Form New form New form Attachment F CDI Health Interview

Clostridium difficile Infection (CDI) Surveillance

Attachment F _ CDI Health Interview Attachment

Telephone Interview

OMB: 0920-0892

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Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx




Community-associated Clostridium difficile Infection (CDI) Surveillance Health Interview


Call Log


Telephone number:__________________________________


Date Time 1 Time 2

(mm/dd/yy) (circle am or pm)

Day 1: _________ ________ am/pm ________ am/pm

Day 2: _________ ________ am/pm ________ am/pm

Day 3: _________ ________ am/pm ________ am/pm

Day 4: _________ ________ am/pm ________ am/pm

Day 5: _________ ________ am/pm ________ am/pm


Call no more than 10 times with 2 attempts per day for 5 days over a two week period: at least one weekday between 5-8pm; and one weekend day (Sat: 9am-6pm or Sun: 1pm-8pm).



Call back at _____________(day) ________________(time)

Call back at _____________(day) ________________(time)


Call back at _____________(day) ________________(time)













Public reporting burden of this collection of information is estimated to average 40 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).


Enrollee Interview – This portion will be Transferred to CDC


Section 1: Identifiers (to be filled out by EIP staff)


  1. Patient ID: _________________________________

  2. State ID: __________________________________

  3. Provider ID: ________________________________

  4. Lab ID: ___________________________________

  5. Specimen ID (accession number): ___________________________________


  1. Specimen Collection Date _____/_____/______

(mm/dd/yyyy)

  1. Age 


  1. Sex Male Female


HAVE A CALENDAR IN FRONT OF YOU.



I will ask you questions about [your/your child’s] illness, healthcare contacts, household contacts, other exposures and medical history. It may be difficult to remember, but I would like your best guess for each question. Because I will be asking about specific dates around the time [your/your child’s] diarrhea began (initial specimen collection date), it may be helpful for you to have a calendar or datebook in front of you. Do you need a minute to go get any of these items?

If interviewees gravitate toward answering that they don’t know/are unsure how to answer questions, encourage them to try to remember one way or another. [See Interviewer Manual]




Specimen collection date: _____/_____/______

(mm/dd/yyyy)


8 weeks before specimen collection _____/_____/______

12 weeks before specimen collection _____/_____/______




Date diarrhea began: _____/_____/______

(mm/dd/yyyy)


1 week before diarrhea began _____/_____/______

2 weeks before diarrhea began_____/_____/______

12 weeks before diarrhea began _____/_____/______




















Section 2: Screening Questions (Please Refer to the screening Form. if patient eligible please proceed)




Section 3: Illness Questions

Now I will ask you questions about [your/your child’s] illness.


11. Did [you/your child] have diarrhea at the time [your/your child’s] stool specimen was collected on [specimen collection date_____/_____/______]? We define diarrhea as 3 or more loose stools in a 24 hour period.

Yes 1 (Go to Q. 11A)

No 2 (Go to Q. 11D)

Don’t know/Not sure 7 (Go to Q.12 and use initial date of specimen collection as reference date.)

Refused 9 (Go to Q.12 and use initial date of specimen collection as reference date.)


11A. If yes, Do [you/your child] remember when [your/your child’s] diarrhea began?

Yes 1 (If Yes –fill in date diarrhea began)

No 2 (fill in date diarrhea began with date of specimen collection.)

Don’t know/Not sure 7 (fill in date diarrhea began with date of specimen collection.)

Refused 9 (fill in date diarrhea began with date of specimen collection.)


Date diarrhea began: _____/_____/______

(mm/dd/yyyy)


1 week before _____/_____/______

2 weeks before _____/_____/______

12 weeks before _____/_____/______










11B. How many days did [your/your child’s] diarrhea last? 


11C. On the worst day of [your/your child’s] diarrhea, what was the approximate number of stools [you/your child] had in a 24-hour period? (Go to Q.12)

3-<5 stools 1

5-10 stools 2

>10 stools 3

Don’t know/Not sure 7

Refused 9


11D. If no to Q.11, why was [your/your child’s] stool tested? (Go to Q.12) ____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________


12. Did [you/your child] have any of the following symptoms associated with [your/your child’s] C. difficile illness?

[READ LIST] Yes No DK/NS Refused

Bloody stools 1 2 7 9

Fever 1 2 7 9

Nausea 1 2 7 9

Vomiting 1 2 7 9

Abdominal pain 1 2 7 9

Other 1 2

Specify:_­­­­­______________________________________________________________


13. Were [you/your child] hospitalized overnight for [your/your child’s] C. difficile illness?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


14. At the time of [your/your child’s] C. difficile diagnosis, were [you/your child] told by a doctor or healthcare provider that [you/your child] had any other stomach [enteric, gastrointestinal] infection?

Yes 1

No 2 (Go to Q.15)

Don’t know/Not sure 7 (Go to Q.15)

Refused 9 (Go to Q.15)

14A. If yes, what was the name of the infection?


[Read list if necessary] Yes No DK/NS Refused

Campylobacter 1 2 7 9

E. coli 1 2 7 9

Listeria 1 2 7 9

Salmonella 1 2 7 9

Shigella 1 2 7 9

Vibrio 1 2 7 9

Yersinia 1 2 7 9

Cryptosporidium 1 2 7 9

Giardia 1 2 7 9

Other 1 2

Specify:____________________________________________________________________________



Section 4: Healthcare contacts

Now I will ask you questions about [you/your child] healthcare contacts in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), which would be from [12 weeks before date] to [date diarrhea began], and ALSO in the 1 week before [your/your child’s] diarrhea began (initial specimen collection date), which would be from [1 week before date] to [date diarrhea began].


15. Did [you/your child] receive care in any doctor’s office, dentist, hospital, nursing home, or any other medical facility in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2 (Go to Q.16)

Don’t know/Not sure 7 (Go to Q.16)

Refused 9 (Go to Q.16)


15A. If yes, was it in the 1 week before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


15B. What type of facility did [you/your child] visit in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

If yes, in the

1 week before

[READ LIST] Yes No DK/NS Refused Yes No

Hospital 1 2 7 9 1 2

Emergency department 1 2 7 9 1 2

Doctor’s office 1 2 7 9 1 2

Dentist 1 2 7 9 1 2

Long term care (skilled nursing facility) 1 2 7 9 1 2

Hemodialysis facility 1 2 7 9 1 2

Other facility 1 2 1 2

Specify:________________________________________________________



15C. During those visits in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date) did [you/your child] have any of the following procedures performed?

If yes, in the

1 week before

[READ LIST] Yes No DK/NS Refused Yes No

Upper Endoscopy 1 2 7 9 1 2

(Did the doctors pass a tube through

your mouth or nose into your stomach?)

Colonoscopy or Sigmoidoscopy 1 2 7 9 1 2

(Did the doctors pass a tube into your

rectum to look into your colon/bowel?)

X-ray that required GI Prep 1 2 7 9 1 2

(Did you have an X-ray performed where

you had to swallow something first?)

Chemotherapy 1 2 7 9 1 2

Surgery in an operating room 1 2 7 9 1 2

If yes, did [you/your child] take an

antibiotic before surgery? 1 2 7 9 1 2

Oral Surgery 1 2 7 9 1 2

If yes, did [you/your child] take an

antibiotic before surgery? 1 2 7 9 1 2

Other procedures 1 2 1 2

Specify:________________________________________________________________________



16. Did [you/your child] visit or accompany anyone to a doctor’s office, dentist, hospital, nursing home, or any other medical facility in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2 (Go to Q.17)

Don’t know/Not sure 7 (Go to Q.17)

Refused 9 (Go to Q.17)


16A. If yes, was it in the 1 week before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


16B. What type of facility did [you/your child] visit or accompany someone to in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

If yes, in the

1 week before

[READ LIST] Yes No DK/NS Refused Yes No

Hospital 1 2 7 9 1 2

Emergency department 1 2 7 9 1 2

Doctor’s office 1 2 7 9 1 2

Dentist 1 2 7 9 1 2

Long term care (skilled nursing facility) 1 2 7 9 1 2

Hemodialysis facility 1 2 7 9 1 2

Other facility 1 2 1 2

Specify:___________________________________________________________________



Section 5: Household contacts

The next few questions are about [you/your child] and persons who lived with [you/your child].


17. Including [yourself/your child], how many persons were spending at least 50% of their nights in [your/your child’s]

home in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)? 

(If patient lived alone, only one person in the household, go to Q.22)


18. How many household members were in each of these age groups? [List number of people in each group]

Ages <1 1 to 3 4 to 10 11 to 18 19 to 34 35 to 59 60+


If children <4 years of age are present in household go to Q.18A; if no children <4 years of age, go to Q.19

18A. Were any of the children in diapers?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


18B. Did any of the children attend a group childcare setting or daycare?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


18B1. If yes, what type of childcare setting? [Read list if necessary]

Home 1

Center 2

Other 3

Specify:__________________________________________________

Don’t know/Not sure 7

Refused 9


19. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did any household member stay overnight in a hospital?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9

20. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did any household member stay overnight in another healthcare institution (long-term care facility, nursing home, chronic care, or rehab unit)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


21. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did anyone else in [your/your child’s] household have diarrhea?

Yes 1

No 2 (Go to Q.22)

Don’t know/Not sure 7 (Go to Q.22)

Refused 9 (Go to Q.22)

21A. If yes, did [you/your child] assist this person with toileting (including diaper changes)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


21B. Was this person diagnosed with C. difficile?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


22. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [your/your child’s] household have any pets?

Yes 1

No 2 (Go to Q.23)

Don’t know/Not sure 7 (Go to Q.23)

Refused 9 (Go to Q.23)


22A. If yes, which of the following pets:

[READ LIST] Yes No DK/NS Refused

Dog 1 2 7 9

Cat 1 2 7 9

Other pet 1 2

Specify: _____________________________________________________________________


22B. Did [your/your child’s] pet have diarrhea in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


23. Did [you/your child] work or volunteer, in any capacity, at a hospital, other medical facility, or in any facility where patient care is provided in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2 (Go to Q.24)

Don’t know/Not sure 7 (Go to Q.24)

Refused 9 (Go to Q.24)


23A. If yes, what type of healthcare setting?

[READ LIST] Yes No DK/NS Refused

Hospital 1 2 7 9

Emergency department 1 2 7 9

Doctor’s office 1 2 7 9

Dentist 1 2 7 9

Long term care (skilled nursing facility) 1 2 7 9

Hemodialysis facility 1 2 7 9

Other facility 1 2

Specify:________________________­­­____________________________________________________


23B. Did [your/your child’s] job involve direct patient care?

Yes 1

No 2 (Go to Q.24)

Don’t know/Not sure 7 (Go to Q.24)

Refused 9 (Go to Q.24)


23B1. If yes, what was [your/your child’s] main job?

____________________________________________________________________________________

Job Code- (Fill in job code after interview is finished)


(If patient lived alone, only one person in the household, go to Q.25)


24. Did any of [your/your child’s] household members work at or volunteer, in any capacity, at a hospital, other medical facility, or in any facility where patient care is provided in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2 (Go to Q.25)

Don’t know/Not sure 7 (Go to Q.25)

Refused 9 (Go to Q.25)


24A. If yes, what type of healthcare setting?

(READ LIST) Yes No DK/NS Refused

Hospital 1 2 7 9

Emergency department 1 2 7 9

Doctor’s office 1 2 7 9

Dentist 1 2 7 9

Long term care (skilled nursing facility) 1 2 7 9

Hemodialysis facility 1 2 7 9

Other facility 1 2

Specify:__________________________________________________________________________


24B. Did their job involve direct patient care?

Yes 1

No 2 (Go to Q.25)

Don’t know/Not sure 7 (Go to Q.25)

Refused 9 (Go to Q.25)


24B1. If yes, what was their main job?

____________________________________________________________________________________

Job Code- (Fill in job code after interview is finished)


25. Did [you/your child] work or volunteer in a veterinary clinic, on a farm, or in other profession caring for animals in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


(If patient lived alone, only one person in the household, go to Q.27)


26. Did any of [your/your child’s] household members work or volunteer in a veterinary clinic, on a farm, or in other profession caring for animals in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9



Section 6: Other Exposures

I’d like to change direction now and ask you about some other exposures [you/your child] may have had.


27. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] travel outside of the US?

Yes 1

No 2 (Go to Q.28)

Don’t know/Not sure 7 (Go to Q.28)

Refused 9 (Go to Q.28)


27A. If yes, where did [you/your child] travel to and when did [you/your child] travel?

Country: ____________________ Date: ____/____/_____ to Date: ____/____/_____

Country: _____________________ Date: ____/____/_____ to Date: ____/____/_____

Country: _____________________ Date: ____/____/_____ to Date: ____/____/_____


28. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] visit a farm, petting zoo, state, county, or local fair, or other events at which animals were present?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9


29. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] have any contact with any of the following live animals?

[READ LIST] Yes No DK/NS Refused

Chicken/baby chick/turkey 1 2 7 9

Cow/bull/steer/calf 1 2 7 9

Goat/sheep/lamb 1 2 7 9

Pig 1 2 7 9

Horse 1 2 7 9


30. In a typical week how frequently do [you/your child] consume the following foods?

[READ LIST] Often Sometimes Rarely Never DK/NS Refused

Beef 1 2 3 4 7 9

Pork 1 2 3 4 7 9

Lamb 1 2 3 4 7 9

Chicken 1 2 3 4 7 9

Turkey 1 2 3 4 7 9

Deli meats 1 2 3 4 7 9

(pre-sliced or sliced at meat counter)

Eggs 1 2 3 4 7 9

Milk 1 2 3 4 7 9



Section 7: Medical History

The next set of questions are about medications [you/your child] may have been taking in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date). Medicine bottles or records may help you remember about specific medications. Would you like to gather this information before we go on?


31. Did [you/your child] take any antibiotics in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)?

Yes 1

No 2 (Go to Q.32)

Don’t know/Not sure 7 (Go to Q.32)

Refused 9 (Go to Q.32)

31A. If yes, how was this antibiotic obtained? [Read list if necessary]

Prescribed for the problem that [you/ your child] had 1

Borrowed from a friend or relative 2

Prescribed in the past for another problem 3

Other 4

Specify: ______________________________________________________

Don’t know/Not sure 7

Refused 9


31B. Why did [you/your child] take this antibiotic?

[DO NOT READ LIST] Yes No DK/NS Refused

Ear, sinus, upper respiratory infection 1 2 7 9

Bronchitis/ pneumonia 1 2 7 9

Urinary tract infection 1 2 7 9

Skin infection 1 2 7 9

Acne 1 2 7 9

Dental cleaning/oral surgery 1 2 7 9

Surgery 1 2 7 9

Other 1 2

Specify:____________________________________________


31C. Which antibiotic(s) did [you/your child] take in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date)? [DO NOT READ LIST]


If yes, in the If yes, in the

2 weeks before 2 weeks before

Yes Yes No Yes Yes No

Amoxicillin 1 1 2 Floxin 1 1 2

Amoxicillin/Clavulanate 1 1 2 Keflex 1 1 2

Ampicillin 1 1 2 Keftab 1 1 2

Augmentin 1 1 2 Levofloxacin 1 1 2

Azithromycin 1 1 2 Levoquin 1 1 2

Bactrim 1 1 2 Monurol 1 1 2

Biaxin 1 1 2 Metronidazole 1 1 2

Ceclor 1 1 2 Norfloxacin or Norflox 1 1 2

Cefaclor 1 1 2 Ofloxacin or Oflox 1 1 2

Cefadroxil 1 1 2 Omnicef 1 1 2

Cefdinir 1 1 2 Penicillin or Pen VK 1 1 2 Ceftin 1 1 2 Pediazole 1 1 2

Cefixime 1 1 2 Septra 1 1 2

Cefuorixime 1 1 2 Suprax 1 1 2

Cefzil 1 1 2 Tetracycline 1 1 2

Cefprozil 1 1 2 Tequin 1 1 2

Cephalexin 1 1 2 Trimox 1 1 2

Cephradine 1 1 2 Trimethoprim/Sulfa 1 1 2

Ciprofloxacin or Cipro 1 1 2 Vancomycin 1 1 2

Clarithromyc 1 1 2 Zagam 1 1 2

Cleocin 1 1 2 Zithromax or Z-Pak 1 1 2

Clindamycin 1 1 2

Dapsone 1 1 2 Other antibiotic 1 1 1 2

Doxycycline 1 1 2 Specify: _______________________________

Duricef 1 1 2 Other antibiotic 2 1 1 2

Erythromycin 1 1 2 Specify: _______________________________

Erythromycin/sulfa 1 1 2 Don’t know/Not sure 1

Flagyl 1 1 2 Refused 1


32. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any acid-reducing medications to treat excessive stomach acid, heartburn, or gastroesophageal reflux disease (GERD)? We define regular use as use of the product at least 3 days per week. Such medications might include Tums, Maalox, Mylanta, Tagamet, Zantac, Prilosec, or Nexium.

Yes 1

No 2 (Go to Q.33)

Don’t know/Not sure 7 (Go to Q.33)

Refused 9 (Go to Q.33)


32A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date).

If yes, in the

2 weeks before

[Read list if necessary] Yes No DK/NS Refused Yes No

Aciphex/rabeprazole 1 2 7 9 1 2

Alka-Seltzer 1 2 7 9 1 2

Maalox 1 2 7 9 1 2

Mylanta 1 2 7 9 1 2

Nexium/esomeprazole 1 2 7 9 1 2

Pepcid/famotidine 1 2 7 9 1 2

Prevacid/lansoprazole 1 2 7 9 1 2

Prilosec/omeprazole 1 2 7 9 1 2

Protonix/pantoprazole 1 2 7 9 1 2

Rolaids 1 2 7 9 1 2

Tums 1 2 7 9 1 2

Tagamet/cimetidine 1 2 7 9 1 2

Zantac/ranitidine 1 2 7 9 1 2

Other 1 2 1 2

Specify:_______________________________________________________


33. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any laxatives? We define regular use as use of the product at least 3 days per week

Yes 1

No 2 (Go to Q.34)

Don’t know/Not sure 7 (Go to Q.34)

Refused 9 (Go to Q.34)


33A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date). This does not include the use of supplemental fiber or Metamucil.

If yes, in the

2 weeks before

[Read list if necessary] Yes No DK/NS Refused Yes No

Alophen 1 2 7 9 1 2

Aqualax 1 2 7 9 1 2

Bisacodyl 1 2 7 9 1 2

Calube 1 2 7 9 1 2

Colace 1 2 7 9 1 2

Correctol 1 2 7 9 1 2

Docusate 1 2 7 9 1 2

Dulcolax 1 2 7 9 1 2

Other 1 2 1 2

Specify:______________________________________________________________


34. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any anti-diarrheal drugs such as Imodium or Pepto-Bismol? We define regular use as use of the product at least 3 days per week


Yes 1

No 2 (Go to Q.35)

Don’t know/Not sure 7 (Go to Q.35)

Refused 9 (Go to Q.35)


34A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date).

If yes, in the

2 weeks before

[Read list if necessary] Yes No DK/NS Refused Yes No

Antispas 1 2 7 9 1 2

Bentylol 1 2 7 9 1 2

Dimor 1 2 7 9 1 2

Imodium 1 2 7 9 1 2

Kaopectate 1 2 7 9 1 2

Levsin 1 2 7 9 1 2

Loperamide 1 2 7 9 1 2

Lopex 1 2 7 9 1 2

Lomotil 1 2 7 9 1 2

Pepto-Bismol 1 2 7 9 1 2

Other 1 2 1 2

Specify:______________________________________________________________


35. In the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] regularly take any non-steroidal anti-inflammatory drugs, or NSAIDS, for fever or pain? We define regular use as use of the product at least 3 days per week. This would include drugs such as aspirin, naproxen, or ibuprofen but does not include Tylenol, or acetaminophen.

Yes 1

No 2 (Go to Q.36)

Don’t know/Not sure 7 (Go to Q.36)

Refused 9 (Go to Q.36)


35A. If Yes, please specify which medicine [you/your child] regularly took in the 12 weeks before [your/your child’s] diarrhea began (initial specimen collection date).

If yes, in the

2 weeks before

[Read list if necessary] Yes No DK/NS Refused Yes No

Advil or ibuprofen 1 2 7 9 1 2

Aspirin 1 2 7 9 1 2

Naproxen or Aleve 1 2 7 9 1 2

Other 1 2 1 2

Specify:______________________________________________________________


Now I am going to ask you about medical conditions [you/your child] may have had in the past 2 years.


36. In the 2 years before [your/your child’s] diarrhea began (initial specimen collection date), did [you/your child] have any of the following medical conditions? [READ LIST – including information in parentheses]


Yes No DK/NS Refused Year of diagnosis

Diabetes 1 2 7 9 _______

High blood pressure 1 2 7 9 _______

Chronic renal (kidney) failure 1 2 7 9 _______

If yes, are [you/your child] on dialysis or

awaiting dialysis? 1 2 7 9 _______

Chronic pulmonary disease 1 2 7 9 _______

(COPD, emphysema, asthma)

Organ transplant 1 2 7 9 _______

Bone marrow transplant 1 2 7 9 _______

Stomach ulcer (peptic/gastric ulcer disease) 1 2 7 9 _______

Stomach surgery 1 2 7 9 _______

Chronic Hepatitis C infection 1 2 7 9 _______

Chronic Hepatitis B infection 1 2 7 9 _______

Sickle cell disease (not sickle cell trait) 1 2 7 9 _______

Lupus 1 2 7 9 _______

Rheumatoid arthritis 1 2 7 9 _______

Inflammatory bowel disease 1 2 7 9 _______

(Crohn’s disease, Ulcerative colitis)

Heart attack 1 2 7 9 _______

Congestive heart failure 1 2 7 9 _______

Stroke 1 2 7 9 _______

Peripheral vascular disease 1 2 7 9 _______

(intermittent claudication, gangrene, peripheral

arterial bypass)

Leukemia or lymphoma 1 2 7 9 _______

Cancer (e.g. breast, prostate, lung cancer) 1 2 7 9 _______

Other 1 2 _______

Specify:__________________________________________________________________________



Section 8: Demographics

Now I would like to ask you a few final questions.


37. How would you describe [your/your child’s] race? [Read list if necessary]

Respondent may choose more than one race

American Indian or Alaskan native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other, Specify: _________________________________________

Unknown

Refused


38. Are [you/your child] of Hispanic or Latino origin?

Yes

No

Don’t know

Refused


That was my last interview question. Thank you very much for your time and participation!


39. Comments: ______________________________________________________________________________


___________________________________________________________________________________________


___________________________________________________________________________________________


___________________________________________________________________________________________


___________________________________________________________________________________________


40. Interview Completed? Yes No


41. Date of interview: ____/____/______

(mm/dd/yyyy)


42. Interviewer initials: ______________


Health Interview Appendix—Job Codes


OFFICE OF MANAGEMENT AND BUDGET - 1998 Standard Occupational Classification


29-0000 Healthcare Practitioners and Technical Occupations

29-1000 Health Diagnosing and Treating Practitioners

29-1010 Chiropractors

29-1020 Dentists

29-1021 Dentists, General

29-1022 Oral and Maxillofacial Surgeons

29-1023 Orthodontists

29-1024 Prosthodontists

29-1029 Dentists, All Other Specialists

29-1030 Dietitians and Nutritionists

29-1040 Optometrists

29-1050 Pharmacists

29-1060 Physicians and Surgeons

29-1061 Anesthesiologists

29-1062 Family and General Practitioners

29-1063 Internists, General

29-1064 Obstetricians and Gynecologists

29-1065 Pediatricians, General

29-1066 Psychiatrists

29-1067 Surgeons

29-1069 Physicians and Surgeons, All Other

29-1070 Physician Assistants

29-1080 Podiatrists

29-1110 Registered Nurses

29-1120 Therapists

29-1121 Audiologists

29-1122 Occupational Therapists

29-1123 Physical Therapists

29-1124 Radiation Therapists

29-1125 Recreational Therapists

29-1126 Respiratory Therapists

29-1127 Speech-Language Pathologists

29-1129 Therapists, All Other

29-1130 Veterinarians

29-1190 Miscellaneous Health Diagnosing and Treating Practitioners

29-1199 Health Diagnosing and Treating Practitioners, All Other

29-2000 Health Technologists and Technicians

29-2010 Clinical Laboratory Technologists and Technicians

29-2011 Medical and Clinical Laboratory Technologists

29-2012 Medical and Clinical Laboratory Technicians

29-2020 Dental Hygienists

29-2030 Diagnostic Related Technologists and Technicians

29-2031 Cardiovascular Technologists and Technicians

29-2032 Diagnostic Medical Sonographers

29-2033 Nuclear Medicine Technologists

29-2034 Radiologic Technologists and Technicians

29-2040 Emergency Medical Technicians and Paramedics

29-2050 Health Diagnosing and Treating Practitioner Support Technicians

29-2051 Dietetic Technicians

29-2052 Pharmacy Technicians

29-2053 Psychiatric Technicians

29-2054 Respiratory Therapy Technicians

29-2055 Surgical Technologists

29-2056 Veterinary Technologists and Technicians

29-2060 Licensed Practical and Licensed Vocational Nurses

29-2070 Medical Records and Health Information Technicians

29-2080 Opticians, Dispensing

29-2090 Miscellaneous Health Technologists and Technicians

29-2091 Orthotists and Prosthetists

29-2099 Health Technologists and Technicians, All Other

29-9000 Other Healthcare Practitioners and Technical Occupations

29-9010 Occupational Health and Safety Specialists and Technicians

29-9011 Occupational Health and Safety Specialists

29-9012 Occupational Health and Safety Technicians

29-9090 Miscellaneous Health Practitioners and Technical Workers

29-9091 Athletic Trainers

29-9099 Healthcare Practitioners and Technical Workers, All Other

31-0000 Healthcare Support Occupations

31-1000 Nursing, Psychiatric, and Home Health Aides

31-1010 Nursing, Psychiatric, and Home Health Aides

31-1011 Home Health Aides

31-1012 Nursing Aides, Orderlies, and Attendants

31-1013 Psychiatric Aides

31-2000 Occupational and Physical Therapist Assistants and Aides

31-2010 Occupational Therapist Assistants and Aides

31-2011 Occupational Therapist Assistants

31-2012 Occupational Therapist Aides

31-2020 Physical Therapist Assistants and Aides

31-2021 Physical Therapist Assistants

31-2022 Physical Therapist Aides

31-9000 Other Healthcare Support Occupations

31-9010 Massage Therapists

31-9090 Miscellaneous Healthcare Support Occupations

31-9091 Dental Assistants

31-9092 Medical Assistants

31-9093 Medical Equipment Preparers

31-9094 Medical Transcriptionists

31-9095 Pharmacy Aides

31-9096 Veterinary Assistants and Laboratory Animal Caretakers

31-9099 Healthcare Support Workers, All Other














Public reporting burden of this collection of information is estimated to average 45 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 current 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).















Health Interview page 2 of 19


File Typeapplication/msword
File TitleBackground and Justification
Authorfwu4
Last Modified Byziy6
File Modified2011-03-01
File Created2011-03-01

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