Form Approved
OMB Control No. 0920-XXXX
Exp. Date: XX/XX/XXXX
ZIKA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
TEAM #: ________________ DATE: ______/_______/_________ Household ID (e.g., S-1-A): _______-______-_____
GPS Coordinates (decimals): _____.____________ , ______.______________ SANID of lab-positive case: ______________
How many people live in this house? _______________people
List all members of household below put yourself first.
Head of household contact number/email to facilitate return of test results:___________________________________________
|
Name (First, Paternal, Maternal) |
Age |
Gender |
Present? |
If yes, agreed to participate? |
Place sticker here |
1 |
|
|
M / F |
Yes / No |
Yes / No |
|
2 |
|
|
M / F |
Yes / No |
Yes / No |
|
3 |
|
|
M / F |
Yes / No |
Yes / No |
|
4 |
|
|
M / F |
Yes / No |
Yes / No |
|
5 |
|
|
M / F |
Yes / No |
Yes / No |
|
6 |
|
|
M / F |
Yes / No |
Yes / No |
|
7 |
|
|
M / F |
Yes / No |
Yes / No |
|
8 |
|
|
M / F |
Yes / No |
Yes / No |
|
Household Characteristics
Housing type (check only one): □ One story house □ Two story house □ Apartment/condo building □Other
Has anyone in your household been acutely ill in the past 3 months? □ Yes □ No □ Don’t recall
How many of your windows and doors have intact screens? □ All □ Some □ None □ Don’t know
Do you use air conditioning in your home? □Yes, in all rooms □Yes, but only in the bedroom at night □ Other □ No
Do you regularly leave your doors or windows open? □ Daytime only □ Night-time only □ Always □ Never
Do you use mosquito coils in your house or patio to keep mosquitos away? □ Yes □ No
Do you use citronela in your house or patio to keep mosquitoes away? □ Yes □ No
What is your approximate annual household income? □ < $25,000 □ $26,000–$50,000 □ $51,000–$75,000 □ > $76,000
□ Decline to answer
Do you have one or more AGO mosquito traps in your home or yard? □ Yes □ No □ Don’t know
If so, compared to before the trap was present, would you say that the number of mosquitos in your home has:
□ Increased □ Decreased □ Not changed □ Do not know □ No trap in yard
Notes:
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Dana Thomas |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |