Form 0920-18ANU Individual Questionnaire

Form Approved

OMB Control No.: 0920-XXXX

Exp. date: XX/XX/XXXX

Individual: sociodemographic characteristics and clinical history

Group number

XX #

Interviewer name:

Interview date: MM / DD / YYYY

Participant number (HHID P PID): X X # # # # P # #

Eligibility criteria and consent

Sleeps in this house 4+ nights/week  Yes

Does not have definite plans to move (6 mo)  Yes

Age: ­­­______ years 1-50 Emancipated minor:

 Lives independently from parents  Married  Has children

Consent (individuals 21+, parents of minors 1-20)

 Written consent completed.

 Agree to do the questionnaire.

 Agree to give a blood sample.

 Agree to the use of blood sample for future studies.

 Agree to be contacted periodically in relation to

this study.

Assent (minors only: verbal 7-11, written 12-20)

 Written consent completed (12-20).

 Verbal consent completed (7-11).

 Agree to do the questionnaire.

 Agree to give a blood sample.

 Agree to the storage of blood sample for use in

future studies.

 Agree to be contacted periodically in relation to

this study.

Name:

_______________ ________________ ______________ ____

Paternal Last Name Maternal Last Name First Name Initial

Sex:  Male  Female  Other

Date of birth: _____ /_____ /_____

MM DD YYYY

 Cell phone:  Text message:  House phone:  Work phone:  Other phone:  Email:	_ ______________________ _______________________ _______________________ _______________________ _______________________ _______________________
 Mail  Use Household Representative information

CLINICAL HISTORY Now I will ask you some questions about your medical history.

C1_0. Have you participated in any research study in which you received a vaccine for Zika or dengue?

 Zika |  Dengue |  No

- Females only: -

C1_1. Are you pregnant?  Yes |  No C1_2. How many weeks pregnant are you? _______

C2_0. Do you have a fever currently or in the last 7 days?

 Yes |  No

C2_1. Date that the fever began: ___ /___ /_____

MM DD YYYY

C2_2. Have you had any of the following symptoms?

Read all the options. Mark all that apply.

 Nasal congestion  Diarrhea  Abdominal pain  Joint pain  Headache  Sore throat  Muscle pain  Eye pain  Calf pain  Chills  Nausea/vomiting

 Red eyes  Light bleeding (gums, nose, petechial, and/or bruising)  Heavy bleeding (bloody vomit/cough/ stool, heavy vaginal bleeding)  Rash  Cough  Other: _________________

C2_3. Did you see a doctor for these symptoms?

 Yes |  No

C2_4. Did the doctor diagnose you with any of the following illnesses?

 Dengue  Chikungunya  Zika

 Viral syndrome  Influenza  Other: _______________

C2_5. Were you hospitalized?  Yes |  No

C2_6. How many days were you hospitalized? _____ days

C2_7. In which hospital?

 San Lucas  Damas  San Cristóbal  Metropolitano/ Dr. Pila  Menonita/Guayama

 Concepción/ San Germán  Metropolitano/ San Germán  Pavía/Yauco  Otro: __________________

C2_8. How many days of work did you miss for being sick? ________ days

C2_9. How many days of school did you miss for being sick? ________ days

C2_10. Did someone else have to miss work to help you while you were sick?

If multiple people took care of the participant,  Yes |  No

add all the days missed together.

C2_11. How many days of work did they miss? ______

C2_12. Did someone else have to miss school to help you while you were sick?

Add all the days missed together. ,  Yes |  No

C2_13. How many days of school did they miss? ______

Individual: sociodemographic characteristics and clinical history

D1. What is the highest level of education that you have obtained?

 No school

 Grades 1 to 5

 Grades 6 to 8

 Grades 9 to 11

 Completed grade 12/GED

 Technical or associate’s degree

 Bachelor’s degree

 Professional degree

 Post-graduate study

D2. What is your current employment status?

Probe if necessary.

 Part-time employee

 Full-time employee

 Business owner

 Casual or Informal work

 Student

 Student and working

 Retired

 Unemployed

 Unable to work due to health problems

 Homemaker

 Other: ____________________

D3. Which of the following best describes your place of work?

 Primarily indoor work

 Primarily outdoor work

 Travel between different buildings or places of work

 Mostly in a car

 Variable

 Other: ____________________

D4. Do you currently have medical insurance?

 Yes |  No

D4a. Type of insurance:

Read all options. Mark all that apply.

 Reforma/Plan Mi Salud  Medicare  Medicaid  Private

 Tricare  Other: _____________

D5. How long have you been living in this community?

_______ (years)

D6. From 6am - 8pm, (14 hrs) how much time do you spend in your house or in this community or urbanization?

Monday: _________ hours Tuesday: _________ hours Wednesday: _____ hours Thursday: ________ hours

Friday: ________ hours Saturday: _____ hours Sunday: _______ hours

C2_14. Approximately how much money did you spend during the illness, including doctor’s visits, medications, and transportation costs? ­­­­$_____  Does not recall

C3_0. Have you had (another) fever in the last 12 months, since this month of the past year?  Yes |  No

C3_1. Date that the fever began: ___ /___ /_____

MM DD YYYY

C3_2. Did you have any of the following symptoms?

Read all the options. Mark all that apply.

 Nasal congestion  Diarrhea  Abdominal pain  Joint pain  Headache  Sore throat  Muscle pain  Eye pain  Calf pain  Chills  Nausea/vomiting

 Red eyes  Light bleeding (gums, nose, petechial, and/or bruising)  Heavy bleeding (bloody vomit/cough/ stool, heavy vaginal bleeding)  Rash  Cough  Other: _________________

C3_3. Did you see a doctor for these symptoms?

 Yes |  No

C3_4. Did the doctor diagnose you with any of the following illnesses

 Dengue  Chikungunya  Zika

 Viral syndrome  Influenza  Other: _______________

C3_5. Were you hospitalized?  Yes |  No

C3_6. How many days were you hospitalized? _____ days

C3_7. In which hospital?

 San Lucas  Damas  San Cristóbal  Metropolitano/ Dr. Pila  Menonita/Guayama

 Concepción/ San Germán  Metropolitano/ San Germán  Pavía/Yauco  Otro: __________________

C3_8. How many days of work did you miss for being sick?

________ days

C3_9. How many days of school did you miss for being sick? ________ days

C3_10. Did someone else have to miss work to help you while you were sick?

If multiple people took care of the participant,  Yes |  No

add all the days missed together.

C3_11. How many days of work did they miss? ______

C3_12. Did someone else have to miss school to help you while you were sick?

Add all the days missed together. ,  Yes |  No

C3_13. How many days of school did they miss? ______

C3_14. Approximately how much money did you spend during the illness, including doctor’s visits, medications, and transportation costs? ­­­­$_____  Does not recall

Public reporting burden of this collection of information is estimated to average 15 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