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pdfForm Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx
Unique ID _____________________________
Follow Up Visit Questionnaire for Men
Section A: To be completed by the Receptionist
1 Unique Study ID:
First, I would like to ask you if your contact information has changed since your last
visit. If someone else answers the phone, we will not tell them any information about the
study. I would like to remind you that your involvement in the study is completely
confidential.
2 Address of residence:
_________________________________________________
3 Village of residence:
_________________________________________________
4 District of residence:
_________________________________________________
5 Telephone:
_________________________________________________
6 Other contact/next of kin:
_________________________________________________
CHECKED BY RECEPTIONIST:
Signature: _____________________
Date: (DD/MM/YYYY)
_____/_____/______
Public reporting burden of this collection of information is estimated to average 15 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).
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Unique ID _____________________________
Section B: To be completed by the Nurse
Thank you for participating in this study. I will be conducting your interview today and
it will last about 10 minutes. I ask all participants in this study the same questions. All
of your answers are confidential. I will mark a response to every question, but if you are
not comfortable answering any question, you can tell me to mark “no answer”. You can
also ask me to go back, or repeat any questions. Are you comfortable proceeding with
the interview now?
Now, I would like to ask you a few questions about the time since we last saw you.
7 Since your last study visit, do you have any new health problems?
01 - Yes
02 - No SKIP TO 9
88 - Don’t know/not sure SKIP TO 9
99 - Refused SKIP TO 9
8 If yes, please specify the new health problems you are experiencing.
MARK ALL THAT APPLY.
Symptom
General (fevers, weight loss, loss of appetite, feeling tired)
Eye problems (itching, ocular redness, eye lid inflammation,
blurred vision, complete loss of vision)
Joint problems
Abdominal Pain
Headache
Neurological (loss of strength in arms, or legs, inability to
balance)
Skin problems (itching, spots)
Psychiatric problems (hallucinations, delusions)
Psychological problems (depression, anxiety)
Other (e.g. loss of hair) SPECIFY ______________________
Yes
No
Refused
9 Since our last meeting, has anyone in your home/household or any of your close contacts
(such as sexual partners or family) gotten Ebola?
01 - Yes
02 - No SKIP TO 11
88 - Don’t know/not sure SKIP TO 11
99 - Refused SKIP TO 11
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Unique ID _____________________________
10 If yes, please specify their relationship to you, and if they recovered or died.
Nurses should capture information on sexual partners, siblings, and children. If more than
one spouse, sibling or child, please list one per row. Write “refused” under relationship if
participant refuses to specify relationship.
No.
Relationship
Did this person
have Ebola before or after you
Outcome
Recovered
Died
Refused
Before
After
Refused
1
2
3
4
5
6
7
11 Since our last meeting, have you participated in sexual activity? Sexual activity includes
oral, vaginal, or anal sex.
01 - Yes
02 - No SKIP TO 14
99 - Refused SKIP TO 14
12 If yes, how often did you use a condom during sex? Choose one.
01 - Never
02 - Some of the time
03 - Every time
88 - Don’t know
99 - Refused
13 How often have you engaged in sexual activities since your last visit?
01 - Every day
02 - 3 or more time a week
03 - 2 times a week
04 - Once per week
05 - Once per month
06 - Once
88 - Don’t know
99 - Refused
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Unique ID _____________________________
14 Since your last visit, did you make any women pregnant?
01 - Yes
02 - No
88 - Don’t know/not sure
99 - Refused
14a If yes, how many times have you made a woman pregnant since your last visit?
___________
estimated
Mark 99 if refused
15 Thank you very much for participating in the survey today. Do you have any other
comments or concerns you would like to share about these topics?
16 Result of questionnaire:
01 - Completed
02 - Partially completed
03 - Participant refused
04 - Other → Specify: _________________
CHECKED BY NURSE:
Signature ________________________
Date:_____/_____/_________
(DD / MM / YYYY)
CHECKED BY RESEARCH ASSISTANT:
Signature ___________________________
Date: _____/_____/________
(DD / MM / YYYY)
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| File Type | application/pdf |
| Author | MARRINAN, Jaclyn Elizabeth |
| File Modified | 2016-03-14 |
| File Created | 2016-01-30 |