Data Collection Forms

Appendix 2 Data Collection Forms.pdf

Emergency Epidemic Investigation Data Collections- -Expedited Review (Y3Q4)

Data Collection Forms

OMB: 0920-1011

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1011 can be found here:

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Form Approved
OMB No. 0920-1011
Exp. Date
1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V7 rev 5/11/2020
(Correctional Facility Transmission Investigation)

Public reporting burden of this collection of information is estimated to average 120 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 (0920-1011).

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V7 rev 5/11/2020
(Correctional Facility Transmission Investigation)
Unit Survey [Complete this survey for each unit of the facility enrolled.]

1. Facility Name:________________________________________________________________________
2. Unit Name: __________________________________________________________________________
3. Location (building, floor, room, etc):______________________________________________________
4. Level of security (check all that apply):

Minimal

Medium

High/Maximum

5. Respondent Name and Title: ____________________________________________________________
6. Interviewer:___________________________ Date Completed: _____________________(MM/DD/YY)
Unit Characteristics
7. Unit is currently: Under quarantine
Under medical isolation
Other:________________
8. When did this unit start quarantine/isolation: _____________________(MM/DD/YY)
9. When was the last day a new detainee was added to this unit:________________(MM/DD/YY)
10. Number of detainees currently in the unit: _______
11. Full capacity of unit: ______
12. Unit type: Individual cells Dormitory (communal) housing
a. How many beds per cell/room or dorm unit:_____________________
b. How many detainees per cell/room or dorm unit:____________________
c. Are any cells currently shared in this unit? Yes No
Unknown
d. If dormitory unit, are the sleeping areas: Cells or rooms with a door Cubbies or other enclosure
without a door open dormitory
Other, specify:______________________
13. Number of levels: ______
14. How many of the following items are present in the common area within the unit:
a. Toilets: ______
b. Sinks/handwashing area: _______
c. Showers:________
d. Phones:_________ ; Describe phone layout:_____________________________________________
15. How many of the following items are present within each cell or dorm:
a. Toilets: ______
b. Sinks/handwashing area: _______
c. Showers:________
Facilities access among detainees in the unit
16. In the past two weeks, identify which facilities/items detainees have had access to:
Access Level
Individual vs. Shared Access
Dining Area/Mess hall
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Recreation Area
All the time Restricted
Cell only Unit only Multiple units
(inside common area)
None Unknown
different time
Multiple units same time
Recreation Area or
All the time Restricted
Cell only Unit only Multiple units
yard (outside)
None Unknown
different time
Multiple units same time
Commissary
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Other:____________
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
2

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V7 rev 5/11/2020
(Correctional Facility Transmission Investigation)

17. Communal space
a. How many detainees are allowed in the common space at a given time?___________
b. How many different units share the common space?_______________
c. How often is the common space cleaned? And how?
How often?
How? (e.g. power washing, bleach, etc.)
Between each group
Multiple times a day, but not between each group
Once a day
Other:_________________
d. For how long each day is each group allowed in the common space?__________hours
18. Dining area
a. Where are meals served?
to each cell individually
dining room or common space
Other, specify:____________________________
b. If dining area, how many different units share the dining area?_______________
19. Is there an outdoor space associated with the unit? Yes No
Unknown
a. How many people are allowed outside at a time?_________________
b. How many different units share the outdoor space?_______________
c. For how long each day is a group allowed in the space?______________hours
Sanitation
20. In the past two weeks, which of the following items have detainees been provided (check all that apply):
Hand Sanitizer
Soap
Face Masks
None
Unknown
21. In the past two weeks, have individuals on this tier been provided with individual hand sanitizer?
Yes No
Unknown
22. Where are the cleaning supplies located?
In an area with free access
Held by CO, and provided upon request
Other, specify:____________________________

Unknown

Work Units
23. In the past two weeks, have any detainees in this unit performed duties or services (e.g., work at the
facility)? Yes No
Unknown
d. If yes, do they work in, Their unit only
Their division only; no areas with other detainees
Their division only; no areas with other detainees
Other:________________________
i. Does the work unit contain detainees from other units?
Yes, at the same time/shift Yes, same areas but different shifts No Unknown
24. In the past two weeks, which jobs have been performed by detainees in this unit?
Kitchen/meals
Library
Education
Laundry
Groundskeeping
Cleaning/Custodial
Unknown
Other, specify: ________________________
25. In which area or unit were these jobs performed in the past two weeks: _____________________
3

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V7 rev 5/11/2020
(Correctional Facility Transmission Investigation)

Staffing
26. Are staff assigned or dedicated to work on this unit only? Yes No
Unknown
e. If yes, for how long? ____________________
f. [For corrections officers) How many shifts cover a 24 hour period? _______________________
27. On an average day, how many staff members are assigned to work in this unit? (extended time in this unit,
or working with detainees from this unit) Total _________ (estimate if exact number not known); by
category:
a. Corrections: ________; do they work on other units? Yes No
Unknown
b. Environmental/maintenance: _______; do they work on other units?
c. Admin: ________; do they work on other units?

Yes

d. Healthcare: ________ do they work on other units?

No
Yes

Yes

Unknown

Unknown
No

Unknown

e. Other:_______________ (specify job class:___________________________________)
i.
do they work on other units? Yes No
Unknown
28. On an average day, how many staff members are within 6ft of the detainees for more than 10 minutes in
this unit for their regular duties?
Total _________ (estimate if exact number not known); by category:
g. Corrections: ________
h. Environmental/maintenance: _______
i. Admin: ________
j. Healthcare: ________
k. Other:_______________ (specify job class:___________________________________)
Interviewer Notes:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Cook County Questionnaire V24 rev 05/05/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________
Administrative Information
1. Interviewer Name: First: ____________________Last:_____________________ Date:
2. Housing [detainee] or work [staff] location: Division: _______ Tier:_________ Other:_____________
3. Date quarantine initiated: _____/______/______
4. At the unit, the number of current: Staff present:_________ Cells:____________ Detainees:____________
5. Interviewee:
Detainee
Staff
Demographic Information
6. Age: _______
Height:_______ (ft, in)
Weight: _______ (lbs)
7. Ethnicity (select one):
Hispanic/Latino
Non-Hispanic/Latino
Not Specified
8. Race (check all that apply):
White
Black
Asian
Am Indian/Alaska Nat
Nat Hawaiian/Other PI
Other, specify:___________
Unknown
9. Sex:
Male
Female
Symptoms
10. Use no-touch thermometer to record current temperature: ________°F
11. In the last two weeks, have you experienced any of the following symptoms?
Symptom Present
Last 2 Weeks?
Fever >100.4°F (38° C)
Subjective fever (felt feverish, or hot/sweaty)
Chills
Muscle aches (myalgia)
Runny nose (rhinorrhea)
Stuffy nose (nasal congestion)
Sore throat
Cough (new onset or worsening of chronic cough)
Shortness of breath (dyspnea)
Abdominal pain
Diarrhea (≥3 loose stools/24hr period)
Nausea
Vomiting
Headache
Loss of taste
Complete
Partial
Loss of smell
Complete
Partial
Other, specify:

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Onset
Date
(mm/dd)
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___

# of Days

Ongoing?

Last 2
Months?

12. For any of these symptoms, have you experienced them in the last two months? That means since _______(month).
Smoking Status Note: Smoking is prohibited in the facility compound for all detainees.
13. [Staff only] Do you currently smoke tobacco on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
14. [Staff only] Do you currently vape or use electronic cigarettes on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
15. In the past, have you smoked tobacco, used e-cigarettes or vaped?
Daily
Less than daily
Not at all
Unknown
16. [If any use] When was the last time? ________________ (MM/YYYY)

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Cook County Questionnaire V24 rev 05/05/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________

Past Medical History
17. Please provide pre-existing medical conditions (complete regardless of age):
Condition
Response
If YES, specify
Health conditions that cause
Yes No
Asthma
COPD (chronic obstructive pulmonary disease)
breathing problems?
Unk/DK/Ref
Emphysema
Lung Cancer
Sleep Apnea
Other, specify:_____________
Diabetes or problems with your
Yes No
Type 1
Type 2
blood sugar?
Unk/DK/Ref Are you taking insulin?
Yes
No
Heart problems or high blood
Yes No
Congenital heart abnormalities
Coronary artery disease
pressure?
Unk/DK/Ref
Heart failure
High cholesterol (Hyperlipidemia)
High blood pressure (Hypertension)
Heart attack (Myocardial infarction)
Other, specify_____________
Kidney problems?
Yes No
Chronic kidney disease
Dialysis
Unk/DK/Ref
End-stage renal disease
Other, specify: ________
Liver problems?
Yes No
Cirrhosis
End-stage liver disease
Unk/DK/Ref
Hepatitis B
Hepatitis C
Other, specify:___________
A disease, medication, or
Yes No
Chemotherapy
HIV/AIDS
Lupus
Steroids
condition that weakens your
Unk/DK/Ref
Other, specify:____________
immune system?
Learning or memory problems or
Yes No
Dementia/Alzheimer’s
Neurodevelopmental Disorder
history of head injury?
Unk/DK/Ref
Stroke
Traumatic Brain Injury
Other, specify:____________
Do you have other
Yes No
Specify:____________________________________________
health/medical problems you
Unk/DK/Ref
would like me to know about?

18. Have you been assigned to any other Divisions or Tiers in the last 2 months?
Yes
No
If yes, how many? _________
If known, specify Division(s) and Tier(s):_________________________________________________________
SARS-CoV-2 testing
19. Have you ever been offered a test for coronavirus?

Yes

a. If yes, have you been tested for coronavirus?

Yes

Refused

Unknown

i. Date of most recent test:_______________________________(MM/DD/YYYY)
ii. Did you experience any symptoms at the time you were tested?

Yes

iii. Result of most recent test:
Positive
Other, specify: _______________

Indeterminate

Negative

Pending

No
Don’t know

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Cook County Questionnaire V24 rev 5/05/2020
(Correctional Facility Transmission Investigation)
Day 3/4 Form
CDC ID: _________
Administrative Information
1. Interviewer Name: First: ____________________Last:_____________________ Date:
/
/
2. Housing [detainee] location: Division: ______ Tier:______ Other:_____________
3. Date quarantine initiated: _____/______/______
4. At the tier, the number of current: Staff present:______ Cells:____________ Detainees:______________
5. Interviewee:
Detainee
Symptoms
6. Use no touch thermometer to record current temperature: ________°F
7. Since we last visited you, have you experienced any of the following symptoms?
Symptom Present
Since Last Visit?
Yes No Unk

Fever >100.4°F (38° C)

Onset Date
(mm/dd)
___/___

Subjective fever (felt feverish, or hot/sweaty)

Yes

Unk

___/___

Chills

Yes

Unk

___/___

Muscle aches (myalgia)

Yes

Unk

___/___

Runny nose (rhinorrhea)

Yes

Unk

___/___

Stuffy nose (nasal congestion)

Yes

Unk

___/___

Sore throat

Yes

Unk

___/___

Cough (new onset or worsening of chronic cough)

Yes

Unk

___/___

Shortness of breath (dyspnea)

Yes

Unk

___/___

Abdominal pain

Yes

Unk

___/___

Diarrhea (≥3 loose stools/24hr period)

Yes

Unk

___/___

Nausea

Yes

Unk

___/___

Vomiting

Yes

Unk

___/___

Headache

Yes

Unk

___/___

Loss of taste

Complete

Partial

Yes

Unk

___/___

Loss of smell

Complete

Partial

Yes

Unk

___/___

Yes

Unk

___/___

Other, specify:

# of Days

Ongoing?

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Cook County Questionnaire V24 rev 5/05/2020
(Correctional Facility Transmission Investigation)
Day 14 Form
CDC ID: _________
Administrative Information
1. Interviewer Name: First: ____________________Last:_____________________ Date:
/
/
2. Housing [detainee] location: Division: ______ Tier:______ Other:_____________
3. Date quarantine initiated: _____/______/______
4. At the unit, the number of current: Staff present:_________ Cells:____________ Detainees:____________
5. Interviewee:
Detainee
Symptoms
6. Use no touch thermometer to record current temperature: ________°F
7. In the last two weeks, have you experienced any of the following symptoms?
Symptom Present Last 2
Weeks?
Fever >100.4°F (38° C)
Subjective fever (felt feverish, or hot/sweaty)
Chills
Muscle aches (myalgia)
Runny nose (rhinorrhea)
Stuffy nose (nasal congestion)
Sore throat
Cough (new onset or worsening of chronic cough)
Shortness of breath (dyspnea)
Abdominal pain
Diarrhea (≥3 loose stools/24hr period)
Nausea
Vomiting
Headache
Loss of taste
Complete
Partial
Loss of smell
Complete
Partial
Other, specify:

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Onset
Date
(mm/dd)
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___

# of Days

Ongoing?

Form Approved
OMB No. 0920-1011
Exp. Date 1/31/2023

Illinois Department of Public Health
Request for COVID-19 / Respiratory Testing

Public reporting burden of this collection of information is estimated to average 5 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 (0920-1011)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Print using upper case letters.
Do not fax this form to the lab.

Request For COVID-19 / Respiratory Testing
SUBMITTER INFORMATION
AUTHORIZATION
CODE
NFORMATION:
SUBMITTER PHONE NUMBER

Fax Number for Reporting Result* (see instructions)

FAX REQUESTED

Yes

SUBMITTER'S NAME

STREET ADDRESS (Include apartment/suite number)

CITY

STATE

ZIP CODE

CONTACT PERSON

PHYSICIAN NAME

PATIENT INFORMATION
PATIENT'S FIRST NAME

AGE

BIRTHDATE

MEDICAID IDENTIFICATION NUMBER

PATIENT'S LAST NAME

PREGNANT
Yes

PATIENT'S IDENTIFICATION NUMBER

STREET ADDRESS (Include apartment/suite number)

No
SEX

ETHNICITY

RACE
White
African American/Black
Native American

Asian/Pacific Islander
Other
Unknown

CITY

STATE

Male
Female

Hispanic
Non-Hispanic

ZIP CODE

CELL NUMBER

TEST INFORMATION
DATE COLLECTED

TIME COLLECTED

APPROVED TESTING CRITERIA

SYMPTOM ONSET DATE

ONLY ONE (1) SAMPLE PER FORM
SPECIMEN SOURCE TYPE

TESTS REQUESTED
COVID-19

Arbovirus Panel

Nasopharyngeal Swab

Nasal Aspirate

Nasopharyngeal wash/aspirate

Respiratory Panel

Influenza

Pharyngeal Swab

Nasal Swab

Broncheoalveolar Lavage "BAL"

Oropharyngeal Swab

Sputum

Lower Respiratory Tract Aspirates

UNK

Other

LAB USE ONLY

Specimen Number Area Below
Reset
55836

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V3 rev 5/06/2020
(Correctional Facility Transmission Investigation)
Unit Survey [Complete this survey for each unit of the facility assessed.]
1.
2.
3.
4.
5.
6.
7.

Facility Name:________________________________________________________________________
Unit Name: __________________________________________________________________________
Location (building, floor, room, etc):______________________________________________________
Level of security (check all that apply): Minimal Medium High
Respondent Name and Title: ____________________________________________________________
Interviewer:___________________________ Date Completed: _____________________(MM/DD/YY)

Unit Characteristics
8. Number of detainees currently in the unit: _______
9. Full capacity of unit: ______
10. Unit type: Single cells Dormitory (communal) housing
a. How many beds per room:_____________________
b. If dormitory unit, are the sleeping areas: Cells or rooms with a door Cubbies or other
enclosure without a door open dormitory
Other, specify:______________________
11. Number of floors: ______
12. How many of the following items are present within the unit:
a. Toilets: ______
b. Sinks/handwashing area: _______
c. Showers:________
Facilities access among detainees in the unit
13. In the past two weeks, identify which facilities/items detainees have had access to and who uses the
facilities/items.
Access Level
Individual vs Shared
Toilets
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Showers
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Dining Area
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Recreation Area
All the time Restricted
Cell only Unit only Multiple units
(inside common area)
None Unknown
different time
Multiple units same time
Recreation Area or
All the time Restricted
Cell only Unit only Multiple units
yard (outside)
None Unknown
different time
Multiple units same time
Phone Access
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Computer Access
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Commissary
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Library
All the time Restricted
Cell only Unit only Multiple units
None Unknown
different time
Multiple units same time
Facility Healthcare
All the time Restricted
Cell only Unit only Multiple units
Clinic
None Unknown
different time
Multiple units same time
1

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V3 rev 5/06/2020
(Correctional Facility Transmission Investigation)
Other:____________

All the time Restricted
None Unknown

Cell only Unit only Multiple units
different time
Multiple units same time

Sanitation
14. In the last two weeks, which of the following items have detainees been provided (check all that apply):
Hand Sanitizer
Soap
Face Masks
None
Unknown
a. If masks are provided, how often are they replaced or washed?______________________
b. If masks are provided, are they typically being worn:
Always
Only outside of cell
Only outside of dorm
c. If soap is provided, is it unlimited? Yes
No Unknown
i. If no, quantity?____________________
15. Could a detainee in this unit wash their hands at all times of the day: Yes
No
Unknown
Work Units
16. Do any detainees in this unit perform duties or services (e.g. work at the facility)? Yes No
Unknown
a. If yes, do they work in, Their unit only
Other common areas
Both
i. [if in other common areas] Do they work with detainees from other units?
Yes, at the same time/shift Yes, same areas but different shifts No Unknown
17. Which jobs are performed by detainees in this unit?
Kitchen
Library
Education
Groundskeeping
Unknown
Other, specify: __________________________

Laundry

Staffing
18. How many staff members are assigned to work in this unit? (extended time in this unit, or working with
detainees from this unit) Total _________ (estimate if exact number not known); by category:
a. Corrections: ________
b. Environmental/maintenance: _______
c. Admin: ________
d. Healthcare: ________
e. Other:_______________ (specify job class:___________________________________)
19. How many staff members potentially are within 6ft of the detainees for any length of time in this unit for
their regular duties? Total _________ (estimate if exact number not known); by category:
a. Corrections: ________
b. Environmental/maintenance: _______
c. Admin: ________
d. Healthcare: ________
e. Other:_______________ (specify job class:___________________________________)

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Correctional Facility Assessment
V3 rev 5/06/2020
(Correctional Facility Transmission Investigation)

Coronavirus
20. How many suspected (individuals with fever, cough, or shortness of breath) or confirmed COVID-19 cases
have been identified in this unit since January 2020? (Write “unknown” if value not known).
Among Detainees
Among Staff
Suspected COVID-19 Cases (PUI)
Confirmed COVID-19 Cases
Suspected Hospitalized COVID-19 Cases (PUI)
Confirmed Hospitalized COVID-19 Cases
Any Death
COVID-19-related Deaths
21. When was the first positive COVID-19 case identified at this unit (staff or detainee)?
________________ (mm/dd/yyyy)
22. When was the most recent positive COVID-19 case identified at this unit (staff or detainee)?
________________ (mm/dd/yyyy)

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V3 rev 05/04/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________
…………………………………………………………………………………………………………………………………
Interviewee Information
Booking or JDE Number:_____________________________

Specimen ID

First:___________________________ Last:_______________________________
Date of birth: /

(MM/DD/YYYY)

CDC ID__________

NOTE: This page is for paper records only. Do not scan for data entry into the electronic database.

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V3 rev 05/04/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________
Administrative Information
1. Interviewer Name: First: ___________________Last:________________ Date:
/
/
2. Housing location: Dorm: ______Other:_____________
3. Sleeping location:
top bunk
bottom bunk
1. Date quarantine initiated in dorm: _____/______/______
2. At the dorm, the number of current: Staff present:_________ Cells:____________ Detainees:____________
Demographic Information
3. Age: _______
Height:_______ (ft, in)
Weight: ______ (lbs)
4. Ethnicity (select one):
Hispanic/Latino
Non-Hispanic/Latino
Not Specified
5. Race (check all that apply):
White
Black
Asian
Am Indian/Alaska Nat
Nat Hawaiian/Other PI
Other, specify:___________
Unknown
6. Sex:
Male
Female
Symptoms
7. Use no-touch thermometer to record current temperature: ________°F
8. In the last two weeks, have you experienced any of the following symptoms?
Symptom Present
Last 2 Weeks?
Fever >100.4°F (38° C)
Subjective fever (felt feverish, or hot/sweaty)
Chills
Muscle aches (myalgia)
Runny nose (rhinorrhea)
Stuffy nose (nasal congestion)
Sore throat
Cough (new onset or worsening of chronic cough)
Shortness of breath (dyspnea)
Abdominal pain
Diarrhea (≥3 loose stools/24hr period)
Nausea
Vomiting
Headache
Loss of taste
Complete
Partial
Loss of smell
Complete
Partial
Other, specify:

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Onset
Date
(mm/dd)
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___

# of Days

Ongoing?

Last 2
Months?

NOTE: For any of these symptoms, have you experienced them in the last two months? That means since ______(month).
Smoking Status Note: Smoking is prohibited in the facility compound for all detainees.
9. In the past, have you smoked tobacco on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
10. [If any use] When was the last time you used tobacco? ________________ (MM/YYYY)
11. In the past, have you vaped or used electronic cigarettes on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
12. [If any use] When was the last time you used electronic cigarettes or vaping? ________________ (MM/YYYY)
2

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V3 rev 05/04/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________

Past Medical History
13. Please provide pre-existing medical conditions (complete regardless of age):
Condition
Response
If YES, specify
Health conditions that cause
Yes No
Asthma
COPD (chronic obstructive pulmonary disease)
breathing problems?
Unk/DK/Ref
Emphysema
Lung Cancer
Sleep Apnea
Other, specify:_____________
Diabetes or problems with your
Yes No
Type 1
Type 2
blood sugar?
Unk/DK/Ref Are you taking insulin?
Yes
No
Heart problems or high blood
Yes No
Congenital heart abnormalities
Coronary artery disease
pressure?
Unk/DK/Ref
Heart failure
High cholesterol (Hyperlipidemia)
High blood pressure (Hypertension)
Heart attack (Myocardial infarction)
Other, specify_____________
Kidney problems?
Yes No
Chronic kidney disease
Dialysis
Unk/DK/Ref
End-stage renal disease
Other, specify: ________
Liver problems?
Yes No
Cirrhosis
End-stage liver disease
Unk/DK/Ref
Hepatitis B
Hepatitis C
Other, specify:___________
A disease, medication, or
Yes No
Chemotherapy
HIV/AIDS
Lupus
Steroids
condition that weakens your
Unk/DK/Ref
Other, specify:____________
immune system?
Learning or memory problems,
Yes No
Dementia/Alzheimer’s
Neurodevelopmental Disorder
stroke, seizure disorder, or
Unk/DK/Ref
Stroke
Traumatic Brain Injury
history of head injury?
Other, specify:____________
Do you have other
Yes No
Specify:____________________________________________
health/medical problems you
Unk/DK/Ref
would like me to know about?
Medication Use
14. Currently, what types of medications do you take for underlying conditions, including prescriptions & inhalers?
Do you take any medications for high blood pressure?
How about for infections caused by fungus, bacteria, or viruses? (If yes, ask questions to fill in table below)
How about any medications that may weaken your immune system and ability to fight infections? These
medications are often used to treat autoimmune disorders or inflammation. (If yes, ask questions to fill in table
below)
Do you use an inhaler? (If yes, ask questions to fill in table below)
Any other medications you may have forgotten? (If yes, ask questions to fill in table below)
Medication Name

Indication

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V3 rev 05/04/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________

Facility Questions
15. At this facility, how many different people are you in contact with (<6 ft) on an average day?__________
16. In the last two weeks, have you had handcuffs put on? (*Other than for this survey*)
Yes
No
Unknown
If yes, how many times per day (1 time would be once per day having them put on and taken off)? _____
Sanitation Levels
17. How many times per day do you wash or sanitize your hands (on average)?____________________
18. When you wash your hands, do you use (check all that apply):

Soap & Water
Hand sanitizer
Don’t wash hands

19. When do you wash your hands (check all that apply)?
Before eating
After coughing or sneezing
After touching another person
After touching dirty laundry
After working
Never
20. Have you worn a mask at the facility in the last 2 weeks?
a. If yes, what type of mask (check all that apply)?

Water alone
Unknown

After touching a shared phone
After using the bathroom
Unknown

Yes
No
Unknown
Cloth
Surgical
Unknown
Other, specify:________________

b. When around others (<6 ft), how often do you wear a mask?
Always
Usually
Sometimes
Never
c. When outside of your cell, how often do you wear a mask?
Always
Usually
Sometimes
Never

Unknown
Unknown

Movement and Activity History
21. While staying in this facility, have you done any of the following activities in the last two weeks?
Activity
Answer
Where?
When?

…traveled outside your dorm?

Yes

...traveled outside the facility?

Yes

…gone to court?
(Excludes video court)
…had a work assignment off your
dorm?

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V3 rev 05/04/2020
(Correctional Facility Transmission Investigation)
Day 0/1 Form
CDC ID: ________
22. Have you been assigned to any other dorms in the last 2 months?
Yes
No
a. If yes, how many? _________
b. If known, specify dorm(s):_________________________________________________________
Potential Exposure
23. In the last two weeks, have you been around any people who appear to be sick with COVID-19 symptoms, such as a
fever, cough, or shortness of breath?
Yes

Unknown (If yes, how many? _________________________)

SARS-CoV-2 testing
24. Have you ever been offered a test for coronavirus?

Yes

a. If yes, have you been tested for coronavirus?

Yes

Refused

Unknown

i. Date of most recent test:_______________________________(MM/DD/YYYY)
ii. Did you experience any symptoms at the time you were tested?

Yes

iii. Result of most recent test:
Positive
Other, specify: _______________

Indeterminate

Negative

Pending

No
Don’t know

Notes:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V1 rev 5/04/2020
(Correctional Facility Transmission Investigation)
Day 3/4 Form
CDC ID: _________
…………………………………………………………………………………………………………………………………
Interviewee Information
Booking or JDE Number:______________________________

Specimen ID

First:_____________________________ Last:_______________________________
Date of birth:

(MM/DD/YYYY)

CDC ID__________

NOTE: This page is for paper records only. Do not scan for data entry into the electronic database.

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V1 rev 5/04/2020
(Correctional Facility Transmission Investigation)
Day 3/4 Form
CDC ID: _________
Administrative Information
1. Interviewer Name: First: ____________________Last:_____________________ Date:

2. Housing location: Dorm:______ Other:_____________
3. Sleeping location:

top bunk

bottom bunk

4. Date quarantine initiated in dorm: _____/______/______
5. At the dorm, the number of current: Staff present:______ Cells:____________ Detainees:______________
Symptoms
6. Use no touch thermometer to record current temperature: ________°F
7. Since we last visited you, have you experienced any of the following symptoms?
Symptom Present
Since Last Visit?
Yes No Unk

Fever >100.4°F (38° C)

Onset Date
(mm/dd)
___/___

Subjective fever (felt feverish, or hot/sweaty)

Yes

Unk

___/___

Chills

Yes

Unk

___/___

Muscle aches (myalgia)

Yes

Unk

___/___

Runny nose (rhinorrhea)

Yes

Unk

___/___

Stuffy nose (nasal congestion)

Yes

Unk

___/___

Sore throat

Yes

Unk

___/___

Cough (new onset or worsening of chronic cough)

Yes

Unk

___/___

Shortness of breath (dyspnea)

Yes

Unk

___/___

Abdominal pain

Yes

Unk

___/___

Diarrhea (≥3 loose stools/24hr period)

Yes

Unk

___/___

Nausea

Yes

Unk

___/___

Vomiting

Yes

Unk

___/___

Headache

Yes

Unk

___/___

Loss of taste

Complete

Partial

Yes

Unk

___/___

Loss of smell

Complete

Partial

Yes

Unk

___/___

Yes

Unk

___/___

Other, specify:

# of Days

Ongoing?

Potential Exposure
8. Since we last visited you, have you been around any people who appear to be sick with COVID-19 symptoms, such as
a fever, cough, or shortness of breath?
Yes

Unknown (If yes, how many? _________________________)

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V1 rev 5/20/2020
(Correctional Facility Transmission Investigation)
Day 14 Form
CDC ID: _________
…………………………………………………………………………………………………………………………………
Interviewee Information
Booking or JDE Number:______________________________

Specimen ID

First:_____________________________ Last:_______________________________
Date of birth:

(MM/DD/YYYY)

CDC ID__________

NOTE: This page is for paper records only. Do not scan for data entry into the electronic database.

Form Approved; OMB No. 0920-1011; Exp Date: 1/31/2023

SARS-CoV-2 Louisiana Questionnaire V1 rev 5/20/2020
(Correctional Facility Transmission Investigation)
Day 14 Form
CDC ID: _________
Administrative Information
1. Interviewer Name: First: ____________________Last:_____________________ Date:
2. Housing location: Dorm: ______Other:_____________
3. Sleeping location:
top bunk
bottom bunk
4. Interviewee:
Detainee

Symptoms
5. Use no touch thermometer to record current temperature: ________°F
6. Since we last tested you, have you experienced any of the following symptoms?
Symptom Present Last 2
Weeks?
Fever >100.4°F (38° C)
Subjective fever (felt feverish, or hot/sweaty)
Chills
Muscle aches (myalgia)
Runny nose (rhinorrhea)
Stuffy nose (nasal congestion)
Sore throat
Cough (new onset or worsening of chronic cough)
Shortness of breath (dyspnea)
Abdominal pain
Diarrhea (≥3 loose stools/24hr period)
Nausea
Vomiting
Headache
Loss of taste
Complete
Partial
Loss of smell
Complete
Partial
Other, specify:

Movement and Activity History
7. Since we last tested you, have you ….?
Activity
… traveled outside your dorm?

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Answer

Onset
Date
(mm/dd)
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___
___/___

# of Days

Ongoing?

Frequency

Yes

Daily

A few times a week

Once a week

… traveled outside the facility?

Yes

Daily

A few times a week

Once a week

…gone to court? (Excludes video court)

Yes

Daily

A few times a week

Once a week

… had a work assignment off your dorm?

Yes

Daily

A few times a week

Once a week

… gone anywhere else?

Yes

If so, where: __________________________________

Potential Exposure
8. Since we last tested you, have you been around any people who appear to be sick with COVID-19 symptoms, such as
a fever, cough, or shortness of breath?
Yes
No
Unknown (If yes, how many? _________________________)

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2023

COVID-19 Test Request Form

5/7/2020

COVID-19 Test Request Form

COVID-19 Test Request Form
Do you have a PUI Number for this request?
Yes
No
2nd Unique ID / PUI # *

LA2020
PUI # should start with "LA2020" and include at least 4 additional characters.

2nd unique ID entered above must be present on sample
Hospitalization Status and Symptoms

This patient is: (check all that apply) *
Hospitalized?
Admitted to ICU?
Intubated (Mechanical Vent)?
ER Visit Only?
None of the Above
Symptoms Reported *
Fever, include temperature below
Sore Throat
Chills
Abdominal Pain
Cough
Shortness of Breath
Headache
Runny Nose
Vomiting
Diarrhea
Muscle Aches
https://appengine.egov.com/apps/la/LDH/Covid-19_Test_request

1/3

5/7/2020

COVID-19 Test Request Form

ARDS
Abnormal Chest X-Ray
Pneumonia, specify below
Other, specify below
None of the Above
Has testing been done to rule out other respiratory illnesses? *
Yes
No
Influenza? *
Not Done
Negative
Positive
Pending
Respiratory Virus Panel? *
Not Done
Negative
Positive
Pending
Blood Cultures? *
Not Done
Negative
Positive
Pending
Other Tests? *
Not Done
Negative
https://appengine.egov.com/apps/la/LDH/Covid-19_Test_request

2/3

5/7/2020

COVID-19 Test Request Form

Positive
Pending
Does the patient have any comorbid conditions? *
Yes
No

Step 1 of 5



CONTINUE



https://appengine.egov.com/apps/la/LDH/Covid-19_Test_request

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File Type	application/pdf
File Modified	2020-10-07
File Created	2020-10-07