Household Questionnaire 24APR2020

Attachment 3b – Household Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date: xx/xx/2020

COVID-19 Community Seroepidemiological Investigation

Household Questionnaire

Please complete the following questions for each household

Team #______ Cluster ID #_______ Census Block ID #: ____________ Household ID #___________

Date (1^st visit) ____/____/______ Date (2^nd visit) ____/_____/______

(mm/dd/yyyy) (mm/dd/yyyy)

Household characteristics

1. Street address: _____________________________________ Apt #: ________

City: __________________________ State: ________ Zip: _________________

Latitude: __________________ Longitude: __________________

2. Type of dwelling

[ ] Single family (1 housing unit in building; including townhouses)

[ ] Multi-family (2-10 housing units in building)

[ ] Apartment/condo building (>10 housing units in building)

[ ] Other (specify_________________)

3. What is the primary language spoken in the household?

[ ] English [ ] Spanish [ ] Other________________

4. How many people live in this household? ___________ people

A household member is defined as an individual who spends an average of ≥2 nights per week in the home.

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 current 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Household members

4. Please answer the following questions for each member of the household

Person#	Individual ID# (CSID)	Age *	Age unit (circle)	Sex (circle)	Race † (1-5, 9)	Ethnicity † (1, 2,9)	Present Visit 1 (circle)	Present Visit 2 If No at visit 1 (circle)	Interviewed (circle)	Blood collected (circle)	Had symptoms ‡ since Jan 2020 ? (circle)	Tested for flu?§ (circle)	Tested for COVID-19?§ (circle)
01			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
02			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
03			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
04			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
05			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
06			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
07			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
08			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
09			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg
10			Y M	M F Other			Y N	Y N	Y N	Y N	Y N Unk	NT NR Pos Neg	NT NR Pos Neg

* If newborn aged <1 month, age is 0 and unit is “M.”

† Race codes Ethnicity codes

1 White 4 Native Hawaiian or Other Pacific Islander 1 Hispanic

2 Black 5 American Indian or Alaska Native 2 Non-Hispanic

3 Asian 9 Unknown/Other 9 Unknown/Other

‡ Symptoms include fever, cough, or difficulty breathing.

§ Covid-19 test codes

NT Not tested Pos Tested positive

NR Tested, no result Neg Tested negative

4. Have you had any visitors spend one or more nights in your home since January 2020?

[ ] Yes [ ] No [ ] Don’t know or can’t remember

Visitors

If YES, visited from:

Visited from (specify state/country)	Arrived (mm/dd/yyyy)	Departed (mm/dd/yyyy)
Don’t know or remember	____/_____/______ Don’t know or remember	____/_____/______ Don’t know or remember
Don’t know or remember	____/_____/______ Don’t know or remember	____/_____/______ Don’t know or remember
Don’t know or remember	____/_____/______ Don’t know or remember	____/_____/______ Don’t know or remember
Don’t know or remember	____/_____/______ Don’t know or remember	____/_____/______ Don’t know or remember
Don’t know or remember	____/_____/______ Don’t know or remember	____/_____/______ Don’t know or remember

4