Appendix 6 - Example of Online Survey

Appendix 6. Online Survey Example – Case Finding Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Case Finding 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)

1. Attendee Information

*1. Please enter the email address you used to register for the [INSERT NAME OF EVENT]

*2. Please select the dates you attended the [INSERT NAME OF EVENT] (check all that apply)

DATE 1

DATE 2

DATE 3

2. Travel Information

1. Please select mode of transportation used to travel to [INSERT LOCATION]

Car

Plane

Train

N/A

Other (please specify)

3. Flight Information

*1. If plane, what airline did you fly (flight number optional)?

4. Hotel Information

1. Please select the hotel you stayed in while attending [INSERT NAME OF EVENT]

SITE 1

SITE 2

SITE 3

*2. Please indicate the dates you stayed in the hotel:

*3. During your stay, did you sue any of the following:

Pool

Spa

Sauna

Steam room

Fitness center showers

None of the Above

5. Symptoms experienced

1. Did you experience any illness prior to the [INSERT NAME OF EVENT]?

Yes

No

If Yes, please specify

2. Did you experience any illness after you attended the [INSERT NAME OF EVENT]?

Yes

No

*3. What date did your symptoms start? (enter n/a if you did not have symptoms)

4. What was the duration of your symptoms?

1-2 days

3-4 days

5+ days

I did not have symptoms

*5. Please indicate symptoms you experienced:

Fever

Chills

Muscle aches

Fatigue

Abdominal pain

Diarrhea

Dry cough

Productive cough (phlegm/mucus)

Shortness of breath

I did not have symptoms

Other (please specify)

6. Medical history

1. Do you have any of the following medical conditions?

Heart condition

Asthma

Bronchitis

Diabetes

Organ transplant recipient

Cancer or cancer treatment

Other medical conditions

2. Do you take any medications regularly?

Yes

No

Please list medications

3. Do you smoke?(Any substance)

Yes

No

7. Illness information

1. Did you see a doctor about your illness?

Yes

No

I was not ill

2. Were you hospitalized overnight?

Yes

No

I was not ill

If Yes, please give name of hospital and dates hospitalized

3. If Yes, were any lab test performed?

Blood tests

Urine tests

Chest x-ray

Sputum test

I was not ill

If Yes, please enter lab result if known

4. Were you given a diagnosis?

Flu

Pneumonia

Viral respiratory illness

I was not ill

Other (please specify)

5. Were you given antibiotics for your symptoms?

Azithromycin (Z-pack)

Levofloxacin (Lavaquin)

Erythromycin

Doxycycline

I was not ill

Other (please specify)

6. Do you still have symptoms?

Yes

No

I was not ill

8. Events attended [INSERT DATE OF EVENT]

1. Did you attend the [INSERT NAME OF EVENT] on [INSERT DATE OF EVENT]?

Yes

No

2. Did you attend the [INSERT NAME OF EVENT] on [INSERT DATE OF EVENT]?

Yes

No

3. Did you attend the [INSERT NAME OF EVENT] at [INSERT SITE AND LOCATION OF EVENT] on [INSERT DATE OF EVENT]?

Yes

No

9. Contact Information (optional)

We thank you for taking the time to complete thus survey. Your cooperation is important as we continue our investigation.

1. Depending on your answers the [INSERT NAME OF INVESTIGATING ENTITY] may want to contact you to obtain more information. We appreciate your cooperation with this investigation.

Name:

Phone number:

2. Are you from [INSERT LOCATION OF EVENT]?

Yes

No

3. Please indicate what country you are from.

4. May we contact you?

Yes

No