Form 0920-0978 CA CP-CRE Survey Questionnaire

Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

Community-Associated CP-CRE Interview

CALL LOG
Telephone number:__________________________________

Date
(mm/dd/yy)

Time 1

Time 2

(circle am or pm)

Day 1: _________

________ am/pm

________ am/pm

Day 2: _________

________ am/pm

________ am/pm

Day 3: _________

________ am/pm

________ am/pm

Day 4: _________

________ am/pm

________ am/pm

Day 5: _________

________ am/pm

________ am/pm

Call no more than 10 times with 2 attempts per day for 5 days over a two week period: at least
one weekday between 5-8pm; and one weekend day (Sat: 9am-6pm or Sun: 1pm-8pm).
Call back at _____________(day) ________________(time)
Call back at _____________(day) ________________(time)
Call back at _____________(day) ________________(time)

Person to speak with:
Patient ________________________________________________________________________
Proxy (patient with dementia or deceased from CRF MuGSI data)
Proxy (parent or guardian if case is under 18 years of age)

Patient county at the time of the positive test for CRE
State: ____________

County: __________

Comments: ___________________________________________________________________

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

_____________________________________________________________________________
_______
_____________________________________________________________________________
_______
_____________________________________________________________________________
_______
_____________________________________________________________________________
_______
_____________________________________________________________________________
_______

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

ENROLLEE INTERVIEW – THIS PORTION WILL BE TRANSFERRED TO CDC
SECTION 1: IDENTIFIERS (TO BE FILLED OUT BY EIP STAFF)
1. Patient ID: _________________________________
2. State ID: __________________________________
3. Provider ID: ________________________________
4. Lab ID: ___________________________________
5. Specimen ID (accession number): ___________________________________

6. Date of incident specimen collection :

_____/_____/______
(mm/dd/yyyy)

7. Age (years)

8. Sex



 Male

 Female

HAVE A CALENDAR IN FRONT OF YOU.
I will ask you questions about [you/your child’s] visits to healthcare, activities of people living in
[you/your child’s] household, occupation, travel, other potentially relevant activities, and other
aspects of [your/your child’s] health. It may be difficult to remember, but I would like your best
guess for each question. I will be asking you about specific dates around the time [you/your child]
tested positive for the CRE germ. For your reference, the germ was identified from [you/your
child] on [incident specimen collection date] _________________ at [facility] __________________.
During this interview, I will call the test for the CRE germ a “positive test for CRE.” The questions I
ask you will pertain to a time period up to three years before the positive test for CRE. If you have
a calendar, planner, or health records (including things like medical bills or health insurance
statements from that time), it may be helpful to get those items to help recall events. Do you need
a minute to go get any of these items?
If interviewees gravitate toward answering that they don’t know/are unsure how to answer questions,
encourage them to try to remember one way or another. [See Interviewer Manual]

Section 2: Screening for healthcare exposures in the past year
(Note to interviewer: this is a screening section to confirm the findings from medical record review that the
MuGSI case is community-associated):

First, I am going to ask you some brief questions about selected healthcare visits and
treatments.

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

A. Did you/your child stay overnight in a hospital in the 12 months before the positive test for
CRE? This includes hospitals in the United States and in other countries.
Yes
No
DK
Refused
a. If YES, Where were you/your child hospitalized? _________________
B. Did you/your child stay overnight in a nursing home in the 12 months before the positive test
for CRE? This includes nursing homes in the United States and in other countries.
Yes
No
DK
Refused
C. Did you/your child have surgery in the 12 months before the positive test for CRE?
Yes

No

DK

Refused

a. If YES, What kind of surgery did you/your child have?
______________________________.
[Reference CRF instructions to verify that the surgery reported qualifies under
MuGSI criteria. If not, change the answer to “No” and record additional details in the
comments section.]
D. Were you/your child receiving dialysis at the time of the positive test for CRE?
Yes

No

DK

Refused

E. I am going to ask about medical devices. These are types of medical equipment that are put
in your body to either give you things, like food or medications or oxygen, or take things out,
like collect blood or urine. On the day of your/your child’s positive test for CRE or in the 2
days before the positive test for CRE, did you/your child have any medical devices in your
body?
Yes

No

DK

Refused

a. If YES, What type of medical device did you/your child have?
______________________________.
[Reference CRF instructions to verify that the medical device reported qualifies under
MuGSI criteria. If not, change the answer to “No” and record additional details in the
comments section.]
[If the patient answered “YES” to any of the questions in the screening section, then
STOP the interview after saying “Thank you for your time. We are only interviewing
people who have not had any of these healthcare encounters. We will contact you if we
have further questions.” If the patient answered “No”, “DK”, “Refused”, then continue
the interview and go to Section 3: Healthcare exposures.]
Section 3: Healthcare exposures
I will now ask you additional questions about your/your child’s healthcare in the past.

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

1. I have already asked you about medical devices during the two days before the positive
test for CRE. Did you/your child have any medical devices in your body in the 12
months before the positive test for CRE?
Yes
No
DK
Refused
a. If YES, specify: ______________________________.
I will now ask you about hospitalizations, staying in a nursing home, surgeries, home medical
care, and medical procedures before the positive CRE test.
2. Had you/your child ever stayed overnight in a hospital before the positive test for CRE?
Yes
No
DK
Refused
a. If YES, when was your/your child’s most recent stay in a hospital? (mm/dd/yy)
___________
3. Had you/your child ever stayed overnight in a nursing home before the positive test for
CRE?
Yes
No
DK
Refused
a. If YES, when was your/your child’s most recent stay in a nursing home? (mm/dd/yy)
___________
4. Did you/your child receive dialysis in the 12 months before the positive test for CRE?
Yes
No
DK
Refused
5. Did you/your child go to a clinic or infusion center to have medications injected through
your/your child’s veins in the 12 months before the positive test for CRE? Medications
commonly injected through the veins include those given for cancer chemotherapy and
some antibiotics. [If needed - an infusion clinic is a place outside of the hospital that
provides medications through your veins; chemotherapy is medication given for cancer
treatment; antibiotics are medicines that fight infections caused by bacteria in humans
and animals by either killing the bacteria or making it difficult for the bacteria to grow and
multiply.]
Yes
No
DK
Refused
a.

If YES, what was the reason for visiting this clinic or facility?
_____________________

6. Did you/your child have any wounds that would not heal for more than two weeks, like a
foot ulcer, in the 12 months before the positive test for CRE?
Yes
No [skip to Q10]
DK [skip to Q10]
Refused [skip
to Q10]
7. Who took care of the wound? This includes care in a clinic, the hospital, or your/your
child’s home. [note: wound care specialists can come from a variety of healthcare
professions such as physicians, nurses, physical/occupational therapists, and
pharmacists] (check all that apply).
Self
Relative or friend
Wound care specialist
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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

Other (specify: ____________)
DK
Refused
8. Did this involve hydrotherapy or whirlpool therapy [if needed - techniques that involves
the use of water to aid with cleaning or healing]?
Yes
No
DK
Refused
9. Was a wound VAC used during your/your child wound care [If needed - a wound VAC is
a device consisting of a machine that connects to a dressing over a wound and sucks
fluid out of the wound to help the wound heal more quickly]?.
Yes
No
DK
Refused
10. Did you/your child receive any care from home healthcare providers (for example,
visiting nurses, wound care providers) in the 12 months before the positive test for CRE?
Yes
No
DK
Refused

a. If YES, can you describe the services they provided for you/your child?
___________________________________________________________________
___________________________________________________________________
____________
11. Did you/your child have urinary procedures or other procedures where a doctor used a
scope to look inside your bowel, stomach, lungs, etc. (e.g. endoscopy, colonoscopy) in
the 12 months before the positive test for CRE?
Yes
No
DK
Refused
a. If YES, what was the name of the
procedure?____________________________________
Section 4: Travel
Next, I will ask you for some information about travel and residence outside of the United States
(U.S).
12. Did you/your child travel or reside outside of the U.S. in the 3 years before the positive
test for CRE?
Yes [complete the table]
No [skip to Section 5]
DK [skip to Section
5]
Refused [skip to Section 5]
a. If YES, What country or countries did you/your child visit? During what year or years
did you/your child go to [country]?
Country
Years
a)
________ to ________
b)
________ to ________
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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

13. Did you/your child receive any dental or medical care during your travels outside of the
U.S. in the 3 years before the positive test for CRE? This includes but not limited to
dental cleanings or dental procedures, visits to outpatient clinics, overnight stays in
hospitals, surgeries, endoscopies, cosmetic surgery, medication infusions, or other
types of medical or dental care.
Yes
No [skip to Section 5]
DK [skip to Section 5]
Refused [skip to
Section 5]
If YES, [use the table below to record responses to the following questions]:
a. In what country did you/your child receive your dental care/healthcare?
b. What type of care did you/your child receive?
c. Approximately what year or years did you/your child receive dental
care/healthcare?
d. Was getting medical care one of the reasons why you/your child travelled?
[medical tourism]
13a. Country

13b. Dental care/Healthcare
Received
Hospitalization
Surgery
Other procedure (specify:
_________)
Dental care
Other healthcare (specify:
_________)

13c. Years

________ to
________

13d. Medical
tourism?
Yes
No

Section 5: Antibiotics
Next, I will ask for information about antibiotics. Antibiotics are medicines that fight infections
caused by bacteria in humans and animals by either killing the bacteria or making it difficult for
the bacteria to grow and multiply.
14. Did you/your child take antibiotics in the 12 months before the positive test for CRE?
For example, people commonly take antibiotics for urinary tract infections, sore throats,
sinus infections, boils or other skin infections, and for dentistry purposes.
Yes
No [skip to Section 6]
DK [skip to Section 6]
Refused [skip to
Section 6]
If YES,
a. Why did you/your child take antibiotics? (check all that apply):
Urinary tract infection
Dental cleaning
Oral surgery
Ear, sinus, or other upper respiratory infection
Pneumonia
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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

Skin infection
Acne
Other infection (specify: ___________)
Other reason (specify: ____________)
DK
Refused
b. What antibiotics did you/your child take? [do NOT read list below; check all that
apply]
DK
Refused
Amoxicillin
Ciprofloxacin or Cipro
Nitrofurantoin
Amoxicillin/Clavulanate
Clarithromycin
Norfloxacin or Norflox
Ampicillin
Cleocin
Ofloxacin or Oflox
Augmentin
Clindamycin
Omnicef
Azithromycin
Dapsone
Penicillin or Pen VK
Bactrim
Doxycycline
Pediazole
Biaxin
Duricef
Septra
Ceclor
Erythromycin
Suprax
Cefaclor
Erythromycin/sulfa
Tetracycline
Cefadroxil
Flagyl
Tequin
Cefdinir
Floxin
Trimox
Ceftin
Keflex
Trimethoprim-sulfamethoxazole
Cefixime
Keftab
Zagam
Cefuorixime
Levofloxacin
Zithromax or Z-Pak
Cefzil
Levaquin
Other antibiotic 1
(specify :___________)
Cefprozil
Macrodantin or macrobid
Other antibiotic 2
(specify: ___________)
Cephalexin
Monurol
Cephradine
Metronidazole

Section 6: Occupation:
For the next questions, I will ask you for information about your/your child’s occupation and
related activities in the 12 months before the positive test for CRE.
15. Were you/your child employed at the time of the positive test for CRE?
Yes
No
DK
Refused
a. If YES, what was your/your child’s job? [Refer to standard list of occupations]
________________________________________________
16. Did you/your child work or volunteer at a hospital, healthcare facility, or home health
agency in the 12 months before the positive test for CRE?
Yes [complete the table] No [skip to Q18]
DK [skip to Q18] Refused [skip
to Q18]

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

If YES, [use the table below to record responses to the following questions]:
For each position that you/your child held in healthcare in the 12 months before the positive test
for CRE:
a. What was your/your child role there?
b. What type of healthcare facility or organization did you/your child work in?
c. Did your/your child’s job involve direct physical contact during care for patients?
16c. Did your/your child’s
job involve direct physical
contact during care for
patients?
Yes [complete Q17 ]
No
DK
Ref
Yes [complete Q17]
No
DK
Ref
[* Facility types include hospital, emergency department, doctor’s office or clinic, dentist, longterm care facility, hemodialysis, home health agency, ambulatory surgery center, other (specify),
and should be independently verified against EIP facility classification lists after receiving the
name of the facility]
16a. Role (complete later with
standard OMB categories)

16b.Healthcare Facility/agency
Type*

17. [If respondent’s job involved direct physical contact during care for patients]
Please describe your/your child’s direct physical contact during care for patients:
____________________________________________________________________________
____
[If the description of diect physical contact during care for patients does not include the
following activities, ask for clarification on each activity]:
Bathing patient
Yes
No
DK
Ref
Assisting with toileting
Yes
No
DK
Ref
Assisting with other hygiene
Yes
No
DK
Ref
Caring for a patient known to have CRE
Yes
No
DK
Ref
a. [If respondent had direct physical contact during care for patients] How old were
these persons you/your child provided care for? (check all that apply)
<1 y.o.

1-17 y.o.

18-39 y.o.

40-65 y.o.

>65 y.o.

DK

Refused

18. Did you/your child work or volunteer in a veterinary clinic or in another animal care
facility in the 12 months before the positive test for CRE?
Yes
No [skip to Section 7]
DK [skip to Section 7]
Refused
[Section 7]
If YES, [use the table below to record answers to]:
a. What was your/your child’s role there?
b. Did you/your child provide direct animal care?
18a. Role (complete later with
standard OMB categories)

18b. Did you/your child provide direct
animal care?
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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

Yes [complete Q. 19]
No
DK
Ref
Yes [complete Q. 19]
No
DK
Ref
19. [If respondent provided direct animal care] Please describe your/your childs animal
care duties, including the types of animals cared for:
____________________________________________________________________________
______
Section 7: Agricultural and animal exposures
Next, I am going to ask you questions about agricultural and animal exposures in the 12 months
before the positive test for CRE.
20. Did you/your child have any pets in your household in the 12 months before the positive
test for CRE?
Yes
No [skip to Q21]
DK [skip to Q21]
Refused [skip to Q21]
a. If YES, what kind of pets? (check all that apply)
Cat
Dog
Rodent
Reptile
Bird
_______________________
Refused

Other:

b. Did your/your child’s pet receive any veterinary care in the 12 months before the
positive test for CRE?
Yes

No

DK

Refused

i. If YES, what type of healthcare did your/your child’s pet receive? (check all that
apply)
Stayed in veterinary hospital
Stayed in ICU
Surgery
Other procedures
Sick clinic visits
Routine clinic visits
Other (specify: ________)
DK
Refused
c. Were you/your child ever told your pet had CRE?
Yes
No
DK
Refused
d. Was your/your child’s pet imported into the United States from another country?
Yes
No
DK
Refused
e. If YES, what country? ________________________________

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

21. Did you/your child live or work with livestock like cattle, sheep, goats or other animals in
the 12 months before the positive test for CRE?
Yes No [skip to Section 8]
DK [skip to Section 8]
Refused [skip to
Section 8]
a. If YES, what types of animals did you/your child live or work with? (check all that
apply)
Dairy cattle
Beef cattle
Goat
Turkey
Swine
Sheep
Chicken
Other: ___________________
Refused
Section 8: Household contacts:
Next, I am going to ask you a few questions about activities of your/your child’s household
members and other contacts, related to some of the topics we have previously talked about with
you. Members of your/your child’s household are persons who spent at least 50% of their nights
in your/your child’s household during the 12 months before the positive test for CRE.
22. How many people, including yourself, lived in your household in the 12 months before
the positive test for CRE? _____
DK [skip to Section 9]
Refused [skip to Section 9]
[If answer to Q22 = 1, i.e., interviewee lives alone, skip to Section G]
Concerning other people who lived in your/your child’s household:
23. Was a member of your/your child’s household diagnosed with a CRE germ in the 12
months before your positive test for CRE?
Yes
No
DK
Refused
IF YES
a. Was this a family member?
Yes
No

DK

Refused

24. Did a member of your/your child’s household stay overnight in a hospital or nursing
home in the 12 months before your positive test for CRE?
Yes
No
DK
Refused
If YES, [ask the following questions]:
a. In what type of facility or facilities did this person stay?
Hospital
Nursing home
25. Did a member of your/your child’s household travel or live outside of the U.S. in the 12
months before your positive test for CRE?
Yes
Section 9]

No [skip to Section 9]

DK [skip to Section 9]

Refused [skip to

26. Did a member of your/your child’s household receive any dental care or medical care
outside of the U.S. in the 12 months before your positive test for CRE? (Incl. but not

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

limited to dental care/procedures, outpatient clinics, inpatient hospitalizations, surgeries,
endoscopies, cosmetic surgery, etc.)
Yes [complete the table]
Refused [skip to Section 9]

No [skip to Section 9]

DK [skip to Section 9]

If YES [to “Received healthcare/dental care,” use the table below to record responses for
the following questions]:
a. In what country did a member of your/your child’s household receive dental care or
medical care?
b. What type of care was received (list choices)?
c. Was getting medical care one of the reasons why this household member travelled?
[Medical tourism]
26a. Country

26b. Dental/Healthcare
Received
Hospitalization
Surgery
Other procedure (specify:
_________)
Dental care
Other healthcare (specify:
_________)

26c. Medical
tourism?
Yes
No
Don’t know

Section 9: Other contacts
Now, I will ask you a couple of questions about other people you/your child may have been in
close contact with who are not members of your/your child’s household .
27. Did you/your child assist someone outside your household with bathing, toileting, or
moving around the house during the 12 months before your positive test for CRE?
Yes
No
DK
Refused
a. If YES, did this person/persons stay overnight in a hospital or nursing home during the
12 months before your positive test for CRE?
Yes
No
DK
Refused
b. How old were these persons? (check all that apply)
<1 y.o.
1-17 y.o.
18-39 y.o.
40-65 y.o.

>65 y.o.

DK

Refused

Section 10: Activities and health
I am going to ask some questions about your/your child’s health at the time of or before
the positive test for CRE on [test date] ____________________.

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Patient ID: _____________ State ID: ______________ Date of incident specimen collection: __/__/____

28. Did you/your child need help bathing, toileting, or moving around the house at the time of
the positive test for CRE?
Yes
No
DK
Refused
29. Did you/your child have repeated urinary tract infections in the 12 months before positive
test for CRE, which is defined as two or more infections in six months or three or more
infections in one year?
Yes

No

DK

Refused

Section 11: Final questions
30. Were you/your child born outside of the U.S.? We ask this because studies have shown
that people who were born in another country are more likely to have antibiotic resistant
bacteria.
Yes
No
DK
Refused
a. If YES, What country were you/your child born in?
_______________________________
31. How do you think you/your child got CRE germ?
_____________________________________
32. Is there anything else you/your child would like to tell
us?_______________________________
33. Can we call you back at this number if we have any further questions?
Yes
No
34. Comments:___________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

35. Interview completed? ____Yes____No
36. Date of interview___/___/________
(mm/dd/yyyy)
37. Interviewer initials:________

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. COMMUNITY-ASSOCIATED (CA) CARBAPENEMASE-PRODUCING
CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CP-CRE)
TELEPHONE INTERVIEW INTRODUCTORY SCRIPT
Not transferred to CDC

INSTRUCTIONS: THIS SCRIPT HAS TWO SECTIONS. USE THE SECTION APPROPRIATE FOR THE
CALL YOU ARE MAKING.

BEFORE CALLING: Complete the information on the Call log sheet. List the County of residence, Patient
ID, State ID, and Case name, and telephone number(s).

SECTION A: ANSWERING MACHINE.
TO THE ANSWERING MACHINE: Hello, my name is _________. I'm calling from the [STATE HEALTH DEPT]. I am
calling to talk with you about an important public health project. Please call me at __________. If I am
unable to answer the phone when you call, please leave a message with your name, phone number, and
a time I may call you back. Thank you.
SECTION B: CASES.
Q1

TO THE PERSON WHO ANSWERS THE PHONE, IF ADULT; OTHERWISE, ASK TO SPEAK TO AN ADULT: Hello,
my name is _________. I’m calling from the [STATE HEALTH DEPT]. We are conducting a public
health project to learn more about a type of germ that is resistant to antibiotics. May I please speak
to [CASE IF OVER 18 YEARS OF AGE/ PARENT OR GUARDIAN IF CASE IS UNDER 18 YEARS OF AGE]?
___YES: PERSON WHO ANSWERED WHO IS POTENTIAL ENROLLEE; GO TO Q4.
___YES: COMING TO THE PHONE; GO TO Q3.
___NO: PERSON IS NOT AVAILABLE NOW; GO TO Q1.1.
___NO: PERSON IS DECEASED: I’m sorry. I was not aware of your loss and want to offer my
condolences to you and your family. As I had mentioned, we are working on a public
health project to learn more about a type of germ that is resistant to antibiotics. Would
this be a good time to talk to you about this project, or should I call back another time?
IF YES NOW IS GOOD TIME; GO TO Q8.
IF YES BUT AT ANOTHER TIME; When would be a good time for me to call back? Record
information on the Call log.
IF NO: Q4.1.
___NO: PERSON IS INCAPACITATED; I’m sorry to hear that. GO TO Q8
___ NO: REACHED WRONG NUMBER; ASK IF YOU HAVE DIALED THE NUMBER NOTED ON CALL LOG.
Sorry, I must have the wrong number. Good-bye. =STOP=
___DOES

ENGLISH; RECORD LANGUAGE IN COMMENT SECTION OF CALL LOG. IF
SPANISH:. We will try to call back with someone who speaks Spanish. IF

NOT SPEAK

LANGUAGE IS

CASE SPEAKS A LANGUAGE OTHER THAN

ENGLISH

OR

SPANISH,

HE/SHE IS NOT ELIGIBLE.

=STOP=
Q1.1

Q2

When would be a good time to reach him/her or is there another phone number to reach
him/her? RECORD PERSON’S NAME TO ASK FOR, AND DAY/TIME TO CALL AND ALTERNATIVE
NUMBER ON CALL LOG. Thank you very much for your time. Good-bye. =STOP=

May I speak with him/her?
___Yes; COMING TO THE PHONE; GO TO Q3.
___No; BUT NOT HOME; GO TO Q2.1.
Q2.1

Is there another phone number at which I could reach him/her?
___Yes; RECORD ALTERNATE PHONE NUMBER ON CALL LOG. Thank you very much
for your time. =STOP=
___No; When would be a good time to call back to reach him/her? [RECORD DAY/
TIME ON CALL LOG]. Thank you very much for your time. =STOP=

Q3

Hello, my name is _________. I’m calling from the [STATE HEALTH DEPT]. We are conducting a
public health project to learn more about a type of germ that is resistant to antibiotics. Are you
[POTENTIAL ENROLLEE]?
___Yes; GO TO Q4.

Q4

___No; GO TO Q2.

The [STATE HEALTH DEPT] is notified whenever a person has had a positive test for a germ called
“carbapenem-resistant Enterobacteriaceae,” or “CRE” for short. We recently learned that you/your
child had a positive test result, which is why we are calling you.
We are doing a public health project with the Centers for Disease Control and Prevention to learn
why some people get CRE. While CRE germs can be dangerous, especially for patients who are
in a healthcare facility, some people can have the germ on their bodies without being sick. These
germs are uncommon in [insert state] and the health department and CDC are working to
understand better how we can prevent CRE. One way to do that is to learn more about people who
have the germ.
Would you be willing to answer a few questions to help us better understand where the germ
might have come from or things that might have put you/your child at risk for getting CRE? If you
decide to answer the survey, it should take about 30 minutes. Your participation is voluntary. You
can stop at any time, and you do not have to answer any question if you do not want to.

Is this something you have time to do now?
___Yes; GO TO Q5.
Q4.1

___No; GO TO Q4.1.

Your/your child participation in this project is very important. We are trying to learn more
about why people in the community have CRE. May I schedule a time to talk that would be
better for you/your child?

15

___Yes; RECORD
=STOP=

DAY/TIME ON

CALL LOG. Thank you very much for your time.

___No, Sorry to have disturbed you. Good-bye. =STOP=
Q5

Before we proceed, I would like to make sure you/your child are/is eligible to be in this public health
project; GO TO Q5.1.
Q5.1

CRITERION: RESIDENCY REQUIREMENT - In what county were you/your child living on
[CULTURE DATE]? VERIFY COUNTY ON THE CALL LOG AND CONFIRM THAT IT IS WITHIN CATCHMENT
AREA. IF ADDRESS IS DIFFERENT BUT STILL IN CATCHMENT AREA RECORD ON CALL LOG.
___YES, COUNTY IS WITHIN EIP SURVEILLANCE AREA You are eligible to be included
in this project. GO TO Q6.
___NO, COUNTY IS NOT WITHIN EIP SURVEILLANCE AREA: Thank you very much for
taking the time to answer these questions. However, we are only including
people who live in a specific area for this project. Even though we were not
able to enroll you in this important project, we appreciate your time and
willingness to participate in the project. Do you have any questions for me?
=STOP=

Q6

DID CASE AGREE TO PARTICIPATE?
___YES. Great—thank you for taking time to speak with me today. First, I have to tell you

that when we do these interviews all information that we collect is private meaning
no one has access to any information about you without your permission. You are
under no obligation to answer my questions and there are no consequences if you
choose not to complete the interview or answer specific questions, but your
participation may help us learn more about this germ. GO TO SECTION 1 OF ENROLLEE
INTERVIEW.
___NO; ASK IF YOU CAN CALL BACK AT MORE CONVENIENT TIME ;
PHONE LOG. Thank you very much for your time. =STOP=

IF

YES, RECORD

DAY/TIME ON

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SECTION C: CASES (PROXY VERSION).
BEFORE CALLING: Complete the information on the Call log sheet. List the County of residence, Study
Id, and Case name, and telephone number(s).
Q7

TO THE PERSON WHO ANSWERS THE PHONE, IF ADULT; OTHERWISE, ASK TO SPEAK TO AN ADULT: Hello,
my name is _________. I'm calling from the [STATE HEALTH DEPT]. Is this the home of [POTENTIAL
ENROLLEE]? The health department finds out whenever a [STATE OR COUNTY NAME] resident has a
positive test for a germ called “carbapenem-resistant Enterobacteriaceae” or “CRE” for short. We
understand that [POTENTIAL ENROLLEE] had recently tested positive for CRE. ADD IF ALREADY KNOWN
TO BE DECEASED: We also understand that he/she has since passed away. Is that correct?
___YES; ADD IF DECEASED: I would like to offer condolences to you and your family. Would
this be a good time to talk to you about a public health project involving CRE or should I
call back another time? GO TO Q8.
___NO, POTENTIAL ENROLLEE IS NOT DECEASED; GO TO Q2.
___NO, PERSON IS NOT AT THIS NUMBER; VERIFY THAT YOU HAVE DIALED THE NUMBER NOTED ON
CALL LOG. Sorry, I must have the wrong number. =STOP=
___Does not speak English [RECORD LANGUAGE IN COMMENT SECTION OF CALL LOG]. We will
try to call back with someone who speaks Spanish. IF LANGUAGE IS SPANISH: IF PROXY
SPEAKS A LANGUAGE OTHER THAN ENGLISH OR SPANISH, HE/SHE IS NOT ELIGIBLE. =STOP=

Q8

We are doing a public health project with the Centers for Disease Control and Prevention to learn
why some people get a type of germ that is resistant to antibiotics, called CRE. While CRE germs
can be dangerous, especially for patients who are in a healthcare facility, some people can have
the germ on their bodies without being sick. These germs are uncommon in [insert state] and the
health department and CDC are working hard to understand better how we can prevent CRE from
spreading. One way to do that is to learn more about people who have the germ.
Would you be willing to answer a few questions to help us better understand where the germ
might have come from or things that might have put [POTENTIAL ENROLLEE] at risk for getting CRE?
If you decide to answer the survey, it should take about 30 minutes. Your participation is
voluntary. You can stop at any time, and you do not have to answer any question if you do not
want to.

Are you legally qualified to answer questions about [POTENTIAL ENROLLEE]?

Q8.1

DECEASED

INCAPACITATED

___ Yes; IF DECEASED, GO TO Q8.1

___ Yes; IF INCAPACITATED, GO TO Q8.3

___ No; IF DECEASED, GO TO Q8.2

___ No; IF INCAPACITATED, GO TO Q8.4

Are you considered [POTENTIAL ENROLLEE]’s next of kin?
___YES: RECORD PROXY NAME ON CALL LOG; GO TO Q9.
___NO: Do you have the name of the person who is [POTENTIAL ENROLLEE]’s next of
kin? IF YES RECORD PROXY NAME ON CALL LOG; GO TO Q10.
___DON’T KNOW OR UNSURE: Thank you but we need to talk with the person who is the
next of kin. Thank you for your time. = STOP =

17

Q8.2

Is there someone else who is legally qualified as the next of kin to answer questions about
[POTENTIAL ENROLLEE]’s home, illness, health care and other exposures?
___Yes; RECORD OR CORRECT PROXY NAME ON CALL LOG; GO TO Q10.
___No; Thank you very much for your time. =STOP=

Q8.3

Do you have power of attorney to act on [POTENTIAL ENROLLEE]’s behalf?
___YES: RECORD PROXY NAME ON CALL LOG; GO TO Q9.
___NO: Do you have the name of the person who has been appointed as [POTENTIAL
ENROLLEE]’s power of attorney? RECORD PROXY NAME ON CALL LOG; GO TO Q10. . IF
NO: Thank you but we need to talk with the person who has power of attorney for
[POTENTIAL ENROLLEE]. Thank you for your time. = STOP =
___DON’T KNOW OR UNSURE: Thank you but we need to talk with the person who has
power of attorney for [POTENTIAL ENROLLEE]. Thank you for your time. = STOP =

Q8.4

Is there someone else who has power of attorney to answer questions about [POTENTIAL
ENROLLEE]’s home, illness, health care and other exposures on his/her behalf?
___Yes; RECORD OR CORRECT PROXY NAME ON CALL LOG; GO TO Q10.
___No; Thank you very much for your time. =STOP=

Q9

Q10

Q11

What is your relationship to [POTENTIAL ENROLLEE]?
___Husband, wife, widow/er; GO TO Q13

___Legal guardian; GO TO Q13

___Son or daughter; GO TO Q13

___Power of attorney; GO TO Q13

___Parent; GO TO Q13

___Caregiver; GO TO Q13

___Sister or brother; GO TO Q13

___Other, please specify_________. GO TO Q13

What is that person’s relationship to [POTENTIAL ENROLLEE]?
___Husband, wife, widow/er; GO TO Q11

___Legal guardian; GO TO Q11

___Son or daughter; GO TO Q11

___Power of attorney; GO TO Q11

___Parent; GO TO Q11

___Caregiver; GO TO Q11

___Sister or brother; GO TO Q11

___Other, please specify_________; GO TO Q11

May I speak with [PROXY NAME]?
___Yes; BUT NOT HOME. GO TO Q11.1.
___Yes; COMING TO THE PHONE; GO BACK TO Q7.
___No; GO TO Q11.2.
Q11.1 Do you know at what phone number I could reach [PROXY NAME]?
___YES, ALTERNATE NUMBER; RECORD ALTERNATE PHONE ON CALL LOG. Thank you very
much for your help. Good-bye. =STOP=
___YES, THIS NUMBER; GO TO Q11.2; HOWEVER, IF RESPONDENT STATES THAT PROXY DOES
NOT LIVE HERE BUT COULD BE REACHED AT THIS NUMBER , GO TO Q11.3.
___NO OR DON'T KNOW; ASK IF YOU HAVE DIALED THE NUMBER NOTED ON CALL LOG. Sorry,
I must have the wrong number. Good-bye. =STOP=

18

Q11.2 We are doing a public health project with the Centers for Disease Control and Prevention to learn
why some people get a type of germ that is resistant to antibiotics, called CRE. His/her participation
in this project is very important. When would be a good time to reach him/her? RECORD PERSON’S
NAME TO ASK FOR, AND DAY/TIME TO CALL ON CALL LOG. Thank you very much for your time. Goodbye. =STOP=
Q11.3 Is there another phone number at which I could reach him/her?
___Yes; RECORD ALTERNATE PHONE NUMBER ON CALL LOG. Thank you very much for
your time. =STOP=
___No; When would be a good time to call back to reach him/her? RECORD DAY/TIME
ON CALL LOG. Thank you very much for your time. =STOP=

Q13

Is this something you have time to do now?
___Yes; GO TO Q15.

Q14

___No; GO TO Q14.

Your participation in this project is very important. We are trying to learn more about why people in
the community have CRE. May I schedule a time to talk that would be better for you?
___Yes [RECORD DAY/TIME TO CALL ON CALL LOG]. Thank you very much for your time. Goodbye. =STOP=
___No; Sorry to have disturbed you. Good-bye. =STOP=

Q15

Before we proceed, I would like to ask few questions to make sure [POTENTIAL ENROLLEE] is eligible
to be in this public health project; GO TO Q15.1.
Q15.1 CRITERION #2: RESIDENCY REQUIREMENT - In what county was he/she living on
[CULTURE DATE]? VERIFY COUNTY ON THE CALL LOG AND CONFIRM THAT IT IS WITHIN CATCHMENT
AREA. IF ADDRESS IS DIFFERENT BUT STILL IN CATCHMENT AREA RECORD ON CALL LOG.
___YES, COUNTY IS WITHIN EIP SURVEILLANCE AREA; GO TO Q16.
___NO, COUNTY IS NOT WITHIN EIP SURVEILLANCE AREA: Thank you very much for taking
the time to answer these questions, however we are only including people who live
in a specific area. Even though we were not able to enroll [POTENTIAL ENROLLEE] in
this important public health project, we appreciate your time and willingness to
participate in this project. Do you have any questions for me? =STOP=

Q16.

DID PROXY AGREE TO PARTICIPATE?
___YES. Great—thank you for taking time to speak with me today. First, I have to tell you that
when we do these interviews all information that we collect is private meaning no
one has access to any information about you without your permission. You are under
no obligation to answer my questions and there are no consequences if you choose
not to complete the interview or answer specific questions, but your participation may
help us learn more about this germ. GO TO SECTION 1 OF ENROLLEE INTERVIEW.
___No; ASK IF YOU CAN CALL BACK AT MORE CONVENIENT TIME; IF YES, RECORD DAY/TIME ON CALL
LOG. Thank you very much for your time. =STOP=

19