Follow-Up Survey - English

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
What date and time did you provide each of the samples?
Urine	Date:	Time:
Semen	Date:	Time:
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
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
Since you sent in your last kit, have you had problems with frequent urination? Circle One Yes No
Since you sent in your last kit, have you had pain or burning with urination? Circle One Yes No
Since you sent in your last kit, have you noticed blood in your urine? Circle One Yes No
Since you sent in your last kit, 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 minute 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