Epi Case Training Manual

Appendix 4d:

EPI CASE

JUST-IN-TIME TRAINING

EPI CASE

JUST-IN-TIME TRAINING

The Epi CASE Toolkit Survey is a surveillance tool that allows stakeholders (e.g., state, tribal, local, and territorial health departments) to quickly assess the health of members of a community who have been affected by a catastrophic incident (e.g., radiological, nuclear, or chemical).

Purpose

• To quickly gain knowledge of the effects of the incident

• To collect data on how to serve those affected during and after incidents

• To communicate with and potentially provide aid to those affected

• To provide contact information and identifiers for future public health activities

Process

• Follow the directions on the forms.

• Complete the collection form in full during the time of interview. If you are unable to complete the form in full, try to complete the form within 24 hours, if possible.

• Use a new form for each interview.

Conducting the interview

Before the start of the interview, complete the incident identification information listed at the top of the first page of the survey.

Registrant ID — Create standard unique identification numbers before data collection.

Incident code — Assign standard incident-specific codes before data collection.

Site number — Create interview site-specific codes before data collection.

Interviewer ID — Use full initials (e.g., SGI) unless instruction provides otherwise.

Interview date — Enter 2-digit format for month and day, and 4-digit year (e.g., 05-02-2004).

Time started — Enter time in hours and minutes, also denoting day or night by AM/PM

Time ended — Enter time in hours and minutes, also denoting day or night by AM/PM

Verbal Consent

Section Notes: Participation is entirely voluntary. A formal written and signed consent, adolescent (13–17 yrs.) Assent, or Parent Permission will be obtained at the beginning of registration.

For some persons, such as young children or severely injured persons, you might not be able to obtain consent. In such situations, when a person is unable to provide his or her own information, try to locate an adult relative to serve as proxy on their behalf. If a person refuses to provide information, you may provide information to them about who to contact should they change their mind. You may ask the person to explain why he or she refused to be interviewed. You can use the data to track the number of exposed or potentially exposed persons who decline enrollment.
Section Script
Hello, my name is __________________. The ___]insert organization]_____________________ Public Health Department is conducting this survey since [insert name of the incident] incident. We are asking you to take part in this survey because you were in the area of the [insert location] or might have been exposed to [the name of chemical/radiological/nuclear/biological substance], which we are calling the INCIDENT. Purpose: This survey collects information to allow us to learn who was affected by the incident. Your participation may benefit you directly by helping you get connected to services or receive helpful information. It also helps scientists better understand the incident, the community, and if any health effects might be related to the incident. Voluntary: Whether you take part in this survey is up to you. You can choose if you want to be interviewed. You can stop the interview at any time. You can also refuse to answer any question. If you refuse to be interviewed, it will not affect any government benefits that you may receive. Confidentiality: Your information will be kept confidential to the fullest extent of the law. We intend to keep your answers for 12 months, after which they will be carefully and completely destroyed. Only authorized persons will be allowed to see your information. Nothing will be published that can identify you. Survey contents: The survey will take about 5 minutes to answer. We will ask you questions about contact information for you and people you know for future contact purposes, where you were during the incident or whether you were exposed, if you got injured or ill as a result of that incident, your immediate needs so we may connect you to the appropriate services, and your Social Security number, your driver’s license number, or another state identification to prevent duplication in the database and for future contact with you. Do I have your permission to ask you questions?  Yes  No Do I have permission to contact you again in the future if we can provide you information or services or to gain more detailed information from you? You are still eligible to participate if you decline.  Yes  No Reason for refusal ____________________________________________________________ If you have any questions about this investigation, you can call (this will more likely be the state or local health department) program at (XXX) XXX-XXXX. By signing below, you agree to take part in the survey. You are also saying that we have given you a copy of this consent form. If there is any part of this form that is not clear to you, be sure to ask about it. In the future, if we have additional questions, may we contact you?  Yes  No _______________________________________ __________________ Signature Date
Identification Information
Item	Field	Script	Notes
	Identification	First, we need some information to uniquely identify you. Can you please provide one of the following: Social Security number Driver’s license Other state ID Other ID	Enter any numerical ID numbers provided by the registrant next to the corresponding ID type. For driver’s license or state ID, provide the 2-letter state abbreviation, the license number, and the expiration date.
Registrant Information
Item	Field	Script	Notes
1	Registrant full name	What is your full name, including your middle initial?	Enter last name, first name and middle initial of registrant. (e.g., Reynolds, Mary, E).
2	Registrant date of birth	What is your date of birth?	Enter 2-digit format for month and day, and 4-digit format for year (e.g., 01-15-1955).
3A	Registrant home address	What is your physical home address, not a post office box?	Enter registrant's physical home address (i.e., place where registrant resides). Include city, county, state, and ZIP code.
3B	Number of children younger than 13 years	How many children younger than 13 years old were in your immediate care during the incident?	Enter total number of children
4	Registrant email address	What is your email address?	Enter registrant’s email address, clarify letters that are unclear (e.g., M as in Mary?), and clarify special characters such as underscores ( _ ) and dashes (–).
5	Registrant social media accounts	Do you have any social media accounts that we may be able to use to contact you, if needed?	Specify social media accounts which registrant uses, verify if case sensitive. Check the last box if refused.
6	Registrant phone numbers	What is the best phone number to use to reach you in the future? Is that a cell, work, or home number?	Check the corresponding box and complete that field.
		What other numbers can we use to reach you?	Complete those next. Leave any field blank if the registrant does not provide data. If time permits, verify phone number(s).
7	Gender	Do you identify as a male, female, or other? Please specify.	Mark the appropriate answer based upon individual's response or add to the other/specify field.
8	Pregnancy status	Is it possible that you are pregnant?	If the registrant is not a female over the age of 12, skip to Item 9. If the registrant identifies as female in Item 7 and is older than 12 years of age, ask the question in the script. Mark the appropriate answer based upon individual's response.
REGISTRANT’S EMERGENCY CONTACT INFORMATION
Section Notes: Collect information for an emergency contact from outside the registrant's household. The contact MUST be someone who will know where the registrant can be contacted in future for follow-up purposes.
Section Introduction Script: “We would like to be able to contact you in case we need to provide you with information or services or if we need more information. If we can’t reach you, is there someone who will always know how to reach you, preferably someone who does not live with you?”
Item	Field	Script	Notes
9	Emergency contact name	What is the first name, middle initial, and last name of an emergency contact from outside of your household who will know how to reach you?	Enter first name, last name, and middle initial of emergency contact.
10	Emergency contact mailing address	What is the physical address including city, state, and ZIP code where emergency contact will most likely receive mail for the next 6 months?	Enter emergency contact’s physical home address (i.e., place where registrant resides). Include city, county, state, and ZIP code.
11	Emergency contact email address	What is your emergency contact’s email address?	Enter registrant’s emergency contact’s email address, clarify letters that are unclear (e.g., M as in Mary?), and clarify special characters such as underscores (_) and dashes (–).
12	Emergency contact phone numbers	What is the best phone number to use to reach your emergency contact, if we cannot reach you? Is that a cell, work, or home number?	Check the corresponding box and complete that field.
		What other numbers I can use to reach that person?	Complete those next. Leave any field blank if the registrant does not provide data. If time permits, verify phone number(s).
13	Exposure information: Role	At the start of the incident, were you a… Resident Employee Passerby First responder Clean-up worker or volunteer Government official including military Other worker Other	Read selections, check all that apply. Employee — someone who works either in the building or affected area in some capacity. Clean-up worker — someone tasked with cleaning up after an incident (e.g. debris removal) Responder or rescue worker — includes police officers, fire fighters, emergency medical teams (EMT), National Guard and other military, etc. Government official — includes all local, state, and federal government personnel, and all government contractors. Include persons in civilian attire presenting government or other appropriate identification. Non-governmental organization/site volunteer — includes private citizens or persons who through their organization affiliation (e.g., American Red Cross) support incident relief activities in many different capacities, including providing food, shelter, and health services. Resident — if the building or affected area is a residence, this person would be an occupant of the building or neighboring building. SKIP to Question 15 Other — Specify other way registrant might have been exposed.
14	Exposure information: Location	At the start of the incident on [say the INCIDENT DATE] at [say the INCIDENT TIME]…
14A		Where were you?	Try to get specific address of registrant's location at the time of incident (e.g., 9 Oak Road).
14B		(To get more precise location) Is there an intersection, building, or landmark nearby?	This is mainly if he/she cannot answer Q 14 A. Enter that specific location in the corresponding space (e.g., intersection of Euclid and Main, Central Financial Square, or bridge).
15	Type of location	At the beginning of the incident, were you… Inside the building where the incident occurred? Inside a car or vehicle near to where the incident occurred. At a location outside of the building(s) where the incident occurred. At some other location?	Read selections, check all that apply. If “other” is indicated, specify location of registrant.
Health and Additional Needs
Item	Field	Script	Notes
16	Illness or injury	We are trying to identify people who might need additional assistance. As a result of this incident, did you get injured or ill?	If “Yes,” show the person the Epi Case Symptom Checker and have them identify all of their symptoms and note the number(s) of all of the symptoms or injuries on the form. Symptoms are grouped by type. The injury or illness may be directly or indirectly related to the incident. An example of an indirect injury would be fall related injury while attempting to flee affected area.
17	Needs	As a result of this incident, do you personally need help getting supplies or services such as… medicine or medical supplies medical care mental health care water shelter food utilities transportation other	Read selections, check all that apply. If “other” is indicated, specify need.
18	Vomiting (radiological and nuclear incidents only)	If you had repeated vomiting AFTER the incident, how long after the incident [date and time] did it start?	Radiological and nuclear incidents only: Read all choices to the registrant and mark the appropriate answer based upon individual's response.
19	Children younger than 13 years who were in person’s immediate care during the incident	Please provide the date of birth OR age, sex, and injuries or illness that resulted of this incident for each child. Refer to the Epi CASE Symptom Checker for codes.	Enter DOB, or Age if DOB is unknown and sex for every child under 13. As with Question 16, show the person the Epi Case Symptom Checker and have them identify all of the symptoms for each child younger than13 years and note the number(s) of all of the symptoms or injuries on the form. Symptoms are grouped by type. The injury or illness may be directly or indirectly related to the incident. An example of an indirect injury would be a fall-related injury while trying to flee an affected area.

Protecting registrants’ personally identifiable information (PII). Keep all paper copies secured and out of view when in the field, such as in a locked case. When returning to the office paper copies should be kept in locked file cabinets when not being handled. CDC Epi Info software users should securely install, configure, and use Epi Info for data collections. Use security controls such as strong passwords and encryption. Be sure to comply with applicable local, state, and federal laws, regulations, and guidance in regard to protecting PII. Unauthorized release of PII should be reported promptly to the relevant parties (incidence response teams, chief privacy officer, etc.) in your organization.