0920-1011 Survey - Day 3-4

Form Approved. OMB No. 0920-1011 Exp. 08/05/2020

S ARS-CoV-2 Louisiana Questionnaire V1 rev 5/04/2020

(Correctional Facility Transmission Investigation)

Day 3/4 Form

CDC ID: _________

…………………………………………………………………………………………………………………………………

Interviewee Information

Specimen ID

Booking or JDE Number:______________________________

First:_____________________________ Last:_______________________________

Date of birth: / / (MM/DD/YYYY)

CDC ID__________

NOTE: This page is for paper records only. Do not scan for data entry into the electronic database.

Administrative Information

1. Interviewer Name: First: ____________________Last:_____________________ Date: / /

2. Housing location: Dorm:______ Other:_____________

3. At the dorm, the number of current: Staff present:______ Cells:____________ Detainees:______________

Symptoms

4. Use no touch thermometer to record current temperature: ________°F

5. Since we last visited you, have you experienced any of the following symptoms?

	Symptom Present Since Last Visit?	Onset Date (mm/dd)	# of Days	Ongoing?
Fever >100.4°F (38° C)	Yes No Unk	___/___
Subjective fever (felt feverish, or hot/sweaty)	Yes No Unk	___/___
Chills	Yes No Unk	___/___
Muscle aches (myalgia)	Yes No Unk	___/___
Runny nose (rhinorrhea)	Yes No Unk	___/___
Stuffy nose (nasal congestion)	Yes No Unk	___/___
Sore throat	Yes No Unk	___/___
Cough (new onset or worsening of chronic cough)	Yes No Unk	___/___
Shortness of breath (dyspnea)	Yes No Unk	___/___
Abdominal pain	Yes No Unk	___/___
Diarrhea (≥3 loose stools/24hr period)	Yes No Unk	___/___
Nausea	Yes No Unk	___/___
Vomiting	Yes No Unk	___/___
Headache	Yes No Unk	___/___
Loss of taste Complete Partial	Yes No Unk	___/___
Loss of smell Complete Partial	Yes No Unk	___/___
Other, specify:	Yes No Unk	___/___

Potential Exposure

6. Since we last visited you, have you been around any people who appear to be sick with COVID-19 symptoms, such as a fever, cough, or shortness of breath?

Yes No Unknown (If yes, how many? _________________________)

Public reporting burden of this collection of information is estimated to average 60 minutes 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 (0920-1011).

3