Edited content for the Self-administered Web Survey (English)

Form Approved

OMB Control No.: 0920-XXXX 1307

Expiration date: XX/XX/XXXX11/30/2023

The Centers of Disease Control and Prevention, in collaboration with your local health department, are collecting information about people who were recently sick with a Shigella infection, also called shigellosis. Shigella are a group of bacteria that cause diarrheal illness. We are trying to determine how you (or the ill person) became sick with a Shigella infection. The information we are collecting in this questionnaire will also help prevent others from getting sick.

You may have already been contacted by the health department. We would like to ask you a few additional questions about your (or the ill person’s) recent illness and about any exposures you (or the ill person) may have had before becoming ill. Your help in the investigation is very important. Your participation is voluntary, and you may refuse to answer any question at any time. All information will be kept confidential to the extent permitted by law. No names or other identifying information will be used in any reports.

This questionnaire will likely take no more than 45 minutes. Are you willing to participate?

• Yes (If yes: You have selected to participate in this survey. Move to the next page to begin the survey.)

• No (If no: You have selected not to participate in this survey. We appreciate your time. Move to the next page in order to end the survey and submit your response. For more information about shigellosis please go to) www.cdc.gov/shigella/

Section 1: INTERVIEW INFORMATION
Are you completing this interview on behalf of yourself or another person? Self Another Person What best describes your relationship to the other person? Spouse Child Other dependent Other I. (specify):__________________

For the following questions please fill in the questionnaire with information on the person sick with shigellosis. If you are taking the survey for another person, answer all questions according to information about the person sick with shigellosis. If you are taking the survey on behalf of yourself, please answer all questions according to information about yourself.

Section 2: CASE INFORMATION
What is your (or the ill person’s) state of residence: _______________	What is your (or the ill person’s) county of residence: ____________________
What is the age of the person sick with shigellosis: __________ ☐ Years ☐ Months ☐ Days
What sex were you (or the ill person) assigned at birth? ☐ Female ☐ Male ☐ Unknown ☐ Refused
5. How do you describe your (or the ill person’s) ethnicity? ☐ Hispanic or Latino ☐ Not Hispanic or Latino
How do you describe your (or the ill person’s) race? (select all that apply) ☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian or Pacific Islander ☐ White ☐ Refused
7. [If case indicates they’re ≥14 years old], what is your (or the ill person’s) current occupation? ______________________________

Section 3: HOUSEHOLD INFORMATION

1. What would best describe the type of housing you (or the ill person) currently live in? For example, a house, apartment, or mobile home.

☐ House/single family home ☐ Apartment ☐ Hotel/motel ☐ Long term care facility ☐ Nursing home/assisted living facility

☐ Mobile home ☐ Shelter ☐ Rehabilitation center ☐ Half-way house ☐ Unknown ☐ Other (specify): _______________

2. In the past 30 days, did you (or the ill person) double up or stay overnight with friends, relatives, or someone you didn’t know well because you didn’t have a regular place to stay at night? ☐ Yes ☐ No ☐ Prefer not to answer ☐ Unknown

3. In the past 30 days, were you (or the ill person) ever homeless? That is, were you living on the street, in a shelter, in a single room occupancy hotel, or in a car? ☐ Yes ☐ No ☐ Prefer not to answer ☐ Unknown

4. What is the water source at your (or the ill person’s) primary place of residence?

☐ Municipal ☐ Well ☐ Unknown ☐ Other (specify): _______________

5. What is the sewer connection at your (or the ill person’s) primary place of residence?

☐ Municipal ☐ Septic tank ☐ Unknown ☐ Other (specify): _______________

6. How many people, including you (or the ill person), live in your (or the ill person’s) primary place of residence? _______ ☐ Unknown

   1. Do any of these people (either children or adults) wear diapers? ☐ Yes ☐ No Prefer not to answer☒ ☐ Unknown

   2. How many people living in your (or the ill person’s) household are under the age of 5? _______ ☐ click here if unknown number of people under the age of 5

7. What was your (or the ill person’s) household income last year from all sources before taxes? That is, the total amount of money earned and shared by all people living in your household.

☐ <$20,000 ☐ $20,000-$39,999 ☐ $40,000-$59,999 ☐ $60,000-$79,999 ☐ $80,000-99,999 ☐ $100,000 or more

☐ Prefer not to answer ☐ Unknown

Section 4: CLINICAL INFORMATION
What date did you (or the ill person) first feel sick? ______ /_____ /_______ ☐ Approximate date ☐ Unknown Month / Day / Year
What date did you (or the ill person) stop feeling sick? ______ /_____ /_______ ☐ Approximate date ☐ Unknown ☐ Ongoing Month / Day / Year If unsure of specific dates in questions 1 and 2, about how many days were you (or the ill person) sick? __________
Yes	No	Don’t Know	Have you (or the ill person) had any of the following symptoms?
☐	☐	☐	Diarrhea (at least 3 loose, watery stools in 24 hours)
			About how many days did you (or the ill person) have diarrhea?________
☐	☐	☐	Abdominal pain/cramps
☐	☐	☐	Fever
☐	☐	☐	Nausea
☐	☐	☐	Vomiting
☐	☐	☐	Bloody stools/bloody diarrhea
☐	☐	☐	Seizures
☐	☐	☐	Achy joints/muscles
☐	☐	☐	Tenesmus (or feeling the need to pass stool [poop] even when bowels are empty)
☐	☐	☐	Other symptoms I didn’t ask about (specify): _________________________________________

Section 5: MEDICAL CARE AND TREATMENT INFORMATION
Yes	No	Don’t Know
☐	☐	☐	As a result of your (or the ill person’s) illness, did you (or the ill person) seek medical care?
			[If yes to question 1] Where did you (or the ill person) seek medical care? (select all that apply) ☐ Doctor’s office ☐ Urgent care ☐ Pharmacy clinic ☐ STD clinic ☐ Emergency department ☐ Hospital ☐ Unknown ☐ Other (specify): _______________
☐	☐	☐	Were you (or the ill person) admitted to a hospital overnight?
			[If yes to question 1b] For how many nights were you (or the ill person) hospitalized? ___________ ☐ click here is unknown number of nights hospitalized
☐	☐	☐	[If yes to question 1b] Were you (or the ill person) admitted to the intensive care unit?
☐	☐	☐	In addition to infection with Shigella, did your (or the ill person’s) doctor tell you that you were sick with any other infection(s)?
			[If yes to question 2] What was the name of the other infection(s): ______________________
☐	☐	☐	Were you (or was the ill person) prescribed any antibiotics for this illness?
			[If yes to question 3] What was the name of the antibiotic(s), dose, and frequency? __________________________________________ ☐ Don’t know
			[If yes to question 3] Which date did you (or the ill person) start taking the antibiotic(s)? ______ /_____ /_______ ☐ Approximate date ☐ Unknown Month / Day / Year
			[If yes to question 3] Which date did you (or the ill person) stop taking the antibiotic(s)? ______ /_____ /_______ ☐ Approximate date ☐ Unknown ☐ Still taking antibiotic(s) Month / Day / Year
			[If yes to question 3] In the 24 hours after taking the antibiotic(s), did your (or the ill person’s) symptoms ☐ Get better/Improve ☐ Stay the Same ☐ Get Worse ☐ Other (specify): _____________

Section 6: EXPOSURE INFORMATION
Yes	No	Don’t Know
☐	☐	☐	In the 7 days before your illness started, did you (or the ill person) spend any time outside of your home state?
			[If yes to question 1] List all U.S. states where you (or the ill person) traveled: _________________________________________________________
			List dates of domestic travel: ______________________ ☐ Did not travel domestically
			What was the purpose of this travel? (select all that apply) ☐ Tourism ☐ Work ☐ Visiting friends/relatives ☐ Other (specify):________________________
			Where did you (or the ill person) stay while traveling domestically? (select all that apply): ☐ Hotel, hostel, guest house, resort ☐ Private home ☐ Hospital ☐ Cruise ship ☐ Other (e.g., school, dormitory, tent) (specify):________________________
			What activities did you (or the ill person) engage in while traveling domestically? (select all that apply) ☐ Purchase or eat food ☐ Go swimming ☐ Attend gathering of people ☐ Drink untreated water ☐ Other (specify):________________________
			[If yes to question 1] List all countries outside the United States where you (or the ill person) traveled: ________________________________ ☐ Did not travel internationally
			List dates of international travel: ___________________________________________
			What was the purpose of this travel? (select all that apply) ☐ Tourism ☐ Work ☐ Visiting friends/relatives ☐ Other (specify):________________________
			Where did you (or the ill person) stay while traveling internationally? (select all that apply): ☐ Hotel, hostel, guest house, resort ☐ Private home ☐ Hospital ☐ Cruise ship ☐ Other (e.g., school, dormitory, tent) (specify):________________________
			What activities did you (or the ill person) engage in while traveling internationally? (select all that apply) ☐ Purchase or eat food ☐ Go swimming ☐ Attend gathering of people ☐ Drink untreated water ☐ Other (specify):__________________________
☐	☐	☐	In the past month, have you (or the ill person) had contact with any individuals who traveled outside the United States?
			[If yes to question 2] Where did they travel? (specify): __________________________________
☐	☐	☐	Were they ill with symptoms similar to your (or the ill person’s) symptoms?
☐	☐	☐	Did you (or the ill person) eat any food or drink any beverages they brought back?
			What did you (or the ill person) eat or drink? (specify): _______________
			In the 7 days before your (or the ill person’s) illness started, did you (or the ill person) attend, visit, work in, or volunteer at any of the following:
☐	☐	☐	A religious gathering (such as church, mosque, or synagogue)? (specify): _______________
☐	☐	☐	Camp? (specify): _______________
☐	☐	☐	Conference or other large meeting? (specify): _______________
☐	☐	☐	Festival, fair, play, or concert? (specify): _______________
☐	☐	☐	Party, picnic, or barbeque? (specify): _______________
☐	☐	☐	Sports practice, sports game, or exercise class? (specify): _______________
☐	☐	☐	Other gathering of people I did not ask about? (specify): _______________
Yes	No	Don’t Know	In the 7 days before your (or the ill person’s) illness started, did you (or the ill person):
☐	☐	☐	Drink water from an untreated source, such as lake, pond, or river? (specify): _______________
☐	☐	☐	Eat any foods prepared by a friend, neighbor, or coworker in their home? (specify): ____________
☐	☐	☐	Eat any foods prepared by a catering company? (such as food served at a wedding or conference?) (specify): _____________________
☐	☐	☐	Eat at a restaurant? (specify): _____________________
☐	☐	☐	Swim in treated water, such as a swimming pool? (specify): ________________________
☐	☐	☐	Swim in untreated water, such as a lake, river, or ocean? (specify): __________________
☐	☐	☐	Play in an interactive water fountain, water table, children’s pool, kiddie pool, or baby pool? (specify): _______________
			In the 7 days before your (or the ill person’s) illness started, did you (or the ill person) visit, work in, or volunteer at:
☐	☐	☐	A place that serves food, such as a restaurant or cafeteria? (specify): _______________
☐	☐	☐	A homeless shelter? (specify): _______________
☐	☐	☐	A health care facility? (specify): _______________
☐	☐	☐	A nursing home, long term care, or assisted living facility? (specify): _______________
☐	☐	☐	In the 7 days before your (or the ill person’s) illness started, did you (or the ill person) have contact with someone with diarrhea (at least 3 loose, watery stools in 24 hours) or symptoms similar to your (or the ill person’s) symptoms?
☐	☐	☐	[If yes to question 6] Was this person diagnosed with a Shigella infection?
☐	☐	☐	Was this person a member of your (or the ill person’s) household? (specify): _______________
☐	☐	☐	Does this person wear diapers?
☐	☐	☐	[If yes to question 6e] Did you (or the ill person) change this person’s diapers?
			While you (or the ill person) were sick with the Shigella infection, did you (or the ill person) do any of the following:
☐	☐	☐	Prepare or handle food for other people? (specify): _______________
☐	☐	☐	Go swimming or play in a swimming pool, baby pool, interactive fountain, or water table? (specify): _______________
☐	☐	☐	Visit, work in, or volunteer at a healthcare facility? (specify): _______________
☐	☐	☐	Visit, work in, or volunteer at a nursing home, long term care, or assisted living facility? (specify): _______________
☐	☐	☐	Visit, work in, volunteer, or attend a school or childcare facility? (specify): _______________
☐	☐	☐	Visit, work in, volunteer, or attend any gathering of people? For example, a picnic, party, concert, conference, or religious gathering. (specify): _________________________________

Section 7: CHILD CARE AND SCHOOL INFORMATION
Yes	No	Don’t Know
☐	☐	☐	In the 7 days before your (or the ill person’s) illness started, did you (or the ill person) visit, work in, volunteer, or attend a child care center, daycare, or preschool?
			[If yes to question 1] What is the name of the facility? ______________________________
☐	☐	☐	At this facility were there any other children or adults ill with diarrhea (at least 3 loose, watery stools in 24 hours) or symptoms similar to yours (or the ill person’s) before you (or the ill person) became ill?
☐	☐	☐	Did you (or the ill person) use a school bus or other school transport to get to and from the child care center, daycare, or preschool?
☐	☐	☐	Were you (or the ill person) excluded from this facility while ill?
			[If yes to question 1d] How many days were you (or the ill person) excluded? _______________
			[If yes to question 1d and case is ≤ 18 years] While excluded from daycare, what alternative care did your child receive? (select all that apply) ☐ Babysitter ☐ Care at home ☐ Other childcare center ☐ Unknown ☐ Other (specify): _______________
☐	☐	☐	In the 7 days before your (or the ill person’s) illness started, did you (or the ill person) attend, visit, work in, or volunteer in a school (such as an elementary, middle, after school center, or other type of school)?
			[If yes to question 2] What is the name of the school? ______________________________
☐	☐	☐	At this school were there any other children or adults ill with diarrhea (at least 3 loose, watery stools in 24 hours) or symptoms similar to your (or the ill person’s) before you (or the ill person) became ill?
☐	☐	☐	Did you (or the ill person) use a school bus or other school transport to get to and from the school?
☐	☐	☐	Were you (or the ill person) excluded from school while ill?
			[If yes to question 2d] How many days were you (or the ill person) excluded? _______________
			[If yes to question 2d and case is ≤ 18 years] While excluded from school, what alternative care did your child receive? (select all that apply) ☐ Babysitter ☐ Care at home ☐ Self-care ☐ Unknown ☐ Other (specify): _______________

[Proceed if participant is ≥ 18 years of age and answering survey on behalf of themself. Otherwise skip section 8 and conclude questionnaire]

Finally, we would like to ask about your recent sexual activity because Shigella can be spread through sexual contact. Shigella germs are very contagious; it takes just a small number of Shigella germs to make someone sick. People can get shigellosis when they put something in their mouths or swallow something that has come into contact with the stool of someone else who is sick with shigellosis. This can happen during sex.

As described previously, your responses are voluntary, and you may refuse to answer any question at any time. We ask all adults who were diagnosed with a Shigella infection these questions. Your answers to these questions will be kept private and may help us to identify how you became sick with a Shigella infection. This will also help us to prevent others from getting sick.

Do you wish to proceed with the next section?

If yes: [Begin section 8]

If no: [information about shigellosis please go to www.cdc.gov/shigella/]For more Thank you for your time. Go to the next page to end survey and submit your responses.

Section 8: RECENT SEXUAL ACTIVITY
Which of the following best represents how you think of yourself? ☐ Lesbian or gay ☐ Straight, that is not lesbian or gay ☐ Bisexual ☐ Something else (specify): _______________ ☐ Unknown/I don’t know ☐ Prefer not to answer
Do you currently describe yourself as male, female, or transgender? ☐ Male ☐ Female ☐ Transgender ☐ None of these ☐ Prefer not to answer
Yes		No		Prefer not to answer
☐		☐		☐		Are you currently sexually active? [If no skip to question 4]
☐		☐		☐		[If yes to question 3] Since your illness started, have you had sexual contact with another person? Sexual contact would include genital sex, anal sex, oral sex, or any other sexual contact.
☐		☐		☐		[If yes to question 3] In the 7 days before your illness started, did you have sexual contact with another person? Sexual contact would include genital sex, anal sex, oral sex, or any other sexual contact.
						[If yes to question 3b] Were your sex partners (select all that apply): ☐ Female ☐ Male ☐ Transgender Female ☐ Transgender Male ☐ Another ☐ Unknown ☐ Prefer Not to Answer
☐		☐		☐		In the 7 days before your illness started did any of your sex partners have diarrhea or symptoms similar to your own?
						[If yes to question 3b] The next questions will be more explicit about the kind of sex you had in the week before your illness started. This will help us to better understand how you could have become sick.
Yes		No		Prefer not to answer		In the 7 days before your illness started, what kind of sexual contact did you have?
☐		☐		☐		Genital sex (for example, penis in the vagina)?
☐		☐		☐		Anal sex (for example, penis in the anus)?
☐		☐		☐		Oral sex (for example, mouth on penis or vagina)?
☐		☐		☐		Anilingus or rimming (meaning mouth on anus)?
☐		☐		☐		Other sexual contact (for example touching your partner’s anus with your hands, your partner touching your anus with their hands, or sharing of sex toys)?
☐		☐		☐		In the 7 days before your illness started did you use drugs or alcohol during or immediately before sex? Some examples include alcohol, Viagra, meth, GHB, cocaine, or poppers. (specify): __________________________________
						In the 7 days before your illness, how many sex partners did you have? (specify):_________
☐		☐		☐		[If yes to question 3bv] Were any of these partners new?
						In the 7 days before your illness started, did you meet your new sex partner(s) at any of the following places?
☐		☐		☐		Bar, restaurant or club? (specify): _______________________
☐		☐		☐		Bathhouse? (specify): _______________________
☐		☐		☐		Bookstore? (specify): _______________________
☐		☐		☐		Gym? (specify): _______________________
☐		☐		☐		Park? (specify): _______________________
☐		☐		☐		Social media sites? (specify): _______________________
☐		☐		☐		Dating or hookup sites? (specify): ______________________
☐		☐		☐		Party, conference, or other type of event? (specify): ______________
☐		☐		☐		Sex club or sex party? (specify): _______________________
☐		☐		☐		Other location I didn’t ask about? (specify): _______________
☐		☐		☐		In the past 12 months have you been told by a doctor that you have a sexually transmitted infection?
						[If yes to question 4] Which infection? (select all that apply) ☐ Chlamydia ☐ Gonorrhea ☐ Syphilis ☐ Genital warts ☐ Herpes ☐ Other (specify):_____________

Section CLOSING: 9
Thank you for completing this survey. Click the button to submit your responses!Submit Survey CDC Team

Public reporting burden of this collection of information is estimated to average 45 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 1307