Never	Rarely	Occasionally	Frequently	Always	Not applicable
	1	2	3	4	5	N/A
Wash your hands before eating	1	2	3	4	5	N/A
Wash your hands after using the bathroom	1	2	3	4	5	N/A
Wash your hands after sex or sexual activity	1	2	3	4	5	N/A
Swallow pool water	1	2	3	4	5	N/A
Swallow ocean water	1	2	3	4	5	N/A
Swallow hot tub water	1	2	3	4	5	N/A
Wash genitals and anus before sex or sexual activity	1	2	3	4	5	N/A
Use barriers when rimming	1	2	3	4	5	N/A
Use gloves or barriers when fingering or fisting	1	2	3	4	5	N/A
Use barriers during anal sex	1	2	3	4	5	N/A
Douche prior to sex or sexual activity	1	2	3	4	5	N/A

Section 7: CLINICAL INFORMATION
When did your symptoms start? Calendar function
When did your symptoms end? Calendar function
For how many days were you sick? Number
Yes	No	Don’t Know	Have you had any of the following symptoms?
☐	☐	☐	Diarrhea (at least 3 loose, watery stools in 24 hours)
			When did your diarrhea start? Calendar function
			When did your diarrhea end? Calendar function
			How many days did you have diarrhea? Number
☐	☐	☐	Bloody stools/bloody diarrhea
☐	☐	☐	Nausea
☐	☐	☐	Vomiting
☐	☐	☐	Abdominal pain/cramps
☐	☐	☐	Achy joints/muscles
☐	☐	☐	Fever
☐	☐	☐	Headache
☐	☐	☐	Tenesmus (or feeling the need to pass stool [poop] even when bowels are empty)
☐	☐	☐	Other symptom not listed

Section 8: MEDICAL CARE AND TREATMENT INFORMATION
Yes	No	Don’t Know
☐	☐	☐	Did you seek medical care for your symptoms?
			If yes to question 1, where did you seek medical care? (select all that apply) ☐ Primary care physician ☐ Urgent care ☐ STD clinic ☐ Emergency department ☐ Unknown ☐ Other
☐	☐	☐	If yes to question 1, In addition to infection with Shigella, did your doctor tell you that you were sick with any other infection(s)? [select all that apply]
			Traveler's diarrhea Food poisoning Giardiasis/Giardia Amebiasis/Entamoeba histolytica Norovirus infection Cryptosporidiosis/Cryptosporidium Campylobacteriosis/Campylobacter Other, not listed here
			If yes to question 1, Were you hospitalized for more than 24 hours for your illness? Yes No
☐	☐	☐	Did you take any antibiotics for this illness?
			If yes to question 3, What type of antibiotic did you take? [select all that apply] Ampicillin Azithromycin Ciprofloxacin Ceftriaxone Trimethoprim-sulfamethoxazole Other More than one antibiotic course (Specify):___________________ Do not know
			If yes to question 3, How many days of antibiotics were you prescribed? (Specify):___________________
			If yes to question 3, For how many days did you take antibiotics? Number
			If yes to question 3, What day did you first start taking antibiotics? Calendar function
☐	☐	☐	If yes to question 33, in the 24 hours after taking the antibiotic(s), did your symptoms ☐ Get better/Improve ☐ Stay the Same ☐ Get Worse ☐ Other
☐	☐	☐	In the 30-days before your illness, did you receive or take any antibiotics? If yes to 4, What type of antibiotic did you take? [select all that apply] Ampicillin Azithromycin Ciprofloxacin Ceftriaxone Trimethoprim-sulfamethoxazole Other not listed More than one antibiotic course (Specify):___________________ Don’t know

Final Module

5. While you had symptoms of stomach or intestinal illness with diarrhea, or in the week after you had symptoms, did you engage in any of the following activities? [select all that apply]

   1. Prepare food for others

   2. Swim in a public swimming pool or public hot tub

   3. Have sex or engage in sexual activity

   4. Work in a healthcare facility, restaurant, childcare setting, or homeless shelter

6. Can we share your survey information with your local health department?

   1. Yes

      1. If yes to 6. Would you be willing to be contacted by your local health department to follow-up on your responses?

         1. Yes, please provide my contact information to my local health department.

            1. If yes, Fill in blank

         2. No, do not contact me again.

Thank you for taking this survey. For more information about shigellosis please go to www.cdc.gov/shigella

<<<END OF SURVEY>>>

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-XXXX