Appendix 2 - Example of GBS Questionnaire

Case Data Collection Worksheet Form Approved

CDC ID:_____

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Appendix 2. Guillain-Barre Syndrome Case Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Guillain-Barre Syndrome Case-control Study

Case 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)

Guillain-Barre Syndrome Case Control Study

Case Questionnaire

Study ID Number MX ___-___ ___-___  Case  Control

The ID number begins with the 3 digit case number (for example MX001) followed by a 0 for case patient, a 1 for the first control number, a 2 for the second control, and a 3 for the third control. For example, the second control subject matched fro case number 8 would be labeled “MX008-2”

Interviewer: ____________________

1. Date of Interview: __ __/___ ___/2011 Time of Interview: ____________________

DD MM YYYY

2. Address: ___________________________________________________

___________________________________________________

3. State:

4. Sex: 1. Male 2. Female

5. Age at time of interview: ______Years

6. Positive Campylobacter test? 1. Yes 0. No 7. Unknown

7. Acute flaccid paralysis? 1. Yes

0. No (Skip to question 10)

8. Guillain-Barre Syndrome? 1. Confirmed 2. Pending Classification

9. Did you have diarrhea in the six weeks before the onset of paralysis?

Paralysis onset date: __ __/__ __/____

DD MM YYYY

1. Yes 0. No 7. Unknown

10. On what date did the diarrhea start? Here is a calendar to help you remember.

Interviewer: If the interviewee is unsure of the date, remind them of the date of the paralysis or the date of hospital admission

Date of diarrhea onset: __ __/ __ __ __/ ____

Day Mo Year

*An approximate onset date is acceptable

** If the case of Guillain-Barre Syndrome did not present with diarrhea, record the date 7 days

before the onset of neurologic symptoms/weakness. If a patient with Campylobacter did not present with diarrhea, record the date 7 days before the positive culture.

11. What was the most number of diarrhea stools that you had in a 24 hour period? _______

 No Diarrhea

12. In the week before the start of diarrhea, did you take any medications to decrease stomach acids?

These medications include Maalox, Pepto-Bismol, Ranitidine, Omeprazole, or many others.

0. No

7. DK SKIP TO QUESTION #14

1. Yes

13. If yes,

Specify which medications: ______________________________________________________________

Section 1: Exposures

Now I will ask some questions about things you have done, food and drinks you might have consumed during a period of time from ___/__ __/ ____ (7 days before the date in question 10) and ___/___ ___/____ (the date in question 10)

14. Were you in [INSERT FIRST LOCATION] during these 7 days?

0. No Go to Question #19

7. DK

1. Yes Go to Question #15

15. If yes, how much time did you spend in [INSERT FIRST LOCATION] during these 7 days?

1. Less than an hour

2. 1-8 hours

3. More than 8 hours and less than 24 hours

4. More than 24 hours and less than 72 hours (3 days)

5. More than 72 hours (3days)

16. How often did you travel to [INSERT FIRST LOCATION] during these 7 days?

1. Daily

2. 1-2 times per week

3. More than twice per week

   

4. Lives in San Luis Rio Colorado Skip to Question #19

17. What was the purpose of your travel to [INSERT FIRST LOCATION] during these days?

1. Visiting family or friends

2. Work

3. Other purpose (specify _______________________)

18. Please list neighborhoods in [INSERT LOCATION] that you visited during these 7 days. Do not include travel through these neighborhoods if you did not stop. (use the map to help identify the neighborhoods)

19. Did you spend time in [INSERT SECOND LOCATION] during these 7 days (circle answer)?

0. N Skip to Question #23

7. DK

1. Yes Skip to Question #19

20. How much time did you spend in [INSERT SECOND LOCATION] during these 7 days?

6. Less than one hour

7. 1-8 hours and less than 24 hours

8. More than 8 hours and less than 24 hours

9. More than 24 hours and less than 72 hours (3 days)

10. More than 72 hours (3days)

21. How often you visit [INSERT SECOND LOCATION] during these 7 days?

1. Daily

2. 1-2 times per week

3. More than twice per week

4. Lives in San Luis Rio Colorado  Skip to Question #23

22. What was the purpose of your travel to [INSERT SECOND LOCATION] during these days?

1. Visiting family or friends

2. Work

3. Other purpose (specify _________________________)

23. Did you travel to the following areas in [INSERT SECOND LOCATION] during these 7 days?

[INSERT AREA 1] Yes No DK/NS  (Where? ________________________)

[INSERT AREA 2] Yes No DK/NS  (Where? ________________________)

[INSERT AREA 3] Yes No DK/NS  (Where? ________________________)

[INSERT AREA 4] Yes No DK/NS  (Where? ________________________)

[INSERT AREA 5] Yes No DK/NS  (Where? ________________________)

[INSERT AREA 6] Yes No DK/NS  (Where? ________________________)

24. Did you travel anywhere else during these 7 days?

1. Yes (Where and When? _____________________________________________)

0. No

7. DK

9. Refused

25. Did you attend an event where food or beverages were served to many people (e.g. parties, community functions, etc.) during these 7 days?

1. Yes (Where and When? ____________________________________________)

0. No

7. DK

9. Refused

26. Do you know anyone else who had diarrhea in the week before or after you were sick with diarrhea?

1. Yes

0. No  Go to Question #28

PART 2. Water

During these 7 days, what were the sources of the water that you drank? For each source I will ask you if you drank it at home or away from home. This also includes water for preparing beverages.

28. Apart from your home and work, where else did you drink water (house of friends or family, school, etc.)? Place #1 ______________________ Place #2 ______________________

**If there are more than 2 house, please attach an additional page **

		Home	Work	Other place #1	Other place #2
In what neighborhood is your…?
In a normal day, how many glasses of water do you drink at this location?		______glasses	______ glasses	______ glasses	______ glasses
Is the water you drink here from the tap?		Y N DK	Y N DK	Y N DK	Y N DK
Is the water you drink here bottled water?		Y N DK	Y N DK	Y N DK	Y N DK
Is the water you drink here from a 5 gallon container (garrafón) ?		Y N DK	Y N DK	Y N DK	Y N DK
If yes, please record the following information -Brand of water -Name of vendor -Location of the store/kiosk (if you don’t know the location of the store, please specify neighborhood)	#1	Brand: ___________ Store: / Kiosk ______________ Location (streets): _______________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): ________________
	#2	Brand: ___________ Store: / Kiosk ______________ Location (streets): _______________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): ________________
	#3	Brand: ___________ Store: / Kiosk ______________ Location (streets): _______________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): ________________
	#4	Brand: ___________ Store: / Kiosk ______________ Location (streets): _______________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): _________________	Brand: ___________ Store: / Kiosk ______________ Location (streets): ________________

29. In these 7 days, where did you get any ice you consumed? (check all that apply)

• Did not consume ice

• Made from tap water

• From garrafón water

• Made from bottled water

• From a store

• Don’t know

• Refused

30. In these 7 days, where did the water come from that you used to wash vegetables, fruits, or meat?

(check all that apply)

• From tap water

• From garrafón water

• From bottled water

• Did not wash these things

• Don’t know

• Refused

31. In these 7 days, where di the water come from that you used to brush your teeth? (check all that apply):

 From tap water

• From garrafón water

• From bottled water

• Don’t know

• Refused

32. In these 7 days, did you consume a drink made with water (e.g. atole, lemonade, punch, etc.)

0. No

7. DK Go to Question #34

1. Yes Go to Question #33

33. In these 7 days, where did you get the water that you drank in your home?

 From tap water

• From garrafón water

• From bottled water

• Don’t know

• Refused

34. In these 7 days, did the water in your house have a different flavor, odor, or appearance?

0. No

1. Yes 

7. DK/NS

35. Does water in your house usually have a bad flavor, odor, or appearance?

0. No

1. Yes  (describe: _____________________________________________________)

7. DK/NS

36. In these 7 days, did the water from the garrafón in your house have a different flavor, odor, or appearance?

0. No

1. Yes

2. No Garrafon

7. DK

37. In these 7 days, did you swim in fresh water like a lake, river, canal, or wash?

0. No  Go to Question #39

1. Yes

7. DK

38. If yes, where did you swim? (Specify the city, country and body of water)

____________________________________________________________

39. In these 7 days, did you visit, work, or stay at a ranch or farm?

0. No  Go to Question #41

1. Yes  (Where _______________________________________________)

7. DK

40. If yes, what animals were in the ranch or farm? (note all animals, including cows, horses, chickens, etc.)

________________________________________________________________________________

41. Please answer “yes” or “no” if during these 7 days, you had contact with the following animals.

Dog Yes No DK/NS

Cat Yes No DK/NS

Birds Yes No DK/NS

Rabbits Yes No DK/NS

Fish Yes No DK/NS

Reptiles Yes No DK/NS

Hamsters Yes No DK/NS

42. In these 7 days, did you eat food from a street vendor or truck?

0. No

1. Yes  (Name ________________________________ Where _________________________________)

7. DK

Food History

Please indicate for each of the food items listed below whether you ate it, maybe ate it, or did not eat it and whether it was cooked or uncooked during the seven days before onset for cases or comparable reference period for controls. The reference period for this case-control set is ____/____/____ to ____/____/____.

Food	Ate	Did not Eat	Maybe Ate	How Prepared			Brand or Variety		Name and location where it was purchased		Restaurant where it was eaten (name and location )
Eggs
Milk
Raw or unpasteurized milk
Agulas Frescas (soft drinks made from water)
Shaved ice
Queso Fresco from raw or unpasteurized milk Y N DK
Cream sauce
Other cheese
Chicken
Beef
Pork
Fish
Shrimp
Shellfish (clams, oysters, etc.)
Deli meat
Other type of meat, poultry, or fish
FRUTUS
Lemon/Lime
Oranges
Grapefruit
Tangerines
Pears
Chicken
Beef
Pork
Fish
Shrimp
Shellfish (clams, oysters, etc.)
Deli meat
Other type of meat, poultry, or fish
FRUTUS
Lemon/Lime
Oranges
Grapefruit
Tangerines
Pears
Apples
Other tree fruit (peaches, nectarines)
Strawberries
Cantaloupe
Honeydew melon
Watermelon
Bagged salad/lettuce
Head lettuce
-iceberg
-Romaine
Spinach
Cabbage
Tomato (not including salsa bandera)
Peppers
Chiles
Celery
Carrots
Zucchini or squash
Onion (not including salsa bandera
-Green Onion
Broccoli
Cilantro (not including salsa bandera)
Cauliflower
Salsa bandera

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