Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
APPENDIX 2: SURVEY INSTRUMENTS
Enumerator Initials ______ Household ID#______ Participant ID# ______
Serologic Survey ENGLISH Questionnaire
(NOTE: Questionnaire will be translated into Haitian Creole for use in the field)
Elicit answers from [name of case].
IF ADULT—Read the consent form and proceed to Q.1 if the person agrees to participate.
IF 7-17 YEARS OLD—Ask to speak with the parent or guardian, read the parent/guardian the parental consent form, read the child the assent form, and proceed to Q1if they agree to participate.
IF 2-6 YEARS OLD— Ask to speak with the parent or guardian, read the parent/guardian the parental consent form, and proceed to Q1if they agree to participate.
**Note to Enumerators**
If the participant is a child between the ages of twelve and seventeen, please ask the parent or guardian if they will permit the child to answer questions for themselves. If the parent or guardian does not give permission, the parent or guardian will answer the questions. The parent or guardian will answer questions for children under twelve years old.
VAR |
|
|
|
|
1. Male 2. Female |
|
77. Refused 99. Don’t Know |
|
|
|
1. Yes 0. No skip to Q15 77. Refused 99. Don’t know |
|
(Do not read, circle one)
77. Refused
|
|
1. Yes 0. No 77. Refused 99. Don’t know |
Public reporting burden of
this collection of information is estimated to average 20
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 Information Collection Review Office, 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No skip to Q15 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
77. Refused 99. Don’t know (approximate date) |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
0. No skip to Q24 77. Refused 99. Don’t Know |
|||||||||||||||||||||||||||||||||||||||||||||
|
I’m very sorry to hear that…
77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
88. Other (specify) ________________ 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
77. Refused 88. Other (specify) ______________ 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused |
|||||||||||||||||||||||||||||||||||||||||||||
|
1. Yes 0. No 77. Refused |
|||||||||||||||||||||||||||||||||||||||||||||
|
88. Other (specify) ______________________ 77. Refused 99. Don’t know |
|||||||||||||||||||||||||||||||||||||||||||||
|
|
Thank you very much for your participation.
House GPS Coordinates [TO BE USED ONLY IN PROSPECTIVE SURVEY FOR FOLLOW-UP] |
N:_____________________________________ W:______________________________________________ |
Enumerator Initials ______ Household ID#______ Participant ID# ______
Follow Up Serologic Survey ENGLISH Questionnaire
(NOTE: Questionnaire will be translated into Haitian Creole for use in the field)
Thank you again for your participation in this study. We have a few last questions. All questions in this survey today will ask about things that happened since our last visit with you.
**Note to Enumerators**
If the participant is a child between the ages of twelve and seventeen, please ask the parent or guardian if they will permit the child to answer questions for themselves. If the parent or guardian does not give permission, the parent or guardian will answer the questions. The parent or guardian will answer questions for children under twelve years old.
VAR |
|
|
|
|
1. Yes 0. No skip to Q12 77. Refused 99. Don’t know |
|
(Do not read, circle one)
77. Refused
|
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
77. Refused 99. Don’t know |
Public reporting burden of
this collection of information is estimated to average 10
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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-XXXX).
|
1. Yes 0. No skip to Q12 77. Refused 99. Don’t know |
|
77. Refused 99. Don’t know |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
77. Refused 99. Don’t know (approximate date) |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
1. Yes 0. No 77. Refused 99. Don’t know |
|
0. No go to end 77. Refused 99. Don’t Know |
|
I’m very sorry to hear that…
77. Refused 99. Don’t know |
|
77. Refused 88. Other (specify) ________________ 99. Don’t know |
Thank you very much for your participation.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Brendan Jackson |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |