0920-18ANU Individual Questionnaire

Communities Organized to Prevent Arboviruses: Assessment of Knowledge, Attitudes, and Vector Control Practices and Sero-Prevalence and Incidence of Arborviral Infection in Ponce, Puerto Rico (COPA)

5. EN Paper Questionnaire - Individual

OMB: 0920-1254

Document [docx]
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Form Approved

OMB Control No.: 0920-XXXX

Exp. date: XX/XX/XXXX


Individual: sociodemographic characteristics and clinical history

Shape1

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?

Shape2 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?

Shape3  Yes | No

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

Dengue

Chikungunya

Zika

Viral syndrome

Influenza

Other: _______________

Shape4 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.

Shape5 Part-time employee

Shape6 Full-time employee

Business owner

Casual or Informal work

Student

 Student and working

Retired

Shape7 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?

Shape8 Shape9 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

Shape10 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?

Shape11  Yes | No

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

Dengue

Chikungunya

Zika

Viral syndrome

Influenza

Other: _______________

Shape12 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


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AuthorLittle, Emma (CDC/OID/NCEZID)
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File Created2023-09-03

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