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Appendix 4 - Example of Personal Interview Questionnaire
ICR 202012-0920-002 · OMB 0920-1011 · Object 106758701.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Appendix 4 - Example of Personal Interview Questionnaire |
| Author | CDC User |
| Last Modified By | Writer |
| File Modified | 2013-11-14 |
| File Created | 2026-08-31 |
| Conversion State | complete |
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Appendix 4. Personal Interview Example Questionnaire – Q Fever
Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/XXXX
Q Fever Questionnaire
Public reporting burden of this collection of information is estimated to average XX 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-XXXX)
Family ID: _______________ Participant ID: _____________ Interviewer Name: ____________________________________
Date of interview: ____________________________________ GPS coordinates: _____________________________________
Q Fever Questionnaire
Section I: Demographic and Contact Information
1. Name: ___________________________________________________________________
2. DOB: ____/____/_______ 3. Sex: Male (1)
Female (2)
4. Are you Hispanic or Latino? Yes (1) No (2)
5. What is your race? (Select one or more responses.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
6. Street address:__________________________________________________________
7. City: ______________________ 8. State: ________ 9. Zip: ___________
10. Contact phone number : ________________________________
11. Email address: ________________________________________________
Section II: Exposure History
12a. Do you live on a property with animals? Yes (1) No (2)
If yes, complete this section; if no skip to question 13.
Which animals? Yes (1) No (2)
12b. Goats
12c. Cats
12d. Dogs
12e. Cows
12f. Sheep
12g. Horses
12h. Other, please specify: _________________________________________________________
13a. Do you work with animals in your profession? Yes (1) No (2)
If yes, complete this section; if no, skip to question 14.
13b. What is your profession? ________________________________________________________
Which animals? Yes (1) No (2)
12b. Goats
12c. Cats
12d. Dogs
12e. Cows
12f. Sheep
12g. Horses
12h. Other, please specify: _________________________________________________________
14. Is the place where you live within 1 mile of any livestock? Yes (1) No (2)
15. Is the place where you work within 1 mile of any livestock? Yes (1) No (2)
16. Have you been on any ranches or farms since [INSERT DATE]? Yes (1) No (2)
If yes, complete this section: if no skip to question 19.
17. Location of ranches or farms? ___________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
18. While you were on a ranch or farm did you have contact with any of the following animals? Yes (1) No (2)
18a. Goats
18b. Cats
18c. Dogs
18d. Cows
18e. Sheep
18f. Horses
18g. Other, please specify: _________________________________________________________
For each animal type in the following questions, try to recall any type of contact/activity with the animal since September 1, 2010. Include any contact/activity, even if you mentioned it already.
19a. Goats Yes (1) No (2)
If yes, complete this section: if no, skip to question 20.
Daily(1)
Several times/ week (2)
Several times/ month (3)
Hardly ever (4)
Never (5)
19b.
Near vicinity(same premises, but not close proximity)
19c.
Close proximity (within 6 feet)
19d.
Direct contact (touching/ handling)
19e.
Feed
19f.
Groom
19g.
Clean animal holding area
19h.
Remove manure
19i.
Replace bedding
19j.
Slaughter
19k.
Vaccinate or give medicine
19l.
Help or observe a birth
19m.
Direct contact with a newborn
19n.
Direct contact with a dead animal
19o.
Direct contact with afterbirth or birth products
20. Cows Yes (1) No (2)
If yes, complete this section; if no, skip to question 21.
Daily(1)
Several times/ week (2)
Several times/ month (3)
Hardly ever (4)
Never (5)
20b.
Near vicinity(same premises, but not close proximity)
20c.
Close proximity (within 6 feet)
20d.
Direct contact (touching/ handling)
20e.
Feed
20f.
Groom
20g.
Clean animal holding area
20h.
Remove manure
20i.
Replace bedding
20j.
Slaughter
20k.
Vaccinate or give medicine
20l.
Help or observe a birth
20m.
Direct contact with a newborn
20n.
Direct contact with a dead animal
20o.
Direct contact with afterbirth or birth products
21a. Sheep Yes (1) No (2)
If yes, complete this section; if no, skip to question 22.
Daily(1)
Several times/ week (2)
Several times/ month (3)
Hardly ever (4)
Never (5)
21b.
Near vicinity(same premises, but not close proximity)
21c.
Close proximity (within 6 feet)
21d.
Direct contact (touching/ handling)
21e.
Feed
21f.
Groom
21g.
Clean animal holding area
21h.
Remove manure
21i.
Replace bedding
21j.
Slaughter
21k.
Vaccinate or give medicine
21l.
Help or observe a birth
21m.
Direct contact with a newborn
21n.
Direct contact with a dead animal
21o.
Direct contact with afterbirth or birth products
22. Have any animals that you have been exposed to since [INSERT DATE] been ill with any of the following symptoms?
22a. Abortion Yes (1) No (2) 22b. If yes, what animals(s)? ___________ 22c. Newborn death Yes (1) No (2) 22d. If yes, what animals(s)? ___________
22e. Poor doer Yes (1) No (2) 22f. If yes, what animals (s)? ___________
22g.Weak newborn Yes (1) No (2) 22h. If yes, what animals (s)? ___________
22i. Decreased fertility Yes (1) No (2) 22j. If yes, what animals (s)? ___________
23. What time of year do the livestock you been exposed to give birth?
N/A
(1)
Dec-Feb
(2)
Mar-May
(3)
Jun-Aug
(4)
Sep-Nov
(5)
All Year
(6)
Unk
(9)
23a. Goats
23a. Cows
23a. Sheep
24a. How do you dispose of dead goats, cows, or sheep (including dead fetuses or newborn)?
Compost (1) Incinerate (2) Burial (3) Other (4) N/A (5)
24b. If other, please describe: ________________________________________________________
25a. Do you clean/disinfect an area after an animal has given birth? Yes (1) No (2)
25b. If yes, please explain: _______________________________________________________________
26. What is done with the manure (animal waste) from the livestock you care for?
• Nothing- don’t pick it up (1)
• Spread in fields (2)
• Spread in garden (3)
• Sell it/give it away (4)
• N/A (5)
Section III: Medical History
27a. Do you recall having an illness with fever since [INSERT DATE]? Yes (1) No (2)
If yes, complete this section; if no, skip to questions 28
27b. When approximately did this illness begin? _____________________ Don’t remember (99)
27c. How many days did the illness last? ____________________________ Don’t remember (99)
27d. Did you miss work due to Illness? Yes (1) No (2)
27e. If yes, how many days were you out? ___________________________
27f. Did you seek medical attention for this illness? Yes (1) No (2)
27g. Physician’s name: ______________________________________________________________ Unk (9)
27h. Visit date: _____/_____/______ (Unk) 9
27i. Were you hospitalized due to this illness? Yes (1) No (2)
If yes, complete this section; if no, skip to question 27m.
27j. Name of hospital: _______________________________________________________________ Unk (9)
27k. Admit date: ____/_____/_____ Unk (9)
27l. Discharge date ____/____/_____ Unk (9)
27m. What diagnosis did you receive for this illness? ________________________________________________
28. Since [INSERT DATE], have you experienced/were you told by your doctor you had any of the following symptoms/ conditions?
Yes
(1)
No
(2)
Unk
(9)
Yes
(1)
No
(2)
Unk
(9)
28n.
Fever
28o.
Joint Pain
28p.
Chills
28q.
Back pain
28r.
Insomnia
28s.
Jaundice
28t.
Cough
28u.
Myocarditis
28v.
Nausea
28w.
Osteomyelitis
28x.
Anorexia
28y.
General fatigue
28z.
Stiff neck
28aa.
Night sweats
28bb.
Hepatitis
28cc.
Weight loss
28dd.
Pneumonia
28ee.
Shortness of breath
28ff.
Endocarditis
28gg.
Diarrhea
28hh.
Meningitis
28ii.
Muscle pain
28jj.
Headache
28kk.
Abdominal pain
28ll.
Rigors
28mm.
Hepatomegaly
28nn.
Rash
28oo.
Miscarriage
28pp.
Chest pain
28qq.
Guillain-Barre
28rr.
Vomiting
28ss. Is there anything else you would like to share about your illness?
29a. Do you have any history of heart problems? Yes (1) No (2)
29b. if yes, please explain: ______________________________________________________
30. Do you currently smoke or have you smokes since [INSERT DATE]?
Yes (1) No (2)
31. Since [INSERT DATE], have you consumed raw (unpasteurized) dairy products, such as goat cheese?
Yes (1) No (2)
Section IV: Human Lab Data
Serum specimen 1
32. Sample date: ____/___/_____
33. IgG Phase I: _________________ 34. IgG Phase II: __________________________
34. IgM Phase I: _________________ 36. IgM Phase II: __________________________
Serum specimen 2
37. Sample date: ____/___/_____
38. IgG Phase I: __________________ 39. IgG Phase II: ____________________________
40. IgM Phase I: __________________ 40. IgM Phase II: ____________________________
42a. Category of analysis: Case (1) Control (2)
42b. if case’ Probable (1) Confirmed (2)