Form 0920-25AU Sexual Contact Interview form

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

ATTACHMENT 7. SEXUAL CONTACT INTERVIEW FORM

Before interview: visit this website to see which countries are listed as having recent human disease cases (as of 10/1/24: Bolivia, Brazil, Colombia, Cuba, Dominican Republic, Guyana, and Peru)

Complete before interviewing contact

Period of interest (from case interview): __________________________________________________

Date of first sexual encounter during period of interest: ______________________________________

Date of last sexual encounter during period of interest: ______________________________________

(provided by case during interview, confirm with contact)

Possible symptom onset window (date of first sexual encounter with index case through 2 weeks after last sexual encounter during the period of interest): _________________________________________

[INTRO SCRIPT, ELIGIBILITY, CONSENT PROCESS]

Did you travel to [LIST COUNTRIES WITH RECENT OROPOUCHE VIRUS DISEASE CASES] since January 1, 2023?

o Yes à end interview o No

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: ___________________________________________________

Pregnancy status (if applicable): o Yes o No o Unknown/Not sure

Between the dates of [possible symptom onset window], did you experience any of the following symptoms?

Symptom
o	Fever (subjective or objective)
o	Headache
o	Muscle aches
o	Joint pain/aches
o	Light sensitivity
o	Eye (retroorbital) pain
o	Rash over large parts of the body
o	Stiff neck
o	Confusion
o	Memory loss
o	Muscle weakness
o	Seizures
o	Other symptom(s): ___________________________________________________________ ___________________________________________________________________________
o	No symptoms experienced

If the respondent reports fever + at least one other listed symptom (NOT an “other” symptom ): Would you be willing to have a blood sample taken to test for signs of Oropouche virus infection? You would receive your results and information about what your test results mean.

o Yes o No

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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).