Zika Investigation - Household Interview Form ENGLISH

Assessment to Estimate the Effect of Community-Wide Vector Control Initiatives on Zika Virus Transmission in Puerto Rico, 2016

Att G - Household questionnaire

Household Questionnaire

OMB: 0920-1137

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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 Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDana Thomas
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File Created2021-01-23

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