Draft - Daily Survey Sample

Attachment 8 Daily Survey

(Ideally this information will be collected via web-based survey or mobile app, though this is a paper example)

Dear Participant,

 

By completing this daily activity log, you will help us understand where people come in contact with ticks. We are sending two copies of this log to each household. One copy should be completed by the head of household (the person who signed the study consent form), and the second should be completed by another household member whose birthday occurs closest to June 1st and is at least 2 years of age. If this person is a child, an adult can complete the log for him or her, based on the child’s activities.

Important: Please begin recording your activities on [insert date]. After you have filled out your log, please mail both logs to us in the enclosed envelope. When we receive your household’s two completed logs, we will send you a $X gift card as a thank you for your time and effort. If you have any questions, please contact us at [insert phone number] or [insert email].

Thank you for your participation!

 

Instructions:

1. There is one page for each day of the week. Please begin on the page marked “[insert date].”

2. Put an X in each 15 minute time slot/box where you spent your time. For extended periods of time spent in one type of place, put an X at the beginning and an X at the end of your time and connect them with a line.

3. If you were in two or more different types of places in the same 15 minute time slot, then put an X in all types of places you were in for that 15 minute time slot. It’s important that you mark every type of location you spend time in, regardless of how much or how little time you spent in that place.

4. If you were in more than one type of place between midnight and 4 a.m., please write in the “Comments/Notes” section what types of places you were in and for how long.

 

For each day, please note where you spent your time in 15 minute time slots for these four types of places:

• Your yard (any outdoor area on your property)

• Someone else’s yard (any outdoor area on someone else’s property)

• Other place outdoors (any other outdoor space, such as parks, school playgrounds, athletic fields, sidewalks in your town, golf courses, or hiking trails, etc.)

• Indoors (inside any building or form of transportation, such as home, school, work, car, bus, train, etc.)

Participant Name:

Date:

Day [X]

Where were you?

4 A.M.

5 A.M.

6 A.M.

7 A.M.

8 A.M.

9 A.M.

10 A.M.

Your yard

Someone else’s yard

Other place outdoors

Indoors

Where were you?

11 A.M.

NOON

1 P.M.

2 P.M.

3 P.M.

4 P.M.

5 P.M.

Your yard

Someone else’s yard

Other place outdoors

Indoors

Where were you?

6 P.M.

7 P.M.

8 P.M.

9 P.M.

10 P.M.

11 P.M.

12 A.M.

Your yard

Someone else’s yard

Other place outdoors

Indoors