Form Approved
OMB Control No.: 0920-1307
Expiration date: xxxx//XXXX
<CLUSTER CODE>
[Please complete Section 1 prior to conducting interview]
Section 1: INTERVIEW INFORMATION |
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Hello, my name is <interviewer name>. I am from <interviewer health department name>. We are contacting you because you (or the ill person) were recently sick with a Shigella infection, also called shigellosis. Shigella are a group of bacteria that cause diarrheal illness. We are trying to determine how you (or the ill person) became sick with a Shigella infection. This interview will also help prevent others from getting sick.
You may have already been contacted by the health department. I would like to ask you a few additional questions about your (or the ill person’s) recent illness and about any exposures you (or the ill person) may have had before becoming ill. Your help in the investigation is very important. Your participation is voluntary, and you may refuse to answer any question at any time. All information will be kept confidential to the extent permitted by law. No names or other identifying information will be used in any reports. This interview will likely take about 25 to 30 minutes. Are you willing to participate?
If yes: Thank you. [Proceed to Section 2]
If no: Thank you for your time. Would you like any additional materials about Shigella or can I answer any questions for you? If you wish at any time to complete the questionnaire, please call <health department phone number>.
For the first few questions, I will ask some basic demographic questions so I can learn more about you (or the ill person).
Section 2: CASE INFORMATION |
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How do you describe your (or the ill person’s): |
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☐ Native Hawaiian or Pacific Islander ☐ White ☐ Refused |
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Now I am interested to learn a little about your household.
Section 3: HOUSEHOLD INFORMATION |
☐ House/single family home ☐ Apartment ☐ Hotel/motel ☐ Long term care facility ☐ Nursing home/assisted living facility ☐ Mobile home ☐ Shelter ☐ Rehabilitation center ☐ Half-way house ☐ Unknown ☐ Other (specify): _______________ |
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☐ Municipal ☐ Well ☐ Unknown ☐ Other (specify): _______________ |
☐ Municipal ☐ Septic tank ☐ Unknown ☐ Other (specify): _______________ |
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☐ <$20,000 ☐ $20,000-$39,999 ☐ $40,000-$59,999 ☐ $60,000-$79,999 ☐ $80,000-99,999 ☐ $100,000 or more ☐ Prefer not to answer ☐ Unknown |
Next, I have a few questions about your (or the ill person’s) recent illness. It may be helpful to have a calendar in front of you because I will be asking about the dates your (or the ill person’s) symptoms started and stopped. Do you need some time to get one?
Section 4: CLINICAL INFORMATION |
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The next set of questions are about any recent medical care and treatment you (or the ill person) may have received.
Section 5: MEDICAL CARE AND TREATMENT INFORMATION |
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☐ Doctor’s office ☐ Urgent care ☐ Pharmacy clinic ☐ STD clinic ☐ Emergency department ☐ Hospital ☐ Unknown ☐ Other (specify): _______________ |
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______ /_____ /_______ ☐ Approximate date ☐ Unknown Month / Day / Year |
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______ /_____ /_______ ☐ Approximate date ☐ Unknown ☐ Still taking antibiotic(s) Month / Day / Year |
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☐ Get better/Improve ☐ Stay the Same ☐ Get Worse ☐ Other (specify): _____________ |
I would now like to know about your (or the ill person’s) recent activities, including travel, events, and contact with others.
Section 6: EXPOSURE INFORMATION |
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☐ Tourism ☐ Work ☐ Visiting friends/relatives ☐ Other (specify):________________________ |
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☐ Hotel, hostel, guest house, resort ☐ Private home ☐ Hospital ☐ Cruise ship ☐ Other (e.g., school, dormitory, tent) (specify):________________________ |
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☐ Purchase or eat food ☐ Go swimming ☐ Attend gathering of people ☐ Drink untreated water ☐ Other (specify):________________________ |
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☐ Tourism ☐ Work ☐ Visiting friends/relatives ☐ Other (specify):________________________ |
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☐ Hotel, hostel, guest house, resort ☐ Private home ☐ Hospital ☐ Cruise ship ☐ Other (e.g., school, dormitory, tent) (specify):________________________ |
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☐ Purchase or eat food ☐ Go swimming ☐ Attend gathering of people ☐ Drink untreated water ☐ Other (specify):__________________________ |
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(specify): _______________ |
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We are nearly finished. I have a few questions about your (or the ill person’s) recent child care or school attendance.
Section 7: CHILD CARE AND SCHOOL INFORMATION |
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☐ Babysitter ☐ Care at home ☐ Other child care center ☐ Unknown ☐ Other (specify): _______________ |
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☐ Babysitter ☐ Care at home ☐ Self-care ☐ Unknown ☐ Other (specify): _______________ |
[Proceed if participant is ≥ 18 years of age and answering survey on behalf of themself. Otherwise skip section 8 and conclude interview]
Finally, I would like to ask about your recent sexual activity because Shigella can be spread through sexual contact. Shigella germs are very contagious; it takes just a small number of Shigella germs to make someone sick. People can get shigellosis when they put something in their mouths or swallow something that has come into contact with the stool of someone else who is sick with shigellosis. This can happen during sex.
As I stated previously, your responses are voluntary, and you may refuse to answer any question at any time. We ask all adults who were diagnosed with a Shigella infection these questions. Your answers to these questions will be kept private and may help us to identify how you became sick with a Shigella infection. This will also help us to prevent others from getting sick.
Do you wish to proceed with the next section?
If yes: Thank you [Begin section 8]
If no: That is OK. We appreciate the information you have given us. ☐ Refused/Prefer Not to Complete
[Skip to Section 9 to close out interview]
Section 8: RECENT SEXUAL ACTIVITY [Only ask if ≥ 18 years of age] |
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☐ Lesbian or gay ☐ Straight, that is not lesbian or gay ☐ Bisexual ☐ Something else (specify): _______________ ☐ I don’t know ☐ Prefer not to answer |
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☐ Male ☐ Female ☐ Transgender ☐ None of these ☐ Prefer not to answer |
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☐ Female ☐ Male ☐ Transgender Female ☐ Transgender Male ☐ Another ☐ Unknown ☐ Prefer Not to Answer |
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If yes to question 3b, read prompt. For the next questions I’m going to be more explicit about the kind of sex you had in the week before your illness started. This will help me to better understand how you could have become sick. |
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☐ Chlamydia ☐ Gonorrhea ☐ Syphilis ☐ Genital warts ☐ Herpes ☐ Other (specify):_____________ |
Section 9: CLOSING |
This is the end of the questionnaire. Thank you very much for your time. Would you like any additional materials about Shigella or can I answer any questions for you? |
Thank you for your time. Have a nice day.
[Conclude interview]
Public reporting burden of this collection of information is estimated to average 45 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 0920-1307
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2023-10-07 |