Household Member Symptom Diary

Form Approved. OMB Control No. 0920-XXXX. Exp date. XX/XX/XXXX

Day of follow-up: 0/14 (Date of specimen collection)

Date (MM/DD/YYYY): ___________________________________

Name (First Last): ______________________________________

Household ID: WI-_________________

HH member ID: WI-_________________

Household Member Symptom Diary

1. Who is providing this information today?

Self Parent/guardian

Other, specify name: ___________________; relationship: _________________________

2. What is the current time? ____________ AM PM

3. Did you sleep in the household last night? Yes No

4. During the past 24 hours, have you experienced any of the following symptoms?

Symptom	Experienced in the past 24 hours?
Documented Fever >=100.4F (38C) Highest temp ______F	Yes No Unknown
Subjective fever (felt feverish)	Yes No Unknown
Chills	Yes No Unknown
Fatigue (tired)	Yes No Unknown
Headache	Yes No Unknown
Muscle aches	Yes No Unknown
Runny nose	Yes No Unknown
Sore throat	Yes No Unknown
Cough (new onset or worsening of chronic cough) Dry Productive	Yes No Unknown
Discomfort/burning while breathing	Yes No Unknown
Shortness of breath	Yes No Unknown
Wheezing	Yes No Unknown
Chest Pain	Yes No Unknown
Nausea/Vomiting	Yes No Unknown
Loss of taste Complete Partial	Yes No Unknown
Loss of smell Complete Partial	Yes No Unknown
Abdominal pain	Yes No Unknown
Diarrhea (≥3 loose/looser than normal stools/24hr period)	Yes No Unknown
Other, specify:	Yes No Unknown

Who should we contact for your daily reminder? Me Other family member __________________________

Preferred method of contact: Phone call Text Email

Phone/email:______________________________________________________________________

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).