0920-1399 CRF Symptom Screener - Enrollment form, symptom screenin

Form Approved

OMB Control # 0920-1399

Expiration 05/31/2024

Respiratory Illness Among People Experiencing Homelessness in Anchorage, Alaska

Enrollment form, symptom screening, and vaccination status

Complete the Enrollment Consent Form before conducting this survey.

1. Date and time: __ __/__ __/ __ __ __ __ ____:____ AM/PM

2. Interviewer name: ____________________________________

3. Site of interview: ____________________________________

4. What is your age? _________ (98-Don’t know; 99-Prefer not to answer)

5. What is your race? (select all that apply)

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

9. Prefer not to answer

6. Do you identify as Hispanic? (check one)

   1. Hispanic or Latino

   2. Non-Hispanic or Latino

8. Unknown

9. Prefer not to answer

7. Do you currently describe yourself as male, female, or transgender?

   1. Male

   2. Female

   3. Transgender male

   4. Transgender female

   5. Another gender identity

9. Prefer not to answer

8. What sex were you assigned at birth, on your original birth certificate?

   1. Male

   2. Female

8. Unknown

9. Prefer not to answer

9. Last night, did you sleep? (select one)

   1. In a shelter

   2. Outside (including in a tent or in a car)

   3. In a hotel or motel room

   4. In a private residence with friends or family

   5. In your own private residence

10. In the past two weeks, have you spent at least one night? (select all that apply)

    1. In a shelter

    2. Outside (including in a tent or in a car)

    3. In a hotel or motel room

    4. In a private residence with friends or family

    5. In your own private residence

    6. Incarcerated

11. In the past two weeks, have you been exposed to someone with COVID-19?

    1. Y

    2. N

8. Don’t know

12. In the past one week, have you experienced any of these NEW or WORSENING symptoms? (Select all that apply):

    1. Feeling feverish

    2. Headaches

    3. Cough

    4. Chills or shivering

    5. Sweats

    6. Sore throat or scratchy throat

    7. Runny or stuffy nose

    8. Feeling more tired than usual

    9. Muscle or body aches

    10. Increased trouble with breathing

    11. Ear pain or ear discharge

    12. Diarrhea

    13. Nausea or vomiting

    14. Rash

    15. Loss of smell or taste

    16. None of the above

13. Is there a place that you USUALLY go to when you are sick or need advice about your health?

    1. Y

    2. N

8. Don’t know

14. Have you received COVID vaccination/s? 

    1. Y ( Go to 14a)

    2. N (Go to 15)

8. Don’t know (Go to 15)

1. If yes, how many have you received? ___ (8-Don’t know; 9-Refuse to answer)

2. When did you receive your last COVID vaccine? __ __/__ __ __ __ (approximate date in MM/YYYY)

15. A. Have you received a flu vaccine (flu shot) ?

    1. Y ( Go to 15a)

       2. N (Go to 15B)

8. Don’t know (Go to 15B)

a.  When did you receive your last flu shot? __ __/__ __ __ __ (approximate date in MM/YYYY)

B. Have you received a RSV shot?

1. Y ( Go to 15b)

2. N ( End survey if no respiratory symptoms or collect swabs if respiratory symptoms present)

8. Don’t know ( End survey if no respiratory symptoms or collect swabs if respiratory symptoms present)

b. When did you receive a RSV shot? __ __/__ __ __ __(approximate date in MM/YYYY)

If any respiratory symptoms are selected, continue to collect swabs.

Swab Collection:

1. Date of collection: __ __ /__ __ / __ __ __ __ (MM/DD/YYYY)

2. Name of individual collecting swab: ____________________________________

3. Specimen collected:

4. Laboratory Result:

Public reporting burden of this collection of information is estimated to average 30 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 H21-8 Atlanta, Georgia 30333; ATTN: PRA 0920-1399