Changes to Questionnaire

Attachment M. TO BE ADDED TO ATTACHMENT ZIPER Pregnancy Questions Added to Questionnaire

V01 Pregnancy Section For all adult women and emancipated female minors, go to pregnancy section after last question in core survey.
#	Question	Choices	Skip
P1	Have you been pregnant since November 2015? This includes if you are currently pregnant, any live births, still births, miscarriage, fetal death, tubal pregnancies, and induced abortions. Miscarriage: refers to a pregnancy that terminates naturally during the first 5 months (20 weeks) of pregnancy. Stillbirth: Refers to a baby that is born dead after 6 or more months (>20 weeks). Tubal pregnancy: Refers to a pregnancy that occurs in the fallopian tube. Induced abortion: Refers to a pregnancy that is terminated during the first 6 months using induced methods.	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If NO (0), END SECTION. Else, continue to P2.
P2	Are you pregnant right now?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If NO, DON’T KNOW, or REFUSE (0, 77, 99), SKIP to P7. Else, continue to P3.
Currently pregnant only
P3	What was the first day of your last menstrual period?	DATE Don’t know 77 Refuse to answer 99
P4	How many weeks pregnant are you?	NUMBER Don’t know 77 Refuse to answer 99
P5	Doctor’s information Name, office, phone number	Name: Office: Tel: Any other notes:
P5	Have you been pregnant any other time since November 2015?	No 0 Yes 1 Don’t know 77 Refuse to answer 99	If NO, DON’T KNOW, or REFUSE (0,77,99), END pregnancy section. If YES (1), continue to P7.
Ever pregnant
P7	How many times have you been pregnant since November 2015? (If you are currently pregnant, do not include now.)	NUMBER Don’t know 77 Refuse to answer 99	If 0, check skip pattern and confirm. If 1, continue. If >1, say, “I am going to ask you about each pregnancy since November. The first time I ask you these questions, please answer based on the first time you were pregnant in that period. The second time, please answer based on the second time you were pregnant in that period. [Add third, fourth, etc. as needed.]” INTERVIEWER: Repeat “past pregnancy” the number of times.
Past pregnancy INTERVIEWER: If you are repeating this section, say, “Now we are going to talk about the first (second, third, fourth, etc.) time you were pregnant between November 2015 and now.”
P8	What was the outcome of the pregnancy? Miscarriage: refers to a pregnancy that terminates naturally during the first 5 months (20 weeks) of pregnancy. Stillbirth: Refers to a baby that is born dead after 6 or more months (>20 weeks). Tubal pregnancy: Refers to a pregnancy that occurs in the fallopian tube. Induced abortion: Refers to a pregnancy that is terminated during the first 6 months using induced methods.	Live birth 1 Still birth, miscarriage, or fetal death (baby died before being born) 2 Ectopic / tubal 3 Induced abortion 4 Other (describe) 5 Don’t know 77 Refuse to answer 99	If 1, skip to P11. If 2, “I am so sorry for your loss.” Skip to P10. If 3 or 4, skip to P10. If 5, continue to P9.
P9	Other (describe)
P10	How long did that pregnancy last?	__ __ number of weeks Don’t know 77 Refuse to answer 99	If repeat, go back to P8. Else, end survey.
P11	Are you currently breastfeeding?	No 0 Yes 1 Don’t know 77 Refuse to answer 99
	END SECTION Thank you for your time.

ZIPER Pregnancy Questions - Spanish

V01 Pregnancy Section For all adult women and emancipated female minors, go to pregnancy section after last question in core survey.
#	Question	Choices	Skip
P1	¿Ha tenido un embarazo desde Noviembre del 2015? Esto incluye si está embarazada actualmente, partos vivos, abortos naturales, muertes fetales, embarazos ectópicos, y abortos inducidos. Interviewer: If participant asks for clarification, you can define the terms as the following: Aborto espontáneo: se refiere a un embarazo que termina naturalmente durante los primeros 5 meses (20 semanas) del embarazo. Muerte fetal: se refiere a un bebé que nace muerte después de 6 meses o más (>20 semanas). Embarazo ectópico: se refiere a un embarazo que ocurre dentro de las trompas de Falopio. Aborto inducido: se refiere a un embarazo que es terminado durante los primeros 6 meses usando métodos inducidos.	No 0 Sí 1 No sabe 77 Se niega a contestar 99	Si NO (0), TERMINA LA SECCIÓN. Otras respuestas, sigue con la P2.
P2	¿Está embarazada ahora?	No 0 Sí 1 No sabe 77 Se niega a contestar 99	Si contesta NO, NO SABE, o SE NIEGA A CONTESTAR (0, 77, 99), PASE a la P7. Si contesta SÍ (1), sigue con la P3.
Solo para mujeres que estén embarazadas actualmente
P3	¿Cuándo fue el primer día de su último periodo menstrual?	FECHA _ _ / _ _ / _ _ _ _ No sabe 77 Se niega a contestar 99
P4	¿Cuántas semanas de embarazo tiene Ud.?	NÚMERO No sabe 77 Se niega a contestar 99
P5	Información del medico Nombre, oficina, número de teléfono	Nombre: Oficina: Tel: Otros comentarios:
P5	¿Ha estado embarazada en cualquier otro momento desde Noviembre del 2015?	No 0 Sí 1 No sabe 77 Se niega a contestar 99	Si contesta NO, NO SABE, o SE NIEGA A CONTESTAR (0, 77, 99), TERMINA la sección de embarazo. Si contesta SÍ (1), sigue con la P7.
Embarazos pasados
NÚMERO	¿Cuántas veces ha estado embarazada desde Noviembre del 2015? (Si está embarazada actualmente, no incluya ahora.)	NÚMERO No sabe 77 Se niega a contestar 99	Si dice 0, chequea el patrón de saltos y confirme. Si contesta 1, continúe. Si contesta >1, diga, “Voy a preguntarle acerca de cada embarazo que ha tenido desde noviembre. La primera vez que le hago estas preguntas, contéstelas acerca de su primer embarazo de esta época. La segunda vez, favor de contestarlas acerca de la segunda vez que estaba embarazada en aquella época. [Agregue la tercera, cuarta vez si es necesario.]” INTERVIEWER: Repita “embarazos pasados” según al número de embarazos reportados.
Resultados del embarazo
P8	¿Cuál fue el resultado del embarazo? Interviewer: If participant asks for clarification, you can define the terms as the following: Aborto espontáneo: se refiere a un embarazo que termina naturalmente durante los primeros 5 meses (20 semanas) del embarazo. Muerte fetal: se refiere a un bebé que nace muerte después de 6 meses o más (>20 semanas). Embarazo ectópico: se refiere a un embarazo que ocurre dentro de las trompas de Falopio. Aborto inducido: se refiere a un embarazo que es terminado durante los primeros 6 meses usando métodos inducidos	Parto vivo 1 Muerte fetal o aborto inducido (feto murió antes de nacer) 2 Ectópico 3 Aborto inducido 4 Otro (describe) 5 No sabe 77 Se niega a contestar 99	Si contesta 1, pase a la P11. Si contesta 2, “Lo siento mucho/lo lamento mucho.” Pase a la P10. Si contesta 3 o 4, pase a la P10. Si contesta 5, sigue con la P9.
P9	Other (describe)
P10	¿Por cuánto tiempo duró el embarazo?	__ __ número de semanas No sabe 77 Se niega a contestar 99	Si tuvo más que un embarazo, vuelva a la P8. Si no, TERMINA LA ENCUESTA.
P11	¿Está amamantando a su bebé actualmente?	No 0 Sí 1 No sabe 77 Se niega a contestar 99	Si contesta sí (1), pide al participante si puede dar una muestra de leche materna.
	END SECTION Gracias por su tiempo.

Attachment N. Informational flyer about ZIPER study and permission to contact for patients identified through passive surveillance

Zika Virus Study

The Centers for Disease Control & Prevention (CDC) in collaboration with the San Lucas Guayama Hospital is carrying out a study on the Zika virus. You could be eligible for this study.

Information for patients

What is Zika?

Zika is an illness caused by the Zika virus which is transmitted by mosquito bites. The Aedes aegypti is the mosquito which is infected with the Zika virus. The Aedes mosquito also transmits the Dengue virus and the Chikungunya virus. Infection with Zika during pregnancy could cause birth defects in the baby.

What is this study about?

We are conducting a study to find out how long the Zika virus can remain in bodily fluids. This study is being done throughout different hospitals including the San Lucas de Guayama Hospital and the Center of Emergency and Integrated Medicine in Arroyo.

Who can participate in this study?

We are inviting patients who have visited the San Lucas Guayama Hospital or the Center of Emergency and Integrated Medicine in Arroyo who have a positive laboratory test for Zika.

What benefits will I receive for participating in this study?

The benefits include free testing to detect how long the virus lasts within your body. You will receive an orientation about what your test results mean and what you can do to protect yourself and your loved ones.

Are you interested in participating?

If you would like more information or if you are interested in the study, please mark “Yes” on the box below. We will be in touch with you only if you have a positive laboratory finding for Zika virus in your blood. If you are in agreement, an employee from the Centers for Disease Control & Prevention (CDC) will get in touch with you to orient you about the study. If you participate in this study, you will receive an incentive on each visit for your time and effort.

□ Yes, I authorize to be called to be given information about this study if Zika virus is found in my blood.

□ No, I do not authorize to be called to be given information about this study if Zika virus is found in my blood.

Patient initials (Please Print): ______________