Household Contact Questionnaire

SARS-CoV-2 Epidemiologic Data Collections

4. HH Transmission_Household Contact Questionnaire_Instrument_23Apr2020

General Public - Household Contact Questionnaire Instrument

OMB: 0920-1297

Document [docx]
Download: docx | pdf

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

H uman Infection with 2019 Novel Coronavirus (nCoV)

Household Contact Questionnaire V1.5 rev 3/24/2020

(Household Transmission Investigation)

State: WI

Household ID: WI-__________

Study ID: WI-_______________


This questionnaire is to be administered to each household member (excluding the index patient).

Interview Information

  1. Date of Interview: / / (MM/DD/YYYY)

  2. Name of Interviewer: _________________________________________

  3. Person completing the interview: Self Parent/guardian: ______________________________

Other: ___________________________________________________

Household Member Information

  1. Household member’s name: First:_____________________________ Last:___________________________

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

  3. Age: _______ years months days

  4. Ethnicity: Hispanic/Latino Non-Hispanic/Latino Not Specified

  5. Race: White Black Asian

Am Indian/Alaska Nat Nat Hawaiian/Other PI Other, specify:___________ Unknown

  1. Sex: Male Female

  2. What is your relationship to [insert name of index patient]?

Spouse Child Parent Grandparent Sibling Employee Other _____________

  1. What is the highest level of education you have completed?

Less than high school

High school diploma/GED

Some college credit, no degree

Technical degree/Associate’s degree

Bachelor’s degree (i.e., B.A., B.S.)

Master’s degree (i.e., MBA)

Doctorate or professional degree


  1. What is your occupation? ____________________________________________________


SARS-CoV-2 testing for household contacts

  1. Have you been tested for coronavirus? Yes No

If yes, please complete the following information:

    1. Date of specimen collection_______________________________(MM/DD/YYYY)

    2. Result of test: Positive Negative Pending Don’t know/other ________________

    3. Date of test result_______________________________(MM/DD/YYYY)

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

      1. Describe:­­­­­­­­­­­­­­­_______________________________________________________________

    5. Date of symptom onset: _____________________________(MM/DD/YYYY)

Notes:________________________________________________________________________________

Past Medical History

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

Asthma/reactive airway disease

Yes

No

Unknown


Emphysema/COPD

Yes

No

Unknown


Active tuberculosis

Yes

No

Unknown

If YES, on treatment: Yes No Unknown

Any other chronic lung diseases

Yes

No

Unknown

If YES, specify:

Diabetes Mellitus

Yes

No

Unknown


Hypertension (high blood pressure)

Yes

No

Unknown


Coronary artery disease/heart attack

Yes

No

Unknown


Congestive heart failure

Yes

No

Unknown


Stroke

Yes

No

Unknown


Congenital heart disease

Yes

No

Unknown


Any other heart diseases

Yes

No

Unknown

If YES, specify:

Any kidney disorders? If YES, answer the following:

Yes

No

Unknown


End-stage renal disease/dialysis

Yes

No

Unknown


Renal insufficiency

Yes

No

Unknown


Other kidney diseases

Yes

No

Unknown

If YES, specify:

Any liver disorders? If YES, answer the following:

Yes

No

Unknown


Alcoholic liver disease

Yes

No

Unknown


Cirrhosis/End stage liver disease

Yes

No

Unknown


Chronic hepatitis B

Yes

No

Unknown


Chronic hepatitis C

Yes

No

Unknown


Non-alcoholic fatty liver disease

(NAFLD)/NASH

Yes

No

Unknown


Other chronic liver diseases

Yes

No

Unknown

If YES, specify:

HIV infection. If YES, answer the following:

Yes

No

Unknown


AIDS or CD4 count currently <200

Yes

No

Unknown


Ever receive a transplant? If YES, answer the following:

Yes

No

Unknown


Solid organ transplant




If YES, date:

Stem cell transplant (e.g., bone

marrow transplant)

Yes

No

Unknown

If YES, date:

Cancer: current/in treatment or diagnosed in last 12 months

Yes

No

Unknown

If YES, specify:___________________


Immunosuppressive therapy/medications

Yes

No

Unknown

If YES, specify:___________________

For what condition: _______________________

Other immunosuppressive conditions

Yes

No

Unknown

If YES, specify:___________________

Any other chronic diseases

Yes

No

Unknown

If YES, specify:

Developmental or neurologic disorder. If YES, answer the following:

Yes

No

Unknown

If YES, specify:

Chromosomal or genetic abnormality

Yes

No

Unknown

If YES, specify:___________________________

Cerebral palsy

Yes

No

Unknown


Epilepsy

Yes

No

Unknown


Any other development or neurologic

Disorder




If YES, specify:___________________________

Any other medical conditions as a child

Yes

No

Unknown

If YES, specify:

Were you born premature?

Yes

No

Unknown

If yes, gestation at birth:____________wks



  1. [If female] Are you currently pregnant? Yes No Unknown N/A

  2. [If female] Are you postpartum ( 6 weeks postpartum)? Yes No Unknown N/A

  3. [If female] Are you breastfeeding? Yes No Unknown N/A

  4. [If child <3 years] Is your child being breastfed? Yes No Unknown N/A


Smoking/Vaping

  1. Do you currently smoke tobacco on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

  1. [If not a daily smoker] 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

  1. 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


Symptoms Prior to Index Case’s Onset

Note to interviewer: record symptom onset date of the index patient from household questionnaire cover sheet. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)


  1. Did you experience any symptoms of a respiratory illness in the 2 weeks prior to [insert name of index patient] becoming ill?

Yes No Unknown


Exposures Outside of the Household

Note to interviewer: remind the interviewee to consult a calendar or diary for the following questions.

Date of index patient symptom onset: ___/____/____(MM/DD/YYYY)

14 days prior to index patient’s symptom onset: ___/____/____ (MM/DD/YYYY)


  1. Since [14 days PRIOR to the index patient’s symptom onset]…

Exposure

Answer

have you traveled (internationally or within the U.S., or on a cruise)?

Yes: with index patient Yes: w/o index patient

No Unknown


attend a mass gathering (e.g., religious event, wedding, party, dance, concert, banquet, festival, sports event, or other events)?

Yes: with index patient Yes: w/o index patient

No Unknown


have close contact (e.g. caring for, speaking with, touching, physically within 6 feet) with any suspected or known COVID-19 case outside of the household?

Yes: with index patient Yes: w/o index patient

No Unknown


work in a healthcare setting?

Yes No Unknown

If yes, what types of healthcare settings:

Hospital

Outpatient Clinic

Emergency Dept

Dental Clinic

Dialysis Center

ICU

Long-term care facility

Other, specify: __________


What type of job do you have at the healthcare setting?

Admin staff

Nurse/Nurse tech

Doctor

EMS

Other, specify: ___________

visit a healthcare setting (e.g. visit someone or have an appointment -- at a hospital, ED, outpatient clinic, dental clinic, long-term care facility)?

Yes No Unknown


attend/work at a daycare?

Yes No Unknown


attend/work at a school?

Yes No Unknown



Symptoms After the Index Case’s Onset

Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)


  1. Since ____/____/____, when [the index case] first became symptomatic, have you experienced any of the following symptoms?

Symptom Present?

Fever >100.4F (38C)c

Yes No Unk

Subjective fever (felt feverish)

Yes No Unk

Chills

Yes No Unk

Muscle aches (myalgia)

Yes No Unk

Runny nose (rhinorrhea)

Yes No Unk

Sore throat

Yes No Unk

Cough (new onset or worsening of chronic cough)

Yes No Unk

Shortness of breath (dyspnea)

Yes No Unk

Nausea/Vomiting

Yes No Unk

Headache

Yes No Unk

Abdominal pain

Yes No Unk

Diarrhea (≥3 loose/looser than normal stools/24hr period)

Yes No Unk

Other, specify:



  1. What date did you first become symptomatic?

___ / __ /_ __ (MM/DD/YYYY)


  1. Are you currently experiencing any symptoms of a respiratory illness, such as fever, cough, or shortness of breath? (Note: Flag any symptomatic household members for workflow planning and offer of self-nasal swab during visit)

Yes No Unknown



Exposures to the Index Patient

Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)


  1. Since [index case]’s symptoms started on [date of symptom onset of the index patient], did you …….?

Exposure

Answer

spend more than 10 minutes within 6 feet of the index patient?

Yes No Unknown

have face to face contact with the index patient (i.e., within about 2 feet)?

Yes No Unknown

spend any time within 6 feet of the index patient while he/she was coughing or sneezing?

Yes No Unknown

shake hands with the index patient?

Yes No Unknown

hug the index patient?

Yes No Unknown

kiss the index patient?

Yes No Unknown

take an object handed from or handled by the index patient? (e.g., pen, paper, food, utensil, etc.)

Yes No Unknown

sleep in the same bedroom as the index patient?

Yes No Unknown

sleep in the same bed as the index patient?

Yes No Unknown

share a bathroom with the index patient?

Yes No Unknown

prepare food with the index patient?

Yes No Unknown

share meals with the index patient?

Yes No Unknown

eat from the same plate as the index patient?

Yes No Unknown

share a utensil with the index patient?

Yes No Unknown

share a drinking cup/glass with the index patient?

Yes No Unknown

travel in the same vehicle (car, bus, airplane), sitting within 6 feet of the index patient?

Yes No Unknown


  1. Did you serve as primary caretaker for the index patient while he/she was ill? Yes No Unknown


  1. When was your last exposure (include any exposures described above) to [name of the index patient]?

___ / __ /_ __ (MM/DD/YYYY) Ongoing exposure

  1. How many days have you spent in the household since [date of symptom onset of index patient]? ____________


  1. How many nights have you spent in the household since [date of symptom onset of index patient]? ___________



Version 1.4 March 24, 2020 16

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 (0920-1011).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPham, Huong T. (CDC/OID/NCHHSTP) (CTR)
File Modified0000-00-00
File Created2021-01-14

© 2024 OMB.report | Privacy Policy