Monthly Survey Sample

Attachment 6 Flesch-Kincaid Grade Level: 6.0

Lyme and Other Tickborne Diseases Prevention Study

Monthly Survey

Hello, my name is (insert name). I’m calling on behalf of the (insert site specific EIP title) regarding a Lyme disease study that is being conducted in conjunction with the Centers for Disease Control and Prevention. (insert participant name) has enrolled in this research study, and as part of this study, we would like to ask him/her to participate in a brief monthly study survey.

May I please speak with (insert participant name)?

 Yes, speaking. (Go to dialog below)

 Yes, let me get (contact name) on the phone. (Repeat introduction dialog above then go to

dialog below)

 Yes, but (contact name) is not home now/busy.

When would be a better time to reach him/her?

(Log date/time on call record.) Thank you for your time today.

 No

Thank you for your time today.

Thank you for your continued participation in the Lyme and Other Tickborne Diseases Prevention Study. We would like to ask you a few brief questions over the phone in order to complete your monthly study survey for [insert date – date]. These questions will be about any tick encounters you experienced in the past month.

If we have your permission, we would like to ask you some questions over the phone for this survey. This survey should take no more than 5 minutes to complete. As compensation for your time and effort, you will receive a gift card at the end of the study.

Would you like to participate in this monthly survey?

 Yes

Great, I will now begin to ask you the survey questions. (Go to survey questions below)

 Yes, but now is not a good time.

When would be a better time to speak?

(Log date/time on call record.) Thank you for your time and interest in this study.

 No

This study will help public health officials and scientists to better understand how to prevent Lyme disease and other tickborne diseases. Your participation would be a valuable contribution to this study. Would you reconsider?

 Yes

Great, I will now begin to ask you the survey questions. (Go to survey questions

below)

 No

Thank you for your time today.

Survey Questions

The first set of questions will ask about tick encounters experienced by you and your family members (NOT including your pets):

1. In the past month, has anyone living in your household (including yourself) found ticks crawling on their body?

• Yes

1. In the past month, how many household members (including yourself) found ticks crawling on their body?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

I am now going to ask you about each household member who found a tick:

2. For the first member in your household who found a tick, could you provide their initials and date of birth? (Initials, DOB)

1. (Member 1) In the past month, how many ticks were found crawling on this household member?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

2. (Member 1) Where do you think this person picked up the tick(s)?

Toolbar Dropdown List: My yard, Another yard, Recreational area (i.e., park, golf course, hiking trail, campsite etc.), Other, Don’t know, Prefer not to answer

3. For the second member in your household who found a tick, could you provide their initials and date of birth? (Initials, DOB)

1. (Member 2) In the past month, how many ticks were found crawling on this household member?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

2. (Member 2) Where do you think this person picked up the tick(s)?

Toolbar Dropdown List: My yard, Another yard, Recreational area (i.e., park, golf course, hiking trail, campsite etc.), Other, Don’t know, Prefer not to answer

Etc…

• No

• Don’t know

• Prefer not to answer

2. In the past month, has anyone living in your household (including yourself) found ticks attached to their body?

• Yes

1. In the past month, how many household members (including yourself) found ticks attached to their body?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

I am now going to ask you about each household member who found a tick:

2. For the first member in your household who found a tick, could you provide their initials and date of birth? (Initials, DOB)

1. (Member 1) In the past month, how many ticks were found attached to this household member?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

3. For the second member in your household who found a tick, could you provide their initials and date of birth? (Initials, DOB)

1. (Member 2) In the past month, how many ticks were found attached to this household member?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

Etc…

• No

• Don’t know

• Prefer not to answer

3. You indicated that you or someone in your household found ticks crawling on or attached to their body in the past month. Do you remember what the tick(s) looked like?

• Yes

1. Do you have access to the Internet? If so, we would like to provide you with a website link in order to view pictures of different ticks.

 Yes

Please go to the following website:

http://www.cdc.gov/ticks/geographic_distribution.html. Can you provide the name of the tick(s) you remember seeing? Was the tick(s) an American Dog tick, a Blacklegged tick, or a Lone Star tick?

		
Blacklegged tick (Ixodes scapularis)	American Dog tick (Dermacentor variabilis)	Lone Star tick (Amblyomma americanum)

• None of these

• Cannot view pictures

 No

• No

• Don’t know

• Prefer not to answer

The final questions will ask about tick encounters experienced by any of your pets:

4. In the past month, have you found any crawling ticks on your pets (dogs or cats)?

 Yes

1. How many total ticks were found crawling on their body?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

 No

 I do not have a pet

 Don’t know

• Prefer not to answer

5. In the past month, have you found any attached ticks on your pets (dogs or cats)?

 Yes

a. How many total ticks were found attached to their body?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t know, Prefer not to answer

b. How many of these ticks were swollen?

Toolbar Dropdown List: 0,1,2,3,4,5,6,7,8,9,10, More than 10, Don’t

know, Prefer not to answer

 No

 I do not have a pet

 Don’t know

• Prefer not to answer

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