Appendix 4 - Example of Personal Interview Questionnaire

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)

2