AppxD Epi CASE Survey SAMPLE

Appendix D Epi Case Survey SAMPLE

Form Approved

OMB No. 0923-0051

Exp XX/XX.XXXX

For official interviewer use only

Household ID _____________Participant ID ______________ Interviewer Initials _____ ____ ___ Interview location _____

Confirmation of Identity (Please select one) Social Security _ _ _ - _ _- _ _ _ _ Driver’s license: State __ __ Number_________________exp __ / __/ __ __	State ID: State __ __ Number________________exp __ / __/ __ ____ Other ID (describe)_________________________
Registrant Information 1. Last name _______________First name _________________ MI ___ 2. Date of Birth (mm/dd/yyyy) __ _/_ _ /_ _ _ _ 3. Sex oMale oFemale à (select one) o Not pregnant o Pregnant à estimated due date (mm/dd/yyyy) __ _/_ _ /_ _ _ _ o Don’t know/refused o Other (specify)_____________________________________
4. Home Address Street ____________________________ City _________________ County_________________ State ________________ ZIP ____________________5. Email address_____________________________________

6. What social media accounts do you use. This helps us know how to best communicate with you. (check all that apply)

o Facebook oTwitter o Instagram oOther _______________________________________ oRefused

7. What are the best telephone numbers to reach you?

A. (_ _ _ ) _ _ _ -_ _ _ _ oCell oHome oWork B. (_ _ _ ) _ _ _ -_ _ _ _ o Cell o Home o Work

Emergency Contact Information (Prefer someone that lives at a different address)

8. Contact’s Last name ___________________ , First Name ___________ MI _____

9. Contacts phone numbers

A. (_ _ _ ) _ _ _ -_ _ _ _ Cell o Home o Work o B. (_ _ _ ) _ _ _ -_ _ _ _ Cell o Home o Work o

10. Contact’s Address

Street ____________________________ City _________________ County_________________

Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 Clearance Officer, 1600 Clifton Road NE, MS H21–8, Atlanta, Georgia 30329

ATTN: PRA (0923-0051)

State ________________ ZIP ____________________ 11. Contact‘s Email address_________________________________

12. Address during the incident

Same as residence check box o Skip to Q 13

Street ____________________________ City _________________ County_________________

State ________________ ZIP If unsure of address, nearest intersection/building/landmark_______________________________________________

13. Physical location during the incident (check all that apply)

o Inside building o Outside o Inside a car/vehicle o Other ________________

14. Do you think or were you told you were in contact with contaminants? oYes oNo o Unsure

15. Were told to decontaminate? oYes oNo o Unsure

16. Did you go to a Community Resource Center (CRC)? oYes oNo o Unsure

17. If you went to a Community Resource Center (CRC) what tracking number did they give you?_______________________

18. Were you decontaminated (i.e. your clothing was removed and/or your body was washed, etc.)?oYes oNo oUnsure

19. Did you shelter-in-place?oYes oNo o Unsure

20. Did you evacuate? oYes oNo oUnsure

21. If you evacuated did you take any pets with you?

oYes, I evacuated with all my pets oYes, I evacuated some of my pets

oNo, I don’t have any pets o No, I left them at home o Unsure

22. As a result of this incident, are you personally in need of anything? (check all that apply)

oMedicine or medical supplies oMedical care oMental health care Water oShelter o Food oUtilities

o Transportation o Other, specify _________________________________oDon’t know/refused

23. How many children younger than 18 years of age were in your immediate care during the incident_______

(Note to survey developer, if electronic generate the corresponding number of children child 1-child N for Q21 and Q 22)

Child 1 Last name _______________, First name _________________ MI ___

b. Age (if less than 1, put 1) ____________________c. Sex oMale oFemale oOther Refuse/Unknown

SYMPTOMS

24. Did you or your children have any of the following types of symptoms start or worsen after the incident?

Answer each row of symptoms If nobody had symptoms check this box and go to the conclusion	Self	Child 1	Child 2
Any symptoms affecting your whole body like fever, chills, weakness,or allover body aches/pains?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms affecting your eyes such as tearing, pain, burning or vision problems?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms related to your ears, nose and throat such as pain in your ear, nose or throat, ringing in your ears, difficulty hearing, runny; stuffy, burning or bleeding nose or throat, or odor on your breath?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms related to your skin such as skin irritation, pain, burning, blistering, rash, discoloration, sweating, cuts, bruising bleeding or hair loss?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms related to your kidneys or urinary tract like difficulty or pain with urinating, blood in your urine, or painful kidneys (often feels like lower back pain)?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms related to your nervous system such as headache, dizziness, seizures, numbness, loss of consciousness or balance, difficulty concentrating/remembering/or speaking?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms related to your heart and lungs like breathing problems {including asthma, coughing or wheezing, pneumonia, bronchitis}; blood pressure and heart rate abnormalities; or chest tightness or pain?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Any symptoms related to your muscles, joints, or bones such as pain, weakness, tremors or twitching of muscles, joint swelling or pain, broken or dislocated bone, sprains or whiplash?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Symptoms involving your mood, thought, or sleep such as feeling anxious, afraid, irritable, hopeless, sad, tired, suspicious, trouble sleeping, or having hallucinations?	Yes No Unsure	Yes No Unsure	Yes No Unsure
Symptoms of your stomach or intestines, such as nausea, vomiting or diarrhea, blood in your stool or vomit, abdominal pain, difficulties with bowel movements, or bowel perforation?	Yes No Unsure	Yes No Unsure	Yes No Unsure
25 For radiological and nuclear incidents only If you had repeated vomiting after the incident, how long after the incident [date and time] did it start?	< 1 hour 1-2 hours 3-6 hours > 6 hours Unsure No vomiting	< 1 hour 1-2 hours 3-6 hours > 6 hours Unsure No vomiting	< 1 hour 1-2 hours 3-6 hours > 6 hours Unsure No vomiting
26. Did you or your children receive medical attention?	Yes No Unsure	Yes No Unsure	Yes No Unsure

Conclusion: Thank you for your time. Would you like a copy of this form o mailed or o emailed to you for your records?

[Type here]