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pdfORCHARDS HOUSEHOLD STUDY FORM
Participant ID: _____________
School ID: 4k P N B R M H
HOUSEHOLD MEMBER NAME: ______________________
Age: ________
RELATIONSHIP TO STUDENT: _______________________
ID
BIRTHDATE: ___/___/______
Race:
White
Ethnicity:
American Indian or Alaskan Native
Hispanic
Black
Gender: Female
Non-Hispanic
Do you work outside the home? Yes No
Do you attend school? Yes No
Asian
Native Hawaiian or Other Pacific Islander
Male
Other: _____________
Number of bedrooms in household: ________
Do you attend Daycare? Yes No
Did you receive an influenza vaccine this year (after August 1, 2020)? Yes No
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Have you been tested for COVID-19? Yes (please list test date and result if known) _______________ No
Have you had cold or flu-like symptoms in the past 14 days?
Yes
(if No, stop here)
No
If yes: How many days ago did your symptoms start? ________
Exposure to a similar illness 1-14 days prior to illness onset?
TODAY
Day 0 ( ___ / ___ / ___ )
Likely Source: Classmate
Friend
No
Family Member (Adult/Child)
Recent Travel? Yes (please list location) ________________
How severe are/were your symptoms?
Yes
Mild
Other: _____________
No
Moderate
Severe
What symptoms have you had in the past 14 days? (circle all that have been present)
Fever
Chills
Cough
Wheezing
Runny Nose
Sore Throat
Fatigue
Muscle Pain
Joint Pain
Headache
Stuffy Nose
Ear Pain
No Appetite
Vomiting
Abdominal Pain
Diarrhea
Conjunctivitis
Shortness of Breath
Loss of smell
Loss of taste
Other:_____________________________
Were you seen by a healthcare provider? Yes No
Where?
Virtual visit Usual Clinic
Urgent Care ER
What diagnosis were your given? _____________________
Were you given an antibiotic or antiviral medication? Yes No _______________________
Were you sent to the hospital? Yes No
Did you miss school or work? Yes No
If yes, how many days did you miss? ________
ID
ORCHARDS HOUSEHOLD STUDY FORM
Participant ID: _____________
School ID: 4k P N B R M H
HOUSEHOLD MEMBER NAME: ______________________
Age: ________
RELATIONSHIP TO STUDENT: _______________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Have you been tested for COVID-19? Yes (please list test date and result if known) _______________ No
Have you had cold or flu-like symptoms in the past 14 days?
If yes:
Are these continuing symptoms from Day 0? Yes
Are you currently experiencing symptoms? Yes
Yes
No (if No, list symptom start date) _______________
No (if No, list symptom end date) _______________
Exposure to a similar illness 1-14 days prior to illness onset?
Likely Source: Classmate
Friend
Yes
Day 7 ( ___ / ___ / ___ )
TODAY
No
Family Member (Adult/Child)
Recent Travel? Yes (please list location) ________________
How severe are/were your symptoms?
(if No, stop here)
No
Mild
Other: _____________
No
Moderate
Severe
What symptoms have you had in the past 14 days? (circle all that have been present)
Fever
Chills
Cough
Wheezing
Runny Nose
Sore Throat
Fatigue
Muscle Pain
Joint Pain
Headache
Stuffy Nose
Ear Pain
No Appetite
Vomiting
Abdominal Pain
Diarrhea
Conjunctivitis
Shortness of Breath
Loss of smell
Loss of taste
Other:_____________________________
Were you seen by a healthcare provider? Yes No
Where?
Virtual visit Usual Clinic
Urgent Care ER
What diagnosis were your given? _____________________
Were you given an antibiotic or antiviral medication? Yes No _______________________
Were you sent to the hospital? Yes No
Did you miss school or work? Yes No
If yes, how many days did you miss? ________
ORCHARDS HOUSEHOLD STUDY FORM
Participant ID: _____________
School ID: 4k P N B R M H
HOUSEHOLD MEMBER NAME: ______________________
Age: ________
ID
RELATIONSHIP TO STUDENT: _______________________
Over the past 2 weeks, have you:
Used a face mask/covering outside of your home (when social distancing is not possible)?
Never
Rarely
Sometimes
Often
Always
Practiced social/physical distancing when outside of your home?
Never
Rarely
Sometimes
Often
Always
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Have you been tested for COVID-19? Yes (please list test date and result if known) ________________ No
Have you had cold or flu-like symptoms in the past 14 days?
If yes:
Are these continuing symptoms from Day 0? Yes
Are these continuing symptoms from Day 7? Yes
TODAY
Day 14 ( ___ / ___ / ___ )
Are you currently experiencing symptoms? Yes
Yes
No (if no, list symptom start date) ____________
No (if no, list symptom start date) ____________
No (if no, list symptom end date) _____________
Exposure to a similar illness 1-14 days prior to illness onset?
Likely Source: Classmate
Friend
Yes
No
Family Member (Adult/Child)
Recent Travel? Yes (please list location) ________________
How severe are/were your symptoms?
(if No, stop here)
No
Mild
Other: _____________
No
Moderate
Severe
What symptoms have you had in the past 14 days? (circle all that have been present)
Fever
Chills
Cough
Wheezing
Runny Nose
Sore Throat
Fatigue
Muscle Pain
Joint Pain
Headache
Stuffy Nose
Ear Pain
No Appetite
Vomiting
Abdominal Pain
Diarrhea
Conjunctivitis
Shortness of Breath
Loss of smell
Loss of taste
Other:______________________________________
Were you seen by a healthcare provider? Yes No
Where?
Virtual visit Usual Clinic
Urgent Care ER
What diagnosis were your given? _____________________
Were you given an antibiotic or antiviral medication? Yes No _______________________
Were you sent to the hospital? Yes No
Did you miss school or work? Yes No
If yes, how many days did you miss? ________
| File Type | application/pdf |
| Author | Jonathan Temte |
| File Modified | 2021-01-21 |
| File Created | 2021-01-21 |