Form 0920-0978 CA CP-CRE Survey Questionnaire

Patient ID: _____________ State ID: ______________ Initial culture date: __/__/____

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: ___________________________________________________________________
____________________________________________________________________________________

1

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

2
05/25/2021, version # 21

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.
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? _________________
3
05/25/2021, version # 21

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

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.
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
4
05/25/2021, version # 21

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

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
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

5
05/25/2021, version # 21

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

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 ________
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

13c. Years

________ to
________

13d. Medical
tourism?
Yes
No

6
05/25/2021, version # 21

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

Other healthcare (specify:
_________)

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
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
7
05/25/2021, version # 21

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

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]

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, long-term 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)
8
05/25/2021, version # 21

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

<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?
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
9
05/25/2021, version # 21

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

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? ________________________________

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 9]
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

No [skip to Section 9]

DK [skip to Section 9]

Refused [skip to Section 9]
10

05/25/2021, version # 21

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

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

No [skip to Section 9]

DK [skip to Section 9]

Refused

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] ____________________.

11
05/25/2021, version # 21

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:________

12
05/25/2021, version # 21