Form 0920-1039 ORCHARDS Screening Form

U.S. Department of Health and Human Services (HHS) OMB Control # 0920-XXXX

Centers for Disease Control and Prevention (CDC) Expiration Date XX/XX/XXXX

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Screener:_____________________
Screening Date:_____________________
Participant ID (if eligible):_____________________

ORCHARDS Phone Screening

Thank you for your interest in participating in this study. I will need to ask you a few questions about you or your child’s illness to see if you or your child might qualify for this study, which will take about 5 minutes. Answering these questions is completely voluntary and you can stop answering them at any time. If you or your child do not qualify or decide not to participate, all the identifiable information that you tell me will be destroyed. If you agree to participate, your screening information will be kept in a password-protected security-ensured database to maintain confidentiality. Only the research team will have access to this data. I do need to let you know that all University of Wisconsin System (UWS) employees are required by law to report child abuse or neglect immediately if the employee, in the course of employment, observes an incident or threat of child abuse or neglect, or learns of an incident or threat of child abuse or neglect, and the employee has reasonable cause to believe that child abuse or neglect has occurred or will occur. Completing this phone screen means that you agree to let us collect your screening information. Is it OK to proceed?

YES NO (circle one)

Remember to enter this data in REDCap. If the participant is ineligible, only keep the following: (1) age (2) gender (3) Jackson score (4) eligibility
Caller’s Name (first & last)
Participant’s Name (first & last)
Participant’s Gender (circle one)			Male Female
Participant’s Age
Address
If address is listed in Wisconsin Department of Corrections Sex Offender Registry (http://offender.doc.state.wi.us/public/ ), family will be ineligible.			Registered? Yes No
Phone Number(s)
School (circle one)			Oregon High School Oregon Middle School Rome Corners Intermediate School Brooklyn Elementary Netherwood Knoll Elementary Prairie View Elementary
Screening Questions about Illness
Do you think you have a cold or flu?	Yes No	Must answer yes to one of these questions to be eligible
Do you think you’re coming down with a cold or flu?	Yes No
Which symptoms are you experiencing?	 Nasal discharge (runny nose)  Nasal congestion (stuffy nose)  Sneezing  Sore throat  Cough  Fever	Must have at least 2 symptoms to be eligible
Jackson Criteria 0 = absent 1 = mild 2 = moderate 3 = severe	___ Nasal discharge (runny nose) ___ Nasal obstruction (stuffy nose) ___ Sneezing ___ Sore throat ___ Cough ___ Malaise (tired, run down) ___ Chilliness ___ Headache	Must have a score of at least 2 to be eligible
When did your symptoms start? (date & time)		Must obtain samples within 4 days (96 hours) of illness onset! Ineligible otherwise.
Eligibility	Eligible Ineligible Declined
If Ineligible or Declined, reason why
If eligible, schedule home visit (date & time)		Must obtain samples within 4 days (96 hours) of illness onset! Ineligible otherwise.

1Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor this survey, 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.