Household Quiestionnaire

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

H uman Infection with 2019 Novel Coronavirus (nCoV)

Household Questionnaire V1.4 rev 3/23/2020

(Household Transmission Investigation)

State: ____WI________

Household ID: __WI-_________

HOUSEHOLD QUESTIONNAIRE COVER SHEET

• If there are multiple confirmed COVID-19 cases in the household at baseline, identify the case with the earliest symptom onset as the index patient.

Index case information (fill out ahead of time from PUI/CRF and verify at time of questionnaire administration)

1. Index patient’s name: First: ________________________ Last: ______________________

2. Phone number: __________________________________

3. Address: ___________________________________________________________________

4. Index patient’s study ID: ___________

5. Index patient’s date of birth: ____/_____/_______ (MM/DD/YYYY)

6. Date of symptom onset of the index patient: / / __(MM/DD/YYYY)

7. Date of specimen collection of index patient (first positive test): ____/____/________ (MM/DD/YYYY)

8. Date index patient received test result: __ /____/____ (MM/DD/YYYY)

Household member(s) (fill out ahead of time and verify/complete at time of questionnaire)

Name (first last)	Study ID	Relationship to case	Age (yrs)	Sex	DOB	Phone number

HOUSEHOLD QUESTIONNAIRE

Note: This questionnaire is to be administered to each household at enrollment. If possible, the head of household should provide information for questionnaire.

Interview information

1. Date of Interview: MM / DD / YYYY

2. Name of Interviewer: _________________________________________

3. Name of household member providing information for interview: _________ ________

Head of household?  Yes  No If no, relationship to head of household: ________________________

4. Location of the interview:

 At the household

 Over the phone

 Other, specify: ____________________________________________

Describing the household

5. Location of the household:

County: __________________________ State: ___________________ ZIP Code: __________________

6. Confirm the number of household members from the cover sheet: __________persons

Note to interviewer: Include resident family members, live-in staff, and long-term visitors.

7. What is the highest level of education completed by the head of the household?

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

8. What is the occupation of the head of the household? _________________________________________

9. Do you live in a single-family home or multi-unit housing (like an apartment)?

 Single-family home  Multi-unit housing  Other (specify):_________________________

10. Do you own or rent your home?  Own  Rent

11. What is the approximate size of the residence: ___________ square feet

12. Number of floors in the residence: _________________

13. Number of bedrooms in the residence:

14. Number of bathrooms in the residence:
    
    

15. What type of heating does this residence have?

 Forced air  Radiator Other, specify:_________  Don’t know

16. Since the index patient developed symptoms on [insert date of symptom onset]:

1. Has air conditioning been used?
   Yes No

2. Has the household opened windows for ventilation?
   Yes No

3. Has any other form of ventilation (e.g. ceiling fans or portable fans) been used?

Yes No

Index patient information

Note to interviewer: if the household member completing the interview is not the index patient, ask if the index patient is available for several questions.

17. Are you still experiencing symptoms related to your COVID-19 illness?

Yes No Never had symptoms

If no, what date were you back to normal health? MM / DD / YYYY

18. Since you developed respiratory illness, have you done any of the following at home? (select all that apply)

 Slept alone in a bed If yes, dates: ______________________________

 Slept alone in separate bedroom If yes, dates: ______________________________

 Used a private bathroom (not shared) If yes, dates: ______________________________

 Wore personal protective equipment If yes, dates: ______________________________

Mask Gloves Other: ________________________________________________________

 Other: _________________________________ If yes, dates: ______________________________

19. Which household member has been assisting you as your primary caretaker during your illness?

Name: ______________________________________ None Unknown

20. What tasks has this primary caretaker assisted you with?

Taking temperature Serving meals Cleaning bedroom Cleaning bathroom Help with toileting
Other, specify _________________________________________________

Other:

21. Does the household have pets? Yes No

If yes, how many? _________ pets

Note to the interviewer: only include mammalian pets (no livestock).

Species (dog, cat)	Age (yrs)	Indoor Pet? (y/n)	Signs of illness? (y/n)	If ill, date of illness onset
1.
2.
3.
4.

Notes:

Version 1.3 March 23, 2020 17

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).