Household Animal Questionnaire

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with SARS-CoV-2

Household Animal Questionnaire

This questionnaire is to be completed by primary caretaker for each pet/companion animal in the household.

State/local ID: _________

Household ID: _________

Pet/Animal ID: _________

Date interview completed: / / (MM/DD/YYYY)

Interviewer Name:________________________________________ State/Local Health Department___________________________________

Who is providing information for this form?

□ Index COVID-19 patient

□ Other, specify name: ______________________________ Relationship to index patient: ____________________________________

How many pets/companion animals belong to the household? ________________________________ (Include service animals and any animals that primarily live outside if the household members consider them “pets” and interact with them regularly.)

1. Pet Name: _________________________________________ Pet ID (e.g. 01, 02, 03…): _________________

1. Primary Caretaker of [PET NAME]: _________________________________________

2. Animal Type:  Dog  Cat  Other (please describe) ____________________________

   1. Breed _________________________________________

3. Age of Pet (years/months): ____________________________________________________ years or months (Circle one)

4. Sex of Pet:  Male  Female

   1. Has [PET NAME] been spayed/neutered:  Yes  No

2. Does [PET NAME] have any current health conditions?  Yes  No

   1. If yes, please describe these health conditions or illnesses including when they started:

      Condition	Date Started	Medications or supplement for the condition

   2. Please describe any other medications or supplements that [PET NAME] takes.

3. On a regular day before [COVID-19 CASE] began home isolation, how long per day and what types of interaction (e.g., walking, grooming, petting, cuddling) did [COVID-19 CASE] usually have with [PET NAME]?

   1. Duration of interaction with pet per day:

<1 hour  1-3 hours  4-6 hours  7-9 hours  10-12 hours  12+ hours

2. Types of interaction/contact with pet (mark all that apply):

Taking for walks	Petting	Sharing food
Grooming	Cuddling	Letting the pet lick their face or hands
Feeding	Sleeping in the same location	Other (please describe): _________________

4. On a regular day since [COVID-19 case] started home isolation, how long per day and what types of interaction has [COVID-19 CASE] had with [PET NAME]?

   1. Duration of interaction with pet per day:

<1 hour  1-3 hours  4-6 hours  7-9 hours  10-12 hours  12+ hours

2. Types of interaction/contact with pet (mark all that apply):

 Taking for walks	 Petting	 Sharing food
 Grooming	 Cuddling	 Letting the pet lick their face or hands
 Feeding	 Sleeping in the same location	 Other (please describe): _________________

3. Was [COVID-19 CASE] wearing any personal protective equipment (e.g. gloves or a cloth face covering)?

 Yes  No

1. If yes, please describe: ___________________________

5. Is your pet:  Primarily indoors,  outdoors or  both?

   1. If both, what percent of time is spent indoors? ____________%

   2. Is [PET NAME] allowed anywhere in the house or restricted to certain areas? ________________

   3. If restricted, specify where: ________________

6. On a regular day since [COVID-19 case] started home isolation, where does [PET NAME] go outside of the home (mark all that apply)?

 On leash walks at park	 Dog park
 Free roaming in neighborhood/on property	 Doggy Daycare
 On leash walks in neighborhood/on property	 Service function (e.g. therapy dog)
 Indoors only	 Other (please describe): _________________________

7. Since [COVID-19 case] was diagnosed, has this pet developed any new health condition (mark all that apply)?

 Coughing	 Runny nose
 Sneezing	 Vomiting
 Difficulty breathing or shortness of breath	 Diarrhea
 Lethargy	 Other (please describe): __________________________

8. Have you/the patient heard or read about the CDC guidelines about a person who is sick restricting contact with pets in the house?  Yes  No

9. Is there any additional information you think we should know about [PET NAME]?

1. If Yes: ___________________________________________________________________________

10. Are there small pets in the household, such as rats, mice, hamsters, gerbils, rabbits, or guinea pigs?  Yes  No

    1. If Yes, please list the type of animal(s) and their name(s):

2. If No  Thank you for your time and participation.

“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).”