A5 Page
Form
Approved
OMB
No. 0920-XXXX
Exp.
Date xx/xx/xxxx
[COMPLETE THIS PAGE AT STUDY ENROLLMENT AFTER INFORMED CONSENT]
A1. Participant’s unique study ID number: ____________________
A2. Study enrollment date: _____________________
A3. Participant’s sex (male or female): _____________________
A4. Participant’s age at study enrollment (in years): _____________________
A5. Participant’s home residency (village/district/subcounty): _____________________
A6. Participant’s contact information (address/es): ______________________________________________________
A7. Participant’s contact information (telephone/s): ________________________________________
A8. Participant’s contact information (email/s): _____________________________________________
A9. Participant’s contact information (other): _____________________________________________
[CONFIRM THESE DETAILS USING ETU DISCHARGE CERTIFICATE, IF POSSIBLE]
A10. Name/clinical ID of ETU where participant was treated for EVD: _____________________
A11. Date of ETU admission: _____________________
A12. Date of ETU discharge: _____________________
A13. Date of 1st blood test positive for Ebola: _____________________
A14. Date of 1st blood test negative for Ebola: _____________________
A15. Date of 2nd blood test negative for Ebola: _____________________
Public reporting burden of
this collection of information is estimated to average 30
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).
Inquire if the participant was part of a research study. For example, did they receive an experimental drug during their illness, such as ZMapp, did they receive convalescent plasma during their illness, did they receive a vaccine to prevent Ebola infections as part of the STRIVE trial, or did they give convalescent plasma after recovering from their illness.
A16. Was the participant included in a clinical trial related to his/her illness with Ebola Virus Disease?
____ No
____ Yes
____ Don’t know
A17. If yes, specify the name of the trial_____________
A18. If known, specify what intervention that he/she received___________
A19. Today’s date: ____________________
A20. Interviewer name/initials: _____________________
Thank you for participating in this study. I will be conducting your interview today, and it will last about 15 minutes. I ask all participants in this survey 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?
First, I would like to ask you a few questions about yourself and your family.
B1.
How many years of school have you completed? Choose one.
___ Less than six years
___ Six to eight years
___ More than eight years
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
B2.
About how much money do you normally earn in a month? Fill in the blank.
Amount in Leones (SLL): __(will create categories)_________________
___ Don’t know/not sure
___ No answer
B3.
Who do you live with? Mark all that apply.
___ Alone
___ With friend/s or roommate/s
___ With spouse or partner
___ With parents or extended family member/s
___ Other (specify) ____________
___ Don’t know/not sure
___ No answer
B4.
How many people live in your household, including yourself?
___ Number
B5.
What is your current relationship status? Choose one.
___ Single
___ Long-term relationship
___ Married
___ Separated, Divorced, or Widowed
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
To be asked of women only (questions B6, B7, and B8):
B6.
How many times have you been pregnant? Choose one.
___ I have never been pregnant
___ One time
___ Two times
___ Three times
___ More than three times (specify) _______________
___ Don’t know/not sure
___ No answer
B7.
Is there any chance you are pregnant today? Choose one.
___ No chance
___ Yes, I am pregnant, and my baby is due on (specify date) _______________
___ Don’t know/not sure
___ No answer
B8.
In the past 7 days, have you breastfed (provided your breast milk to any children, or allowed a child to suckle at your breast)? Choose one.
___ No
___ Yes
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer / prefer not to answer
For men and women:
B9.
Do you and your main sexual partner use any method of contraception to avoid pregnancy?
__Yes
__No
__No answer
__Don’t know
__Don’t remember
__No sexual partner
If answered yes to the previous question, which method/s are you using?
___ Condom
___ Pill/oral contraception
___ Intrauterine device
___ Injection/hormone shot
___ Other
Now I would like to ask some questions about the time when you were sick with Ebola.
C1.
What was the month and approximate day or date when you first began to feel sick from Ebola? It is ok to guess if you are not sure of the exact date.
___________
C2.
When you were sick with Ebola, did you have vomiting? Choose one.
___ No vomiting
___ Yes, I vomited
___ Don’t know/not sure
___ No answer
C3.
When you were sick with Ebola, did you have diarrhea? Choose one.
___ No diarrhea
___ Yes, I had diarrhea
___ Don’t know/not sure
___ No answer
C4.
When you were sick with Ebola, were you ever too sick to get up to relieve yourself in the toilet (or other usual location)? Choose one.
___ No
___ Yes
___ Don’t know/not sure
___ No answer
C5.
When you were sick with Ebola, were you ever too sick to drink anything for a day or more? Choose one.
___ No
___ Yes
___ Don’t know/not sure
___ No answer
C6.
Were you pregnant during your Ebola illness?
___ No / I am a man
___ Yes
___ Don’t know/not sure
___ No answer
C7.
If yes, did the baby live? Choose one.
___ I was not pregnant during my Ebola illness / I am a man
___ Yes, I am still pregnant now
___ Yes, the baby was born and is living now
___ No, the baby was born alive but died later
___ No, the baby was not born alive / miscarriage / stillbirth
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
C8.
Has anyone else in your family had Ebola?
___ No
___ Yes
___ Don’t know/not sure
___ No answer
If yes, how many of your family members had EBOLA,
____#Please specify their relationship to you
1.
2.
3.
Next I would like to ask about your health today.
D1.
How is your overall health and wellbeing now, compared to before you had Ebola?
___ My overall health now is back to normal or the same as before I had Ebola
___ My overall health now is worse than before I had Ebola
___ My overall health now is better than before I had Ebola
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D2.
Since you recovered from Ebola, do you have any new health problems?
___ No, not that I know of
___ Yes
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D3.
If answer yes to the above question, please specify
___ Eye/vision problems
___ Muscle pains
___ Joint pains
___ Weight loss
___ Feeling depressed (unable to concentrate, feeling very sad, poor appetite, other)
___ Sexual problems (specify) _______________
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D4 Since recovering from Ebola, do you have the same level of sexual desire as before you were sick?
___ No
___ Yes
___ Don’t know
___ No answer/prefer not to answer
For men only:
D5 Since recovering from Ebola, have you had any difficult getting or maintaining an erection, or ejaculating?’
___ No
___ Yes
___ Don’t know
___ No answer/prefer not to answer
For men and women:
D6.
Do you have tuberculosis? Choose one.
___ No, not that I know of
___ Yes, I have tuberculosis
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D7.
Do you have diabetes? Choose one.
___ No, not that I know of
___ Yes, I have diabetes
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D8.
Have you ever had a test for HIV? Choose one.
___ No, not that I know of
___ Yes, I have been tested for HIV
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D9.
Do you have HIV? Choose one.
___ No, not that I know of
___ Yes, I have HIV
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D10.
If you have HIV, are you taking any HIV medications (antiretrovirals or ARVs)?
___ No, they weren’t offered to me
___ No, I can’t afford the cost
___ No, I don’t want to take them
___ Yes, I am taking HIV medications
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
D11.
Do you now have any symptoms of a possible sexually transmitted infection, such as genital (penile, vaginal, or anal) ulcers, sores, lesions, warts, or discharge?
___ No, I do not have any of those symptoms now
___ Yes, I have one or more of those symptoms now
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
The following section E includes questions that should only be asked to men:
In addition to questions about your health we will ask you how often you have engaged in sexual activity since recovery, if at all. The reason for us asking this questions is to understand more about how any viral remains in your semen could relate to how often you have ejaculated. These questions may disturb you and you can choose not to answer them or any questions that disturb you, at any time.
To be asked to men only:
E1
Since recovering from Ebola, have you resumed sexual activity?
__No (stop here, go to section F below)
__Yes (continue to the next question E2)
If yes:
E2 What was the date/ month you resumed sexual activities? It is okay to guess.
Fill in the blank.
Date: ___________________
___ Don’t know/not sure
___ No answer/prefer not to answer
E3
How often have you engaged in sexual activities with a partner since recovery from Ebola?
__every day
__> 3 times a week
__3 times weekly
__< 3 times weekly
__once every week
__once/one-off meeting
__Never
__No answer/prefer not to answer
To finish the interview we would like to understand what kind of information and advise you received when you left the ETU, and how you have related to that information on sexual activity and also breast-feeding. It is important to us to understand if the information is clear and easy to understand and follow, or if it is sometimes not provided, forgotten easily or difficult to understand or follow.
For men and women:
F1.
Before today, did you receive information from anyone about when it is safe for someone who had Ebola to have sex? Mark all that apply.
___ No
___ Yes, from friends or family members
___ Yes, from leaders in my community
___ Yes, from staff at the clinic where I was treated / other doctors or medical professionals
___ Yes, from public health or government officials
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
F2.
What advice did you hear about when it is safe for someone who had Ebola to have sex? Mark all that apply.
___ Don’t remember hearing any advice
___ Abstain from sex for ____ days or months
___ Use condoms for ____ days or months
___ Abstain or use condoms for ___ days or months
___ Safe to have unprotected sexual intercourse immediately
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
F3.
Before today, did you receive information from anyone about when it is safe for someone who has had Ebola to breastfeed? Mark all that apply.
___ No
___ Yes, from friends or family members
___ Yes, from leaders in my community
___ Yes, from staff at the clinic where I was treated / other doctors or medical professionals
___ Yes, from public health or government officials
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
F4 Did you engage in sexual activity following three first months after recovering from Ebola Ebola recovery
Yes (continue)
_ No (Go to G1 or finish the interview)
___ Don’t know/not sure (Go to G1 or finish the interview)
___ No answer/prefer not to answer (Go to G1 or finish the interview)
If yes:
During the three first months after recovering from Ebola, how often did you use a condom during sex? Choose one.
___ Never
___ Some of the time
___ Every time
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer/prefer not to answer
F5 Where did you get the condoms you used?
Mark all that apply.
___ I did not use any condoms
___ I got them at the ETU where I was treated
___ Free donation from another organization
___ I bought them from a shop/market/pharmacy
___ Gift from a friend/family member/loved one
___ I already had them before I got sick
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
The following question (G2+3) will be asked of lactating women only:
G1.
What advice did you hear about when it is safe for someone who has had Ebola to breastfeed? Mark all that apply.
___ Don’t remember hearing any advice
___ Resume/continue breastfeeding as soon as possible
___ Do not breastfeed for 2 months
___ Give the child formula instead of breast milk
___ Give the child animal milk instead of breast milk
___ Give the child water instead of breast milk
___ Other (specify) _______________
___ Don’t know/not sure
___ No answer
G2.
Did you receive any ready-to-use infant formula (RUIF) when you were discharged from the ETU? Choose one.
___ No
___ Yes
___ Other (please specify) _____________
___ Don’t know/not sure
___ No answer
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?
Specify ___________________________________
For staff use only |
||
|
Date |
Staff initials |
Questionnaire administered |
|
|
Questionnaire checked for completeness |
|
|
Data entered |
|
|
Data entry checked for completeness |
|
|
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |