First Follow-Up Survey - English

Persistence of Zika virus in semen and urine of adult men in the United States with confirmed Zika virus infection

Att. D1 -- First Follow-Up Survey

Follow-Up Survey

OMB: 0920-1139

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Form Approved

OMB Control No. 0920-XXXX

Exp. Date: XX/XX/XXXX

FOR OFFICE USE ONLY: Insert Onset Date - End Date: [Place Lab ID label here]

F OLLOW-UP SURVEY

  1. What date and time did you provide each of the samples?

Urine

Date:

Time:

Semen

Date:

Time:

  1. Prior to collecting today’s sample, how many times have you ejaculated (had an orgasm) in the past 7 days, including sex or masturbation? Circle One


0 1 2 3 4 5 6 7 8 9 10+ times

  1. Prior to collecting today’s sample, how many days has it been since your last ejaculation (orgasm)? Circle One


0 1 2 3 4 5 6 7 8 9 10+ days

  1. Since we spoke to you on the phone, have you had problems with frequent urination? Circle One


Yes No

  1. Since we spoke to you on the phone, have you had pain or burning with urination? Circle One


Yes No

  1. Since we spoke to you on the phone, have you noticed blood in your urine? Circle One


Yes No

  1. Since we spoke to you on the phone, have you noticed blood in your semen? Circle One


Yes No





Thank you for including this survey in your return kit! Please email ZikaMalesStudy@cdc.gov with any questions.

Public reporting burden of this collection of information is estimated to average 1 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHook, Sarah A. (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2021-01-23

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