Form 0920-1039 ORCHARDS HOUSEHOLD STUDY FORM B

ORCHARDS 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? ________