0920-1316 Symptom survey

[NCEH] Aerosols from cyanobacterial blooms: exposures and health effects in a highly exposed population

Att7 Symptom Survey 20200212

OMB: 0920-1316

Document [docx]
Download: docx | pdf

Attachment 7


Symptom Survey


Form Approved

OMB No. 0920-0079

Exp. Date XX/XX/XXXX


Fleisch-Kincaid Reading Level: 5.6

Aerosols from cyanobacterial blooms: exposures and health effects in highly exposed populations


Symptom Survey



Date: ___/___/____

mm dd yyyy


Time: ____AM PM



Your assigned study ID number: _________________



















CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0079).



PART 1: Pre-exposure symptom survey: Please answer the following questions.


Do you currently have a head cold, chest cold, flu, or pneumonia?

No 1

Yes 2

Don’t know 8

Refused 9


Do you currently have a gastrointestinal illness, such as a stomach ache?

No 1

Yes 2

Don’t know 8

Refused 9


Please tell me if you have experienced any of the following symptoms or problems within the last 7 days. If you did have that symptom or problem, please tell me when it started and when it ended, and whether you still have the symptom or problem. Note that the start date may have been before the last 7 days.



Symptom or Problem

When did it start?

Do you still have the symptom or problem?

When did it end?









Fever

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Chills

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Headache

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Sore throat

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Ear ache

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Discharge or fluid running from ear

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Abdominal pain

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Nausea

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Vomiting

Y

N

____/____/____

DD MM YY


Y

N


____/____/____

DD MM YY

Diarrhea

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Diarrhea with blood

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Other general symptoms or problems (specify)_______________

Y

N



____/____/____

DD MM YY





Y

N



____/____/____

DD MM YY

Blurred Vision

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Irritation or pain

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Redness or discharge from eyes

Y

N


____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Conjunctivitis (Pink eye)

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Other eye problems (specify)___________

Y

N


____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY









Cough or choke

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Shortness of breath

Y

N

___/____/____

DD MM YY


Y

N

___/____/____

DD MM YY

Nasal congestion or runny nose

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Throat irritation

Y

N

____/____/____

DD MM YY


Y

N

____/____/____

DD MM YY

Other breathing-related symptoms (specify)_________________

Y

N


____/____/____

DD MM YY



Y

N


____/____/____

DD MM YY


Asthma-related symptoms: Just as a reminder for me, has a doctor, nurse, or other health professional ever told you that you had asthma?


No (SKIP TO next section)

Yes 2

Don’t know (SKIP TO NEXT SECTION) 8

Refused (SKIP TO NEXT SECTION) 9



Wheezing

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Coughing

Y

N

___/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Trouble breathing

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Other asthma-related symptoms (specify)_________________

Y

N


____/____/____

DD MM YY

Y

N


____/____/____

DD MM YY


Nerve-related symptoms.


Agitation

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Confusion

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Dizziness

Y

N


____/____/____

DD MM YY

Y

N


____/____/____

DD MM YY

Lethargy

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Loss of consciousness

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Weakness

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Seizures

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Numbness

Y

N

____/____/____

DD MM YY

Y

N


____/____/____

DD MM YY

Tremor

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Other nerve-related symptoms (specify)

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY


Skin-related symptoms


Itchy skin

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Red skin

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Hives or welts

Y

N

____/____/____

DD MM YY

Y

N


____/____/____

DD MM YY

Skin irritation/pain

Y

N

____/____/____

DD MM YY

Y

N


____/____/____

DD MM YY

Rash (describe) ____________________

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY

Infected cuts or scrapes

Y

N

____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY


Oher skin-related symptoms (specify) _________________

Y

N


____/____/____

DD MM YY

Y

N



____/____/____

DD MM YY




Now, I just have a few more questions about your household pets


1P. Do you have any pets?

No (SKIP TO END)

Yes 2

Don’t know (SKIP TO END) 8

Refused (SKIP TO END) 9


If yes, please describe:

Dog 1

Cat 2

Horse 3

Other _________________


2P. Do your pets go into the water?

No (SKIP TO END)

Yes 2

Don’t know (SKIP TO END) 8

Refused (SKIP TO END) 9


3P. Have any of your pets been sick after going in the water?

No (SKIP TO END)

Yes 2

Don’t know (SKIP TO END) 8

Refused (SKIP TO END) 9


4P. Can you describe the sickness your pet had?


Describe: _________________________________


5P. Did you see a veterinarian about your pet’s sickness?

No (SKIP TO 6P)

Yes 2

Don’t know (SKIP TO 6P) 8

Refused (SKIP TO 6P) 9


5Pa. What was the diagnosis?

Describe: _____________________________


What medications did your veterinarian prescribe for your pet?

Describe: _____________________________


6P. Is your pet well now?

No

Yes 2

Don’t know 8

Refused 9



6Pa. If your pet is not well now, can you tell me what is wrong with it?


Describe: _____________________________



Thank you.











Pulmonary function test results


Parameter

Value

Forced vital capacity (FVC) in L


Forced expiratory volume in the first second you exhale (FEV1 ) in L/sec.


Forced expiratory volume in the first second over forced vital capacity (FEV1/FVC) in %


Forced expiratory flow from 25% to 75% of vital capacity (FEF25%-75% ) in L/sec


Peak expiratory flow rate (PEF) in L/sec.














Thank you for being in our study.


SURVEY PART 2: POST EXPOSURE SYMPTOM SURVEY


Thank you for coming back for the second part of our study today.

We can get started on the questions.


Did you notice any cyanobacteria (also called blue-green algae) blooms?

Yes

No

Not sure


Was the water discolored?

 Yes

No

Not sure


If it was discolored, what color(s) did you notice?


Red

Brown

Green

Black

Yellow

White

Not sure


Did you notice an unusual odor?

Yes

No

Not sure


If you noticed an unusual odor, can you describe it?

_________________________________________

_________________________________________


Did you see any dead fish?

Yes

No

Not sure


If you saw dead fish, do you know about how many dead fish you saw?

Now, please tell me if you have experienced any of the following symptoms or problems today. If you did have that symptom or problem, please tell me when it started and when it ended, and whether you still have the symptom or problem.




Symptom or Problem

When did it start?

Do you still have the symptom or problem?

When did it end?


Fever

Y

N


-------- am pm

Y

N


--------- am pm

Chills

Y

N


-------- am pm

Y

N


--------- am pm

Headache

Y

N


-------- am pm

Y

N


--------- am pm

Sore throat

Y

N


-------- am pm

Y

N


--------- am pm

Ear ache

Y

N


-------- am pm

Y

N


--------- am pm

Discharge or fluid running from ear

Y

N


-------- am pm

Y

N


--------- am pm

Abdominal pain

Y

N


-------- am pm

Y

N


--------- am pm

Nausea

Y

N


-------- am pm

Y

N


--------- am pm

Vomiting

Y

N


-------- am pm

Y

N


--------- am pm

Diarrhea

Y

N


-------- am pm

Y

N


--------- am pm

Diarrhea with blood

Y

N


-------- am pm

Y

N


--------- am pm


Other general symptoms or problems (specify)_______________

Y

N



-------- am pm

Y

N



--------- am pm


Eye-related symptoms


Blurred Vision

Y

N


-------- am pm

Y

N


--------- am pm

Irritation or pain

Y

N


-------- am pm

Y

N


--------- am pm

Redness or discharge from eyes

Y

N


-------- am pm

Y

N


--------- am pm

Conjunctivitis (Pink eye)

Y

N


-------- am pm

Y

N


--------- am pm

Other eye problems (specify)___________

Y

N


-------- am pm

Y

N


--------- am pm














Breathing-related symptoms


Cough or choke

Y

N


-------- am pm

Y

N


--------- am pm

Shortness of breath

Y

N


-------- am pm

Y

N


--------- am pm

Nasal congestion or runny nose

Y

N


-------- am pm

Y

N


--------- am pm

Throat irritation

Y

N


-------- am pm

Y

N


--------- am pm

Other breathing-related symptoms (specify)_________________

Y

N


-------- am pm

Y

N


--------- am pm



Asthma-related symptoms.






Wheezing

Y

N

-------- am pm

Y

N

-------- am pm


Coughing

Y

N

-------- am pm

Y

N

-------- am pm


Trouble breathing

Y

N

-------- am pm

Y

N

-------- am pm


Other asthma-related symptoms (specify)_________________

Y

N

-------- am pm

Y

N

-------- am pm



Nerve-related symptoms.


Agitation

Y

N


-------- am pm

Y

N


--------- am pm


Confusion

Y

N


-------- am pm

Y

N


--------- am pm


Dizziness

Y

N


-------- am pm

Y

N


--------- am pm


Lethargy

Y

N


-------- am pm

Y

N


--------- am pm


Loss of consciousness

Y

N


-------- am pm

Y

N


--------- am pm


Weakness

Y

N


-------- am pm

Y

N


--------- am pm


Seizures

Y

N


-------- am pm

Y

N


--------- am pm


Numbness

Y

N


-------- am pm

Y

N


--------- am pm


Tremor

Y

N


-------- am pm

Y

N


--------- am pm


Other nerve-related symptoms (specify)

Y

N


-------- am pm

Y

N


--------- am pm








Itchy skin

Y

N


-------- am pm

Y

N


--------- am pm

Red skin

Y

N


-------- am pm

Y

N


--------- am pm

Hives or welts

Y

N


-------- am pm

Y

N


--------- am pm

Skin irritation/pain

Y

N


-------- am pm

Y

N


--------- am pm

Rash (describe) ____________________

Y

N


-------- am pm

Y

N


--------- am pm

Infected cuts or scrapes

Y

N


-------- am pm

Y

N


--------- am pm

Oher skin-related symptoms (specify) _________________

Y

N


-------- am pm

Y

N


--------- am pm


Did anyone on your boat (other than you) complain about symptoms during your trip?


Yes

No

If someone did complain about symptoms, what were the symptoms?

__________________________________

__________________________________

__________________________________

__________________________________



Pulmonary function test results (to be included for the three appointments only)


Parameter

Value

Forced vital capacity (FVC) in L


Forced expiratory volume in the first second you exhale (FEV1 ) in L/sec.


Forced expiratory volume in the first second over forced vital capacity (FEV1/FVC) in %


Forced expiratory flow from 25% to 75% of vital capacity (FEF25%-75% ) in L/sec


Peak expiratory flow rate (PEF) in L/sec.



**REMINDERS**:


  1. Please collect a urine specimen and leave it with study staff.

  2. Please collect a nasal swab and leave it with study staff.

  3. Please make sure study staff remove the air sampling pump from your boat.

  4. Please provide study staff with the fish if you caught one today.

  5. Please collect your gift card from study staff.



Thank you for being in our study.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Titlemicrocystins in drinking water protocol
Authorlfb9
File Modified0000-00-00
File Created2024-07-22

© 2024 OMB.report | Privacy Policy