Household Close-Out Form

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

H uman Infection with 2019 Novel Coronavirus (nCoV)

Household Close-Out Form V1.1 4/6/2020

(Household Transmission Investigation)

State: ____WI________

Household ID: __WI-_________

HOUSEHOLD CLOSE-OUT FORM

Please fill out this form when scheduling the final household visit.

1. Date of questionnaire: ____/____/________

2. Date of final household visit (i.e., last serum collection): ____/____/________

3. Is there extended symptom monitoring for confirmed cases beyond the final household visit?  Yes  No

If yes, please provide approximate end date of symptom monitoring for this household: ____/____/_____

4. Have you changed anything in your household behaviors to prevent spread in the family? Check all that are mentioned and DO NOT read the choices. Only include behaviors/interventions since time of enrollment:

 Ill person/people (or persons diagnosed with COVID-19) wore a mask in the home

 My family is wearing masks, regardless of symptoms

 Ill person/people (or persons diagnosed with COVID-19) slept in a different room

 Ill person/people (or persons diagnosed with COVID-19) used a separate bathroom

 Ill person/people (or persons diagnosed with COVID-19) eat separately

 Ill person/people (or persons diagnosed with COVID-19) moved out of the house

 Used bleach wipes on high touch surfaces

 Used Lysol/cleaning spray on high touch surfaces

 Used Lysol/cleaning spray frequently in the bathroom

 Used Lysol/cleaning spray on high touch surfaces

 My family is washing hands frequently.

 My family stopped sharing plates/utensils/cups/food.

 My family increased the use of fans/open windows to increase air flow.

 My family stopped sharing common items like towels.

 My family is wearing gloves in the home.

 Other: specify_______________________________________________________________________________________________________________________

If a family member mentions wearing masks, ask questions 5-6:

5. What type of masks were worn (check all that apply):

 Cloth

 Medical/Surgical

 N-95

 Other, non-traditional mask (e.g., scarves, other barriers, etc.): specify_____________________________________________________________________

6. If there is more than 1 ill person (or persons diagnosed with COVID-19) in the household, did all ill people wear a mask?  Yes  No  Not applicable

7. Did any household pets become sick during the follow-up period?  Yes  No  Not applicable

If yes, describe symptoms and duration: ________________________________________

8. Please provide details for each household member in the table below:

Name	Study ID	Hospitalized due to COVID-19	If confirmed by PCR, provide preliminary determination of primary vs. secondary cases*	Withdrawal?
		 Yes  No	 Primary case  Secondary case if secondary, suspected outside infection? Yes No, explain: ______________________________ ______________________________ ______________________________  N/A	Withdrawal?  Yes  No If withdraw, date of withdrawal: ____/____/_______ Reasons: hospitalized, alive ­deceased moved declined other________________
		 Yes  No	 Primary case  Secondary case if secondary, suspected outside infection? Yes No, explain: ______________________________ ______________________________ ______________________________  N/A	Withdrawal?  Yes  No If withdraw, date of withdrawal: ____/____/_______ Reasons: hospitalized, alive ­deceased moved declined other________________
		 Yes  No	 Primary case  Secondary case if secondary, suspected outside infection? Yes No, explain: ______________________________ ______________________________ ______________________________  N/A	Withdrawal?  Yes  No If withdraw, date of withdrawal: ____/____/_______ Reasons: hospitalized, alive ­deceased moved declined other________________
		 Yes  No	 Primary case  Secondary case if secondary, suspected outside infection? Yes No, explain: ______________________________ ______________________________ ______________________________  N/A	Withdrawal?  Yes  No If withdraw, date of withdrawal: ____/____/_______ Reasons: hospitalized, alive ­deceased moved declined other________________
		 Yes  No	 Primary case  Secondary case if secondary, suspected outside infection? Yes No, explain: ______________________________ ______________________________ ______________________________  N/A	Withdrawal?  Yes  No If withdraw, date of withdrawal: ____/____/_______ Reasons: hospitalized, alive ­deceased moved declined other________________
*The determination can be made at the time the patient is confirmed to be positive (i.e., at baseline, an interim visit, or day 14)

Notes for field investigators:

• Primary case/s

  • Primary case is the confirmed COVID-19 case with the earliest symptom onset in the household. Oftentimes, this will be the index patient.

  • If there are multiple household cases who have the earliest symptom onset (within a day; or, not within a day but they have a known common exposure), we will consider them as co-primary cases who introduced the virus into the household. Please check them as primary cases in the table.

• Secondary cases

  • Ideally, we’d like to identify secondary cases as household members who are subsequently infected by the primary case/s.

  • However, in practice, we may not be able to differentiate secondary vs. tertiary (or further generations of) transmission, or infections due to exposure outside of the household

  • Thus, for now, we plan to consider all subsequent infections in the household as secondary cases, and estimate the overall risk of infection (i.e., % household members subsequently infected) as a proxy for household secondary attack rate

    • This approach assumes that all subsequent infections in the household are due to exposures to the primary case/s

    • As the above assumption may be violated, please mark household cases with suspected/known infection due to outside sources as; as a sensitivity analysis, we will consider excluding them when estimating the secondary attack rate

FINAL April 6, 2020 3

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).