Appendix 3 - Example of Hantavirus Questionnaire

Appendix 3. Hantavirus Pulmonary Syndrome Questionnaire

Form Approved

OMB No. 0920XXXX Exp. Date XX/XX/XXXX

Hantavirus 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)

Contact information

First I want to make sure we have the correct contact information for you.

1. Last name______________________________ 2. First name ______________ 3. M.I_____

4. Date of Birth____________________________5. Sex

6. Address________________________________7.City_____8.State_____9. Zip_______

10. Phone 1:_______________________Home/Work/Cell/Other Phone 2:________________

11. Are you Hispanic or Latino?

• Yes

• No

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

• American Indian or Alaska Native

• Asian

• Black or African American

• Native American or Other Pacific Islander

• White

13. (If surrogate is answering the questions), What is your relationship to the case?

• Spouse or domestic partner

• Sibling

• Friend

• Other, specify:

14. What is your occupation? ___________________________

Section B: These next questions may require you to look at a calendar (as we are trying to collect accurate information about your stay and your lodging)

1. Did you visit [INSERT LOCATION] between <date> And <date>? Yes  No		1b. Did you stay overnight at [INSERT LOCATION] during your visit? Yes proceed to question 2 No
2. How many different locations did you stay? ____________ 2b. Name(Location) Date Stayed Type of Lodging 1_________________________________________________ 2._________________________________________________ 3._________________________________________________ 4._________________________________________________
3. What type of place did you stay at (record dates)? “Signature cabin” _____________ (< ask if it was a cabin numbered in the 900s>>) Regular Tent-Cabin ______________ Wood of log cabin _______________ i. With a bath: ____________ ii. Without a bath: ____________ Lodge (please specify): Other (please specify) :			3b. Which part of the [INSERT LOCATION] was the lodging located, what room number was the lodging, could you describe to me the lodging structure.
	LODGING AREA 1					LODGING AREA 2	LODGING AREA 3	LODGING AREA 4	LODGING AREA 5
4. Did you see any live or dead rodents? (Inside/Outside)	Y/N/DK I/O					Y/N/DK I/O	Y/N/DK I/O	Y/N/DK I/O	Y/N/DK _____
5. What type of rodent (s) did you see? (check all that apply) can also add ground squirrels as an option	Mouse Rat Other:					Mouse Rat Other:	Mouse Rat Other:	Mouse Rat Other:	Mouse Rat Other:
6. Did you see any rodent droppings? (Inside/Outside)	Y/N/DK I/O					Y/N/DK I/O	Y/N/DK I/O	Y/N/DK I/O	Y/N/DK _____
7. Did you see any rodent nests? (Inside/Outside)	Y/N/DK I/O					Y/N/DK I/O	Y/N/DK I/O	Y/N/DK I/O	Y/N/DK _____
8. Did I you see or hear any other signs of rodent activity (e.g. noises, mouse holes, gnaw marks, food)? (Inside /Outside)	Y/N/DK I/O					Y/N/DK I/O	Y/N/DK I/O	Y/N/DK I/O	Y/N/DK _____
9. Did you handle :  Rodents  Y  N  DK  Droppings  Y  N  DK  Nests  Y  N  DK  Other, specify: __________	7a. Type of rodent:_________________ 7b. Did you wear gloves:  Y  N  DK 7c. Did you wash your hands after handling:  Y  N  DK
10. Did you get bitten or scratched by any wildlife?  Yes  No	8b. Which species of animal: _______________ 8c. Cleaning procedure: _________________
11. Did you clean, dust or sweep any part of the lodging?  Y  N  DK
12. Did you eat food inside your lodging? __ Y  N  DK 12b. Did you store food inside your lodging? __ Y  N  DK If yes, proceed to 13 and 14_____________
13. Did you put food in the bear box?  Y  N  DK 14. Did you notice any mouse activity or mouse droppings in the bear box?  Y  N  DK
15. During your stay, did you sleep?  On the floor with or without a mattress  Off the floor ( e.g. bed or cot)  Other, specify: ___________________
16. Was any of your luggage or personal belongings placed under the beds or stored on the floor?  Yes  No				If so, were these materials subsequently placed on the beds?  Yes  No
17. If you slept in a tent cabin which bed did you sleep on (when facing the cabin door):  Bed to the left  Bed to the right  Bed against the back wall 18. Can you describe the condition of your mattress:  New  Old ?
19. When you slept: (use diagram for clarification-may be best to carefully define what each of these positions means) Did your head face the wall? Was your head next to the heater? Was your head facing the door? Was your head away from the door? Was your head near the window?
20. What kind of linens did you use? Provided by the park Own linens brought from home
21. What kind of pillow did you use? Provided by the park Own pillow brought from home
22. Did you: Turn the heater on at any point in your stay? Use a fan in your cabin? Sleep with your window flaps open? Sleep on your stomach?
23. How many hours did you stay in your lodging each day For sleeping at night only For sleeping plus 2-3 hours per day Was in the lodging for most of the day and night ( 15 hours per day or longer) _____________					How long were you in bed/sleeping in your lodging each night_________ Did you (or anyone) get up in the middle of the night and leave the cabin (e.g. bathroom, fresh air)____________ Did anyone in your party open the door in the middle of the night_______
19. When you slept: (use diagram for clarification-may be best to carefully define what each of these positions means) Did your head face the wall? Was your head next to the heater? Was your head facing the door? Was your head away from the door? Was your head near the window?
20. What kind of linens did you use? Provided by the park Own linens brought from home
21. What kind of pillow did you use? Provided by the park Own pillow brought from home
22. Did you: Turn the heater on at any point in your stay? Use a fan in your cabin? Sleep with your window flaps open? Sleep on your stomach?
23. How many hours did you stay in your lodging each day For sleeping at night only For sleeping plus 2-3 hours per day Was in the lodging for most of the day and night ( 15 hours per day or longer) _____________					How long were you in bed/sleeping in your lodging each night_________ Did you (or anyone) get up in the middle of the night and leave the cabin (e.g. bathroom, fresh air)____________ Did anyone in your party open the door in the middle of the night_______
24. How and where do you believe you were infected? ___________
25. During your stay, did you or any members of your party perform, any of the following activities? If yes, location (s) this activity occurred: Cleaning: __________ Dusting: __________ Sweeping: _________ Moving/ rearranging: __________ Digging in the ground/ collecting natural souvenirs/artifacts: _____________ Building a campfire and handling or collecting firewood: ____________ Feeding/ leaving food out for wildlife: _________ Other activities that may have resulted in dust (explain): ___________
26. Which of the following activities did you do during your trip? Visitor’s center Museum Gallery Native American village (if yes, did they enter any of the dugout structures?) Nature Centers Horseback riding Rock climbing Hiking Biking

• Valley tour

• River activities (e.g. swimming, wading, tubing

• Other (<<can you describe any other activities or places you may have visited during your trip>>)

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Section C: Medical History << I’d like for you to take a moment and tell me about your illness>>

1. On what date did you first begin to feel ill after your visit to Yosemite? ______________________ (mm/dd/yy)
2. What were the first symptoms you had? ______________________________________________________________________________________________
3. Which of the following symptoms did you have: (circle those that apply) Fever Upper respiratory symptoms (e.g. cough, runny nose) Muscle ache Abdominal pain Chills Nausea/vomiting Diarrhea Headache Cough Shortness of breath
4. When did you first see a doctor? Yes No	Name Phone# 1. _________________________________ 2. What was the initial diagnosis (if known)? ____________________________________
5. Were you hospitalized for this illness? Yes No	Name and phone # of hospital and /or provider? ________________________ Did you stay overnight? ______ Were you in the Intensive Care Unit? ______ Did you require a ventilator/breathing tube? ______ Date admitted/ Date Discharged? ______________
6. Was anyone who stayed with you in Yosemite have been ill afterwards? Yes No	Name of person: ____________________________ Phone number: ______________________________ Relationship: _________________________________
7. Do you suffer from any medical conditions: Cardiovascular disease (e.g. CHF) Pulmonary disease (e.g. COPD, Asthma) Diabetes
Renal disease Liver disease Autoimmune /Connective Tissue ( e.g. RA., SLE) Cancer Organ transplant Suppressed Immune System (e.g. HIV, prednisone therapy) Other, please specify
8. Have you taken any medications within 4 weeks of presentation of current illness: Antibiotics: ________________________________________________________________ Anti-convulsants: __________________________________________________________ Antidepressants and psychiatric drugs: _________________________________________ Antihistamines: ____________________________________________________________ Anti-inflammatory /analgesics: _______________________________________________ Anti-virals: ________________________________________________________________ Asthma medications: ________________________________________________________ Chemotherapeutics: ________________________________________________________ Insulin: ___________________________________________________________________ Steroids: __________________________________________________________________ Other:_____________________________________________________________________
9. Do you smoke? Yes  No	How much do you smoke each day? < 1pk/day 1-2 pk/day >2 pk/day

Section D: << I’m going to asking you a few more questions about recent travel- just to find out if there any other places that you may have been >>

1. Have you traveled away from home (includes day and over night trips) Yes  No Unsure/Don’t know	If Yes the answer the following for each trip: City State Country Dates ___________________________________________ ___________________________________________ ___________________________________________
2. Have you traveled away outside the U.S. (includes day and overnight trips): Yes No	If Yes the answer the following for each trip: City State Country Dates ___________________________________________ ___________________________________________ ___________________________________________
3. Were there other people who stayed overnight with you (e. g. in the same room, same campground, same party)? Yes  No	For other attendees, specific Name Relationship Phone # 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________

<Is possible to talk to someone that you stayed with during your visit? We will be discussing with them may of the same questions that we have already talked about today.

Again, the information you provide is essential to us finding out if there was something from your visit that made people ill making sure that no other people are put at risk.

Thank you very much for your time today. Do you have any questions today? If you think of anything after we talk today, here is a number to call ( ). At times, other questions may come to mind, if they do would you mind if I contact you again. If so, what time works best for you?

Thank you and have a good day.

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