0920-1011 Survey - Day 14

Emergency Epidemic Investigation Data Collections - Burden Hour Increase 01SEP2020

Appendix 4. Survey Day 14

OMB: 0920-1011

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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 14 Form

CDC ID: _________


…………………………………………………………………………………………………………………………………

Interviewee Information


Shape1

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

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

  2. In the last two weeks, 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


Facility Questions (these questions are about a typical day in the last two weeks)

  1. At this facility, how many different people are you in contact with (<6 ft) on an average day?__________

  2. In the last two weeks, have you [had handcuffs put on / placed handcuffs on a detainee]?

Yes No Unknown

    1. If yes, how many times per day (1 time would be once per day having them put on and taken off)? _____

Sanitation levels

  1. How many times per day do you wash or sanitize your hands (on average)?____________________

  2. When you wash your hands, do you use (check all that apply): Soap Hand sanitizer Water

Don’t wash hands Unknown


  1. When do you wash your hands (check all that apply)? Before eating After touching a shared phone

After coughing or sneezing After touching another person After using the bathroom After touching dirty laundry After working Never Unknown


  1. Have you worn a mask at the facility in the last 2-weeks? Yes No Unknown

    1. If yes, what type of mask (check all that apply)? Cloth Surgical Unknown

Other, specify:_________

    1. When around others (<6 ft), how often do you wear a mask? Always Sometimes

Occasionally Never Unknown

    1. When outside of your cell, how often do you wear a mask? Always Sometimes

Occasionally Never Unknown



Movement and Activity History

  1. While in this facility, have you done any of the following activities in the last two weeks?

Activity

Answer

Frequency

shaken hands with a person?

Yes No

Daily A few times a week Once a week

played cards or a game with a person?

Yes No

Daily A few times a week Once a week

used a phone that is shared with others?

Yes No

Daily A few times a week Once a week

used a computer that is shared with others?

Yes No

Daily A few times a week Once a week

shared items with a person? (cards, checkers, remote control, basketball, pen, pencil, dominos, etc)

Yes No

Daily A few times a week Once a week

exercised, worked out, or played sports with a person?

Yes No

Daily A few times a week Once a week

slept in the same cell/room as a person?

Yes No

Daily A few times a week Once a week

shared a cigarette or vape pen with a person?

Yes No

Daily A few times a week Once a week

shared a plate, utensil, or drinking cup/glass with a person?

Yes No

Daily A few times a week Once a week

used a bathroom that is shared with others?

Yes No

Daily A few times a week Once a week

traveled in the same vehicle (car, bus), sitting within 6 feet of a person?

Yes No

Daily A few times a week Once a week

gone to court?

Yes No

Daily A few times a week Once a week

[detainee only] had a work assignment off your tier?

Yes No

Daily A few times a week Once a week


Potential Exposure

  1. In the last two weeks 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? _________________________)


SARS-CoV-2 testing

  1. Have you ever been offered a test for coronavirus? Yes No Refused Unknown


    1. If yes, have you been tested for coronavirus? Yes No


      1. Date of most recent test:_______________________________(MM/DD/YYYY)


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


      1. Result of most recent test: Positive Negative Pending Indeterminate Don’t know/other _______________



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).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPham, Huong T. (CDC/OID/NCHHSTP) (CTR)
File Modified0000-00-00
File Created2021-01-13

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