0920-1011 Survey - Day 0

Emergency Epidemic Investigation Data Collections - Burden Hour Increase 01SEP2020

Appendix 2. Survey Day 0

OMB: 0920-1011

Document [docx]
Download: docx | pdf

Form Approved. OMB No. 0920-1011 Exp. 08/05/2020

S ARS-CoV-2 Louisiana Questionnaire V1 rev 05/04/2020

(Correctional Facility Transmission Investigation)

Day 0/1 Form

CDC ID: ________

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

Interviewee Information


Shape1

Specimen ID


Booking or JDE Number:______________________________


First:_____________________________ Last:_______________________________


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


CDC ID__________






NOTE: This page is for paper records only. Do not scan for data entry into the electronic database.









Administrative Information

  1. Interviewer Name: First: ____________________Last:_____________________ Date: / /

  2. Housing location: Dorm: ______ Other:_____________

  1. Sleeping location: top bunk bottom bunk

  2. Date quarantine initiated in dorm: _____/______/______

  3. At the dorm, the number of current: Staff present:_________ Cells:____________ Detainees:____________


Demographic Information

  1. Age: _______ Height:_______ (ft, in) Weight: _______ (lbs)

  2. Ethnicity (select one): Hispanic/Latino Non-Hispanic/Latino Not Specified

  3. Race (check all that apply): White Black Asian Am Indian/Alaska Nat Nat Hawaiian/Other PI Other, specify:___________ Unknown

  4. Sex: Male Female


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?


Symptom Present Last 2 Weeks?

Onset Date

(mm/dd)

# of Days

Ongoing?

Last 2 Months?

Fever >100.4°F (38° C)

Yes No Unk

___/___


Subjective fever (felt feverish, or hot/sweaty)

Yes No Unk

___/___


Chills

Yes No Unk

___/___


Muscle aches (myalgia)

Yes No Unk

___/___


Runny nose (rhinorrhea)

Yes No Unk

___/___


Stuffy nose (nasal congestion)

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

___/___


Abdominal pain

Yes No Unk

___/___


Diarrhea (≥3 loose stools/24hr period)

Yes No Unk

___/___


Nausea

Yes No Unk

___/___


Vomiting

Yes No Unk

___/___


Headache

Yes No Unk

___/___


Loss of taste Complete Partial

Yes No Unk

___/___


Loss of smell Complete Partial

Yes No Unk

___/___


Other, specify:

Yes No Unk

___/___



NOTE: For any of these symptoms, have you experienced them in the last two months? That means since ______(month).


Smoking Status Note: Smoking is prohibited in the facility compound for all detainees.

  1. 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. [If any use] When was the last time you used tobacco? ________________ (MM/YYYY)


  1. In the past, have you vaped or used electronic cigarettes on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

  1. [If any use] When was the last time you used electronic cigarettes or vaping? ________________ (MM/YYYY)





Past Medical History

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

Condition

Response

If YES, specify

Health conditions that cause breathing problems?

Yes No

Unk/DK/Ref

Asthma COPD (chronic obstructive pulmonary disease) Emphysema Lung Cancer Sleep Apnea

Other, specify:_____________

Diabetes or problems with your blood sugar?

Yes No

Unk/DK/Ref

Type 1 Type 2

Are you taking insulin? Yes No

Heart problems or high blood pressure?

Yes No

Unk/DK/Ref

Congenital heart abnormalities Coronary artery disease Heart failure High cholesterol (Hyperlipidemia)

High blood pressure (Hypertension)

Heart attack (Myocardial infarction)

Other, specify_____________

Kidney problems?

Yes No

Unk/DK/Ref

Chronic kidney disease Dialysis

End-stage renal disease

Other, specify: ________

Liver problems?

Yes No

Unk/DK/Ref

Cirrhosis End-stage liver disease

Hepatitis B Hepatitis C Other, specify:___________

A disease, medication, or condition that weakens your immune system?

Yes No

Unk/DK/Ref

Chemotherapy HIV/AIDS Lupus Steroids

Other, specify:____________

Learning or memory problems or history of head injury?

Yes No

Unk/DK/Ref

Dementia/Alzheimer’s Neurodevelopmental Disorder

Stroke Traumatic Brain Injury

Other, specify:____________

Do you have other health/medical problems you would like me to know about?

Yes No

Unk/DK/Ref

Specify:____________________________________________




Medication Use

  1. Currently, what types of medications do you take for underlying conditions, including prescriptions & inhalers?

Do you take any medications for high blood pressure?

How about for infections caused by fungus, bacteria, or viruses? (If yes, ask questions to fill in table below)

How about any medications that may weaken your immune system and ability to fight infections? These medications are often used to treat autoimmune disorders or inflammation. (If yes, ask questions to fill in table below)

Do you use an inhaler? (If yes, ask questions to fill in table below)

Any other medications you may have forgotten? (If yes, ask questions to fill in table below)


Medication Name

Route

Frequency

Indication


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________



PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________



PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________




Facility Questions

  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? (*Other than for this survey*)

Yes No Unknown

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)?____________________


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

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 Usually Sometimes Never Unknown

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

Always Usually Sometimes 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? (Excludes video court)

Yes No

Daily A few times a week Once a week

had a work assignment off your dorm?

Yes No

Daily A few times a week Once a week




  1. Have you been assigned to any other dorms in the last 2 months? Yes No

    1. If yes, how many? _________

    2. If known, specify dorm(s):_________________________________________________________


Potential Exposure

  1. In the last two weeks, have you been around any people who appear to be sick with 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. Did you experience any symptoms at the time you were tested? Yes No


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

Other, specify: _______________

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). 15


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

© 2024 OMB.report | Privacy Policy