0920-1011 Survey - Day 3-4

Emergency Epidemic Investigation Data Collections - Burden Hour Increase 01SEP2020

Appendix 3. Survey Day 3

OMB: 0920-1011

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

S ARS-CoV-2 Louisiana Questionnaire V1 rev 5/04/2020

(Correctional Facility Transmission Investigation)

Day 3/4 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:_____________

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

Symptoms

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

  2. Since we last visited you, have you experienced any of the following symptoms?


Symptom Present Since Last Visit?

Onset Date

(mm/dd)

# of Days

Ongoing?

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

___/___



Potential Exposure

  1. Since we last visited you, 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? _________________________)



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).

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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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