0920-1011 Survey - Day 3-4

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 3/4 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

Symptoms

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

6. Since we last visited you, 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

Potential Exposure

7. Since we last visited you, 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? _________________________)

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).