0920-1011 Survey - Day 0

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

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

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

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

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

7. Sex: Male Female

Symptoms

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

9. 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.

10. 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

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

12. 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

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

Past Medical History

14. 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

15. 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

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

17. 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

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

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

Don’t wash hands Unknown

20. 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

21. 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:________________

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

Always Usually Sometimes Never Unknown

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

Always Usually Sometimes Never Unknown

Movement and Activity History

22. 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

23. 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

24. 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

25. 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)

2. Did you experience any symptoms at the time you were tested? Yes No

3. 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