0920-1011 Survey - Day 0

Form Approved. OMB No. 0920-1011 Exp. 08/02/2020

S ARS-CoV-2 Cook County Questionnaire V22 rev 4/30/2020

(Correctional Facility Transmission Investigation)

Day 0/1 Form

CDC ID: ________

…………………………………………………………………………………………………………………………………

Interviewee Information

Specimen ID

Booking or JDE Number:______________________________

First:_____________________________ Last:_______________________________

Date of birth: / / (MM/DD/YYYY)

CDC ID__________

Administrative Information

1. Interviewer Name: First: ____________________Last:_____________________ Date: / /

2. Housing [detainee] or work [staff] location: Division: ______ Unit: ______ Tier:______ Other:_____________

3. At the unit, the number of current: Staff present:______ Cells:____________ Detainees:______________

4. Interviewee: Detainee Staff

Demographic Information

5. Age: _______ Height:_______ (ft, in) Weight: _______ (lbs)

6. Ethnicity (select one): Hispanic/Latino Non-Hispanic/Latino Not Specified

7. Race (check all that apply): White Black Asian Am Indian/Alaska Nat Nat Hawaiian/Other PI Other, specify:___________ Unknown

8. Sex: Male Female

Symptoms

9. Use no touch thermometer to record current temperature: ________°F

10. In the last two weeks, have you experienced any of the following symptoms? [If symptoms are still ongoing, mark the checkbox and leave the second date blank]

	Symptom Present ?	Onset Date (mm/dd)	End Date/Ongoing (mm/dd)
Fever >100.4F (38C)c	Yes No Unk	___/___	___/___ Ongoing
Subjective fever (felt feverish, or hot/sweaty)	Yes No Unk	___/___	___/___ Ongoing
Chills	Yes No Unk	___/___	___/___ Ongoing
Muscle aches (myalgia)	Yes No Unk	___/___	___/___ Ongoing
Runny nose (rhinorrhea)	Yes No Unk	___/___	___/___ Ongoing
Nasal congestion	Yes No Unk	___/___	___/___ Ongoing
Sore throat	Yes No Unk	___/___	___/___ Ongoing
Cough (new onset or worsening of chronic cough)	Yes No Unk	___/___	___/___ Ongoing
Shortness of breath (dyspnea)	Yes No Unk	___/___	___/___ Ongoing
Abdominal pain	Yes No Unk	___/___	___/___ Ongoing
Diarrhea (≥3 loose/looser than normal stools/24hr period)	Yes No Unk	___/___	___/___ Ongoing
Nausea	Yes No Unk	___/___	___/___ Ongoing
Vomiting	Yes No Unk	___/___	___/___ Ongoing
Headache	Yes No Unk	___/___	___/___ Ongoing
Loss of taste Complete Partial	Yes No Unk	___/___	___/___ Ongoing
Loss of smell Complete Partial	Yes No Unk	___/___	___/___ Ongoing
Other, specify:	Yes No Unk	___/___	___/___ Ongoing

Smoking Status Note: Smoking is prohibited in the facility compound for all detainees.

11. [Staff only] Do you currently smoke tobacco on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

12. [Staff only] Do you currently vape or use electronic cigarettes on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

13. In the past, have you smoked tobacco on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

14. [If any use] When was the last time you used tobacco? ________________ (MM/DD/YYYY)

15. In the past, have you vaped or used electronic cigarettes on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

16. [If any use] When was the last time you used electronic cigarettes or vaping? ________________ (MM/DD/YYYY)

Past Medical History

17. Please provide pre-existing medical conditions (complete regardless of age):

Condition	Response	If YES, specify
Health conditions that cause breathing problems?	Yes No Unknown	Emphysema Lung Cancer Asthma Sleep Apnea COPD (chronic obstructive pulmonary disease) Other, specify:__________
Diabetes or problems with your blood sugar?	Yes No Unknown	Type 1 Type 2 Are you taking insulin? Yes No Unk
Heart problems or high blood pressure	Yes No Unknown	Coronary artery disease) Hyperlipidemia (high cholesterol) Heart failure Congenital heart abnormalities Hypertension/High blood pressure Myocardial infarction/heart attack Other, specify_____
Kidney problem	Yes No Unknown	Requires dialysis End stage renal disease) Chronic kidney disease Other, specify: ________
Liver problems	Yes No Unknown	Cirrhosis/ End stage liver disease Hepatitis B Hepatitis C Other, specify:____________
A disease, medication or condition that weakens your immune system?	Yes No Unknown	HIV/AIDS Lupus Steroids Chemotherapy Other, specify:____________
Learning or memory problems or history of head injury?	Yes No Unknown	Stroke Dementia/Alzheimer’s Traumatic brain injury Neuro Development disorder Other, specify:____________
Do you have other health/medical problems you would like me to know about?	Yes No Unknown	Specify:

Facility Questions

18. At this facility, how many different people are you in contact with (<6 ft) on an average day?__________

19. In the last two weeks, have you [had handcuffs put on / placed handcuffs on a detainee]?

Yes No Unknown

1. If yes, how many times per day (1 time would be once per day having them put on and taken off)? _____

Sanitation levels

20. How many times per day do you wash or sanitize your hands (on average)?____________________

21. When you wash your hands, do you use (check all that apply): Soap Hand sanitizer Water

Don’t wash hands Unknown

22. When do you wash your hands (check all that apply)? Before eating After touching a shared phone

After coughing or sneezing After touching another person After using the bathroom After touching dirty laundry After working Never Unknown

23. Have you worn a mask at the facility in the last 2-weeks? Yes No Unknown

    1. If yes, what type of mask (check all that apply)? Cloth Surgical Unknown

Other, specify:_________

2. When around others (<6 ft), how often do you wear a mask? Always Sometimes

Occasionally Never Unknown

3. When outside of your cell, how often do you wear a mask? Always Sometimes

Occasionally Never Unknown

Movement and Activity History

24. While in this facility, have you done any of the following activities in the last two weeks?

Activity	Answer	Frequency
…shaken hands with a person?	Yes No	Daily A few times a week Once a week
…played cards or a game with a person?	Yes No	Daily A few times a week Once a week
…used a phone that is shared with others?	Yes No	Daily A few times a week Once a week
…used a computer that is shared with others?	Yes No	Daily A few times a week Once a week
…shared items with a person? (cards, checkers, remote control, basketball, pen, pencil, dominos, etc)	Yes No	Daily A few times a week Once a week
…exercised, worked out, or played sports with a person?	Yes No	Daily A few times a week Once a week
…slept in the same cell/room as a person?	Yes No	Daily A few times a week Once a week
…shared a cigarette or vape pen with a person?	Yes No	Daily A few times a week Once a week
…shared a plate, utensil, or drinking cup/glass with a person?	Yes No	Daily A few times a week Once a week
…used a bathroom that is shared with others?	Yes No	Daily A few times a week Once a week
…traveled in the same vehicle (car, bus), sitting within 6 feet of a person?	Yes No	Daily A few times a week Once a week
…gone to court?	Yes No	Daily A few times a week Once a week
…[detainee only] had a work assignment off your tier?	Yes No	Daily A few times a week Once a week

Potential Exposure

25. In the last two weeks have you been around any people who appear to be sick and have COVID-19 symptoms, such as a fever, cough, or shortness of breath?

Yes No Unknown (If yes, how many? _________________________)

SARS-CoV-2 testing

26. Have you ever been offered a test for coronavirus? Yes No Refused Unknown

1. If yes, have you been tested for coronavirus? Yes No

1. Date of most recent test:_______________________________(MM/DD/YYYY)

2. Were you experiencing symptoms when you were tested? Yes No

3. Result of most recent test: Positive Negative Pending Indeterminate Don’t know/other _______________

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).

9