Form 0920-25AU INITIAL CLINCAL AND SOCIAL SURVEY

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

ATTACHMENT 3. INITIAL CLINCAL AND SOCIAL SURVEY

Today’s Date: ________/_______/_________ Interviewer Name: _____________________________

Investigation ID: __________________________

County of residence: ________________________ State of residence: ________

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

o Female o Male o Other o Prefer not to answer/decline

How do you currently describe yourself? (check all that apply)

o Female o Male o Transgender o Prefer not to answer/decline

o I use a different term: ___________________________________________________

What is your race and/or ethnicity? Select all that apply and enter additional details in the spaces below.

o American Indian or Alaska Native – Provide details below. Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

______________________________________________________________________________o Asian – Provide details below.

o Chinese o Asian Indian o Filipino o Vietnamese

o Korean o Japanese

If needed: enter, for example, Pakistani, Hmong, Afghan, etc

______________________________________________________________________________o Black or African American – Provide details below.

o African American o Jamaican o Haitian o Nigerian

o Ethiopian o Somali

If needed: enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc

______________________________________________________________________________

o Hispanic or Latino – Provide details below.

o Mexican o Puerto Rican o Salvadoran o Cuban

o Dominican o Guatemalan

If needed: enter, for example, Colombian, Honduran, Spaniard, etc

______________________________________________________________________________

o Middle Eastern or North African – Provide details below.

o Lebanese o Iranian o Egyptian o Syrian

o Iraqi o Israeli

If needed: enter, for example, Moroccan, Yemeni, Kurdish, etc

______________________________________________________________________________

o Native Hawaiian or Pacific Islander – Provide details below.

o Native Hawaiian o Samoan o Chamorro o Tongan

o Fijian o Marshallese

If needed: enter, for example, Chuukese, Palauan, Tahitian, etc

______________________________________________________________________________

o White – Provide details below.

o English o German o Irish o Italian

o Polish o Scottish

If needed: enter, for example, French, Swedish, Norwegian, etc

______________________________________________________________________________

We are going to ask you questions about the illness you had this year, for which you tested positive for Oropouche.

1) What date did your initial symptoms with this illness begin? (mm/dd/yyyy) _______/_________/________

2) Were you hospitalized during your initial illness? o Yes o No o Prefer not to answer

2a) If yes, for how many days? ______________ days (dates of hospitalization if possible)

4a.1) Date of admission (mm/dd/yyyy):________________________

4a.2) Date of discharge (mm/dd/yyyy):_________________________

2b) If yes, did you spend time in the intensive care unit (ICU)?

o Yes o No o Prefer not to answer

3) During your initial illness, what were your symptoms?

Fever o Yes o No o Unknown Highest temp: __________°F	Chills o Yes o No o Unknown		Headache o Yes o No o Unknown
Fatigue/malaise o Yes o No o Unknown	Muscle aches (myalgia) o Yes o No o Unknown		Joint pain (arthralgia) o Yes o No o Unknown
Back pain Yes o No o Unknown	Red eyes (conjunctival injection) o Yes o No o Unknown		Retroorbital or eye pain o Yes o No o Unknown
Light sensitivity (photophobia) o Yes o No o Unknown	Muscle weakness o Yes o No o Unknown		Seizures o Yes o No o Unknown
Stiff neck or neck pain o Yes o No o Unknown	Confusion o Yes o No o Unknown		Tremors/Shaking o Yes o No o Unknown
Numbness or tingling o Yes o No o Unknown	Loss of appetite o Yes o No o Unknown		Nausea o Yes o No o Unknown
Vomiting o Yes o No o Unknown	Diarrhea o Yes o No o Unknown		Abdominal pain o Yes o No o Unknown
Sore throat o Yes o No o Unknown	Cough o Yes o No o Unknown		Shortness of breath o Yes o No o Unknown
Chest pain o Yes o No o Unknown	Painful urination (dysuria) o Yes o No o Unknown		Urinary incontinence o Yes o No o Unknown
Difficulty emptying bladder (retention) o Yes o No o Unknown	Painful ejaculation o Yes o No o Unknown o Not applicable		Scrotal and/or testicular pain (epididymitis, orchitis) o Yes o No o Unknown o Not applicable
Vaginal discharge (if applicable) o Yes o No o Unknown o Not applicable If yes, please describe:		Penile discharge (if applicable) o Yes o No o Unknown o Not applicable If yes, please describe:
Dizziness, lightheadedness, or vertigo o Yes o No o Unknown If yes, please describe:		Paralysis o Yes o No o Unknown If yes, please describe:
Rash o Yes o No o Unknown If yes, please describe:		Excessive sweating o Yes o No o Unknown
Hemorrhage (bleeding) [List out all options below] o Yes o No o Unknown If yes, then specify: o Nose bleeds o Bleeding gums o Blood in stool o Heavy or abnormal menstruation o Tiny spots of bleeding under the skin or mucous membranes (petechiae) o Blood in urine (hematuria) o Blood in semen (hematospermia)
Other: ___________________________________________________________________________________

4) Was there any point in your illness where your symptoms improved but then came back later?

o Yes o No o Unknown/Not sure

4a) If yes, how many times did this occur? _____________________ times

4b) If yes, if you can remember, what dates did your symptoms go away and then come back:

Remittance:__________________________ Relapse:________________________________

4b.1) If the patient has had multiple relapses, use table below:

Recurrence number	Remittance Date (improved)	Relapse date (worsened or recurred)
1
2
3
4
5

4c) If yes, how would you describe the severity of the symptom relapse compared to your initial illness?

o More severe o Similar severity o Less severe o Unknown/Not sure

4d) If yes, please describe any relapsing symptoms that occurred, and whether this symptom reoccurred or was ongoing

Fever o Yes o No o Unknown Highest temp: __________°F o Recurrence, #: ______ OR o Ongoing symptom	Chills o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Headache o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Fatigue/malaise o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Muscle aches (myalgia) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Joint pain (arthralgia) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Back pain Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Red eyes (conjunctival injection) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Retroorbital or eye pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Light sensitivity (photophobia) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Muscle weakness o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Seizures o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Stiff neck or neck pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Confusion o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Tremors/Shaking o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Numbness or tingling o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Loss of appetite o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Nausea o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Vomiting o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Diarrhea o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Abdominal pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Sore throat o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Cough o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Shortness of breath o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Chest pain o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Painful urination (dysuria) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom		Urinary incontinence o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Difficulty emptying bladder (retention) o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom	Painful ejaculation o Yes o No o Unknown o Not applicable o Recurrence, #: ______ OR o Ongoing symptom		Scrotal and/or testicular pain (epididymitis, orchitis) o Yes o No o Unknown o Not applicable o Recurrence, #: ______ OR o Ongoing symptom
Vaginal discharge (if applicable) o Yes o No o Unknown o Not applicable If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom		Penile discharge (if applicable) o Yes o No o Unknown o Not applicable If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom
Dizziness, lightheadedness, or vertigo o Yes o No o Unknown If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom		Paralysis o Yes o No o Unknown If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom
Rash o Yes o No o Unknown If yes, please describe: o Recurrence, #: ______ OR o Ongoing symptom 5		Excessive sweating o Yes o No o Unknown o Recurrence, #: ______ OR o Ongoing symptom
Hemorrhage (bleeding) [List out all options below] o Yes o No o Unknown If yes, then specify: o Nose bleeds o Bleeding gums o Blood in stool o Heavy or abnormal menstruation o Tiny spots of bleeding under the skin or mucous membranes (petechiae) o Blood in urine (hematuria) o Blood in semen (hematospermia) o Recurrence, #: ______ OR o Ongoing symptom
Other, please describe: o Recurrence, #: ______ OR o Ongoing symptom

4e) If yes, did you seek healthcare when these symptoms recurred?

o Yes o No o Prefer not to answer

4e.1) If yes, where did you seek care? Please provide dates if possible.

o Emergency department o Primary care doctor o Urgent care

o Other, specify:______________________

Date(s) of care:______________________________________________________

Next, we have some questions about your medical history.

5) Do you have any underlying medical conditions?

o Yes o No o Don’t know/Not sure o Prefer not to answer

If yes, check any of the following conditions that apply.

o Asplenia (no spleen)

o Autoimmune disease (e.g., lupus, rheumatoid arthritis): Describe_______________________________________________ Medication(s):__________________________________________________________________

o Blood problems (e.g., sickle cell disease): Describe_________________________________________________________

o Diabetes mellitus: o Type I o Type II

o Cancer: Describe ____________________________________________________________________ Medication(s):__________________________________________________________________

o Cardiovascular (heart or blood vessel) disease o Hypertension (high blood pressure)

o Chronic hepatitis or liver disease

o Chronic lung disease

o Immunosuppressive condition (any medical conditions that limit your ability to fight infections):

Describe_______________________________________________________________________ Medication(s):___________________________________________________________________

o Renal (kidney) disease o On dialysis

o Other______________________________________________________________________________

_____________________________________________________________________________________

6) Do you take any medications that suppress your immune system?

o Yes o No o Unknown

7) In the 2 months before your illness, did you receive a blood transfusion or organ or tissue transplant?

o Yes o No o Unknown

7a) If yes, what did you receive (please provide dates)?

o Both o Blood transfusion only o Organ donation only o Unsure

Dates: __________________________________________

8) (if applicable) Are you currently pregnant or were you at any point during your illness?

o Yes o No o Unknown/Not sure

8a) If yes, at what point in gestation did you become ill? ___________ months/weeks (circle)

8b) If yes, did you experience any complications such as stillbirth, spontaneous abortion, or fetal birth defects? o Yes o No o Unknown/Not sure

8c) If yes to 8b, please specify: ________________________________________

9) (if applicable) Are you currently breastfeeding?

o Yes o No

9a) (If yes to 9) Would you be willing to submit a sample of breast milk to test for Oropouche virus? [Make sure information is also recorded in the consent]

o Yes o No

9b) (If yes to 9) Did your baby travel with you on the trip before your illness?

o Yes o No

9c) (If yes to 9) Has your baby had any symptoms such as fever, loss of appetite, increased irritability, more sleepy, or rash since your illness (or around the time of your illness if the baby traveled)?

o Yes o No o Unknown/Not sure

o Other:___________________________________________________________________

Note to interviewer: if their child has any worrisome symptoms, recommend they discuss with their pediatrician if Oropouche virus testing is appropriate.

10) If participant consented to sample collection and/or sexual history interview:

(if applicable) Have you had a vasectomy?

o Yes o No o Unknown/Not sure

10a) If yes, when? (approximate month and year) _____________________________

10b) If yes, did you have the vasectomy reversed? o Yes o No o Unknown/Not sure

10c) If reversed, when? (approximate month and year) _________________________

11) If the participant is male and participating in the sample collection investigation:

In the past 7 days, how many times did you ejaculate (not including ejaculation to collect a sample for this investigation)? ____________________________________

Finally, we are going to ask you some questions about travel and potential risks of exposure to Oropouche virus in the 2 weeks before your illness began.

12) During the 14 days before [initial symptom onset] were you traveling away from your home internationally?

o Yes o No o Unknown/not sure o Prefer not to answer

13) During the 14 days before [initial symptom onset] were you traveling away from your home within the US?

o Yes o No o Unknown/not sure o Prefer not to answer

14) If yes to Q8 or Q9, list ALL locations, including overnight transits and layovers:

Departure Date (MM/DD/YYYY)	Departure city, state/province/country	Arrival Date (MM/DD/YYYY)	Arrival city, state/province/country
Trip 1
Trip 2
Trip 3
Trip 4
Trip 5

15) What outdoor activities did you do during your international trip? (in the 14 days before symptom onset) [Check all that apply]

c Sitting outdoors c Walking c Running c Hunting / fishing c Yard-work

c Hiking or camping c Playing

c Other (specify) ________________________________ c Don’t know

16) During what time periods did you typically spent more than 15 minutes outdoors doing these types of activities during your trip?

15a) Early morning (4am to 8am) c Yes c No c Don’t know

15b) Daytime (8am to 5pm) c Yes c No c Don’t know

15c) Evening (5pm to 9pm) c Yes c No c Don’t know

15d) Nighttime (9pm to 4am) c Yes c No c Don’t know

17) During your travel, how many hours per day did you typically spend outside?

o <1 hour o 1-4 hours o 5-8 hours o >8 hours

18) During your trip, in the 14 days before your illness began, do you recall any of the following?

Yes No Unknown

o o o Being bitten by a mosquito

o o o Being bitten by a biting midge (“punkies” or “no-see-ums”)

18a) What time(s) of day did you get bitten by mosquitoes?

Early morning (4am to 8am) c Yes c No c Don’t know

Daytime (8am to 5pm) c Yes c No c Don’t know

Evening (5pm to 9pm) c Yes c No c Don’t know

Nighttime (9pm to 4am) c Yes c No c Don’t know

18b) What time(s) of day did you get bitten by midges?

Early morning (4am to 8am) c Yes c No c Don’t know

Daytime (8am to 5pm) c Yes c No c Don’t know

Evening (5pm to 9pm) c Yes c No c Don’t know

Nighttime (9pm to 4am) c Yes c No c Don’t know

19) During your trip, how often did you do the following?

19a) Wear long sleeves and long pants when outside

c Always c Most of the time c Sometimes c Never c Don’t know

19b) Wear insect repellant when outdoors for 15 minutes or more

c Always c Most of the time c Sometimes c Never c Don’t know

[If NEVER or DK, skip to Q.19]

19b.1) Do you recall the brand or active ingredient (such as DEET) of mosquito repellant that you usually use? _____________________________ c Don’t know

20) During the 14 days before your illness, did you have close contact (e.g. caring for, speaking with, touching, or having sex) with anyone who was recently sick with a similar illness?

c Yes c No c Don’t know

20a) If yes, can you describe any contact you had with that person?

c Physical contact c Sexual contact c In close proximity

c Other, describe:__________________________________________________

Thank participants for their time and willingness to provide information to help us learn more about Oropouche virus disease.

CDC estimates the average public reporting burden for this collection of information as 30 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).