Household Contact Questionnaire

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

H uman Infection with 2019 Novel Coronavirus (nCoV)

Household Contact Questionnaire V1.5 rev 3/24/2020

(Household Transmission Investigation)

State: WI

Household ID: WI-__________

Study ID: WI-_______________

This questionnaire is to be administered to each household member (excluding the index patient).

Interview Information

1. Date of Interview: / / (MM/DD/YYYY)

2. Name of Interviewer: _________________________________________

3. Person completing the interview: Self Parent/guardian: ______________________________

Other: ___________________________________________________

Household Member Information

4. Household member’s name: First:_____________________________ Last:___________________________

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

6. Age: _______ years months days
   
   

7. Ethnicity: Hispanic/Latino Non-Hispanic/Latino Not Specified

8. Race: White Black Asian

Am Indian/Alaska Nat Nat Hawaiian/Other PI Other, specify:___________ Unknown

9. Sex: Male Female

10. What is your relationship to [insert name of index patient]?

Spouse Child Parent Grandparent Sibling Employee Other _____________

11. What is the highest level of education you have completed?

Less than high school

High school diploma/GED

Some college credit, no degree

Technical degree/Associate’s degree

Bachelor’s degree (i.e., B.A., B.S.)

Master’s degree (i.e., MBA)

Doctorate or professional degree

12. What is your occupation? ____________________________________________________

SARS-CoV-2 testing for household contacts

13. Have you been tested for coronavirus? Yes No

If yes, please complete the following information:

1. Date of specimen collection_______________________________(MM/DD/YYYY)

2. Result of test: Positive Negative Pending Don’t know/other ________________

3. Date of test result_______________________________(MM/DD/YYYY)

4. Were you experiencing symptoms when you were tested? Yes No

   1. Describe:­­­­­­­­­­­­­­­_______________________________________________________________

5. Date of symptom onset: _____________________________(MM/DD/YYYY)

Notes:________________________________________________________________________________

Past Medical History

14. Please provide pre-existing medical conditions (complete regardless of age):

Asthma/reactive airway disease	Yes	No	Unknown
Emphysema/COPD	Yes	No	Unknown
Active tuberculosis	Yes	No	Unknown	If YES, on treatment: Yes No Unknown
Any other chronic lung diseases	Yes	No	Unknown	If YES, specify:
Diabetes Mellitus	Yes	No	Unknown
Hypertension (high blood pressure)	Yes	No	Unknown
Coronary artery disease/heart attack	Yes	No	Unknown
Congestive heart failure	Yes	No	Unknown
Stroke	Yes	No	Unknown
Congenital heart disease	Yes	No	Unknown
Any other heart diseases	Yes	No	Unknown	If YES, specify:
Any kidney disorders? If YES, answer the following:	Yes	No	Unknown
End-stage renal disease/dialysis	Yes	No	Unknown
Renal insufficiency	Yes	No	Unknown
Other kidney diseases	Yes	No	Unknown	If YES, specify:
Any liver disorders? If YES, answer the following:	Yes	No	Unknown
Alcoholic liver disease	Yes	No	Unknown
Cirrhosis/End stage liver disease	Yes	No	Unknown
Chronic hepatitis B	Yes	No	Unknown
Chronic hepatitis C	Yes	No	Unknown
Non-alcoholic fatty liver disease (NAFLD)/NASH	Yes	No	Unknown
Other chronic liver diseases	Yes	No	Unknown	If YES, specify:
HIV infection. If YES, answer the following:	Yes	No	Unknown
AIDS or CD4 count currently <200	Yes	No	Unknown
Ever receive a transplant? If YES, answer the following:	Yes	No	Unknown
Solid organ transplant				If YES, date:
Stem cell transplant (e.g., bone marrow transplant)	Yes	No	Unknown	If YES, date:
Cancer: current/in treatment or diagnosed in last 12 months	Yes	No	Unknown	If YES, specify:___________________
Immunosuppressive therapy/medications	Yes	No	Unknown	If YES, specify:___________________ For what condition: _______________________
Other immunosuppressive conditions	Yes	No	Unknown	If YES, specify:___________________
Any other chronic diseases	Yes	No	Unknown	If YES, specify:
Developmental or neurologic disorder. If YES, answer the following:	Yes	No	Unknown	If YES, specify:
Chromosomal or genetic abnormality	Yes	No	Unknown	If YES, specify:___________________________
Cerebral palsy	Yes	No	Unknown
Epilepsy	Yes	No	Unknown
Any other development or neurologic Disorder				If YES, specify:___________________________
Any other medical conditions as a child	Yes	No	Unknown	If YES, specify:
Were you born premature?	Yes	No	Unknown	If yes, gestation at birth:____________wks

15. [If female] Are you currently pregnant? Yes No Unknown N/A

16. [If female] Are you postpartum ( 6 weeks postpartum)? Yes No Unknown N/A

17. [If female] Are you breastfeeding? Yes No Unknown N/A

18. [If child <3 years] Is your child being breastfed? Yes No Unknown N/A

Smoking/Vaping

19. Do you currently smoke tobacco on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

20. [If not a daily smoker] In the past, have you smoked tobacco on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

21. Do you currently vape or use electronic cigarettes on a daily basis, less than daily, or not at all?

Daily Less than daily Not at all Unknown

Symptoms Prior to Index Case’s Onset

Note to interviewer: record symptom onset date of the index patient from household questionnaire cover sheet. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)

22. Did you experience any symptoms of a respiratory illness in the 2 weeks prior to [insert name of index patient] becoming ill?

Yes No Unknown

Exposures Outside of the Household

Note to interviewer: remind the interviewee to consult a calendar or diary for the following questions.

Date of index patient symptom onset: ___/____/____(MM/DD/YYYY)

14 days prior to index patient’s symptom onset: ___/____/____ (MM/DD/YYYY)

23. Since [14 days PRIOR to the index patient’s symptom onset]…

Exposure	Answer
…have you traveled (internationally or within the U.S., or on a cruise)?	Yes: with index patient Yes: w/o index patient No Unknown
…attend a mass gathering (e.g., religious event, wedding, party, dance, concert, banquet, festival, sports event, or other events)?	Yes: with index patient Yes: w/o index patient No Unknown
…have close contact (e.g. caring for, speaking with, touching, physically within 6 feet) with any suspected or known COVID-19 case outside of the household?	Yes: with index patient Yes: w/o index patient No Unknown
…work in a healthcare setting?	Yes No Unknown If yes, what types of healthcare settings:  Hospital  Outpatient Clinic  Emergency Dept  Dental Clinic  Dialysis Center  ICU  Long-term care facility  Other, specify: __________ What type of job do you have at the healthcare setting?  Admin staff  Nurse/Nurse tech  Doctor  EMS  Other, specify: ___________
…visit a healthcare setting (e.g. visit someone or have an appointment -- at a hospital, ED, outpatient clinic, dental clinic, long-term care facility)?	Yes No Unknown
…attend/work at a daycare?	Yes No Unknown
…attend/work at a school?	Yes No Unknown

Symptoms After the Index Case’s Onset

Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)

Since ____/____/____, when [the index case] first became symptomatic, have you experienced any of the following symptoms?	Symptom Present?
Fever >100.4F (38C)c	Yes No Unk
Subjective fever (felt feverish)	Yes No Unk
Chills	Yes No Unk
Muscle aches (myalgia)	Yes No Unk
Runny nose (rhinorrhea)	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
Nausea/Vomiting	Yes No Unk
Headache	Yes No Unk
Abdominal pain	Yes No Unk
Diarrhea (≥3 loose/looser than normal stools/24hr period)	Yes No Unk
Other, specify:

25. What date did you first become symptomatic?

___ / __ /_ __ (MM/DD/YYYY)

26. Are you currently experiencing any symptoms of a respiratory illness, such as fever, cough, or shortness of breath? (Note: Flag any symptomatic household members for workflow planning and offer of self-nasal swab during visit)

Yes No Unknown

Exposures to the Index Patient

Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)

27. Since [index case]’s symptoms started on [date of symptom onset of the index patient], did you …….?

Exposure	Answer
…spend more than 10 minutes within 6 feet of the index patient?	Yes No Unknown
…have face to face contact with the index patient (i.e., within about 2 feet)?	Yes No Unknown
…spend any time within 6 feet of the index patient while he/she was coughing or sneezing?	Yes No Unknown
…shake hands with the index patient?	Yes No Unknown
…hug the index patient?	Yes No Unknown
…kiss the index patient?	Yes No Unknown
…take an object handed from or handled by the index patient? (e.g., pen, paper, food, utensil, etc.)	Yes No Unknown
…sleep in the same bedroom as the index patient?	Yes No Unknown
…sleep in the same bed as the index patient?	Yes No Unknown
…share a bathroom with the index patient?	Yes No Unknown
…prepare food with the index patient?	Yes No Unknown
…share meals with the index patient?	Yes No Unknown
…eat from the same plate as the index patient?	Yes No Unknown
…share a utensil with the index patient?	Yes No Unknown
…share a drinking cup/glass with the index patient?	Yes No Unknown
…travel in the same vehicle (car, bus, airplane), sitting within 6 feet of the index patient?	Yes No Unknown

28. Did you serve as primary caretaker for the index patient while he/she was ill? Yes No Unknown

29. When was your last exposure (include any exposures described above) to [name of the index patient]?

___ / __ /_ __ (MM/DD/YYYY) Ongoing exposure

30. How many days have you spent in the household since [date of symptom onset of index patient]? ____________

31. How many nights have you spent in the household since [date of symptom onset of index patient]? ___________

Version 1.4 March 24, 2020 16

Public reporting burden of this collection of information is estimated to average 10 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).