Form 8 Form 8 NARMS SIRI Module 4

Form Approved

OMB No: 0XXX-XXXX

Expires: XX/XX/20XX

Module 4: Campylobacter

Dog exposure details (At Home): Now I have a few questions about any interaction you/your child may have had with dogs or puppies at home in the 7 days before illness began.
Yes	Maybe			No		Don’t Know	Did you (the patient):
☐	☐			☐		☐	Have a dog or puppy in the household?
							What was the age of the dog or puppy at the time of your (the patient’s) illness? ☐ <6 months ☐ 6 months – 1 year ☐ >1 year ☐ Don’t know What was the breed of the dog or puppy? Breed 1: _____________________________ Breed 2: ____________________________ Breed 3: _____________________________ ☐ Don’t know
If “no” or “don’t know” to question 1, skip to next section
☐	☐			☐		☐	Touch the dog or puppy?
☐	☐			☐		☐	Hold or snuggle the dog or puppy?
							How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after touching the dog or puppy? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after touching the dog or puppy? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐			☐		☐	Kiss the dog or puppy?
☐	☐			☐		☐	Feed or give water to the dog or puppy?
☐	☐			☐		☐	Touch the dog’s or puppy’s cage or enclosure? ☐ Do not have cage/enclosure (If checked, skip to question 8)
☐	☐			☐		☐	Clean the dog’s or puppy’s cage or enclosure?
							How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after touching the cage/enclosure? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after touching the dog or puppy? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐			☐		☐	Pick up the dog’s or puppy’s poop?
							How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after picking up the poop? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after picking up the poop? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐			☐		☐	In the 7 days before your (the patient’s) illness began, did the dog or puppy have diarrhea (defined as unformed or loose stools, usually occurring in larger amounts and/or more often than usual)?
							Did your (the patient’s) dog or puppy die? ☐ Yes ☐ No ☐ Don’t know
☐	☐			☐		☐	In the 30 days before your (the patient’s) illness, was the dog or puppy purchased from a pet store? (If “no” or “don’t know” skip to next section)
							At what store was the dog purchased? Store Name: ____________________________ Location: ______________________________ ☐ Don’t know When was the dog purchased? _____/_____/______ ☐ Don’t know We would like to share this information about your puppy with the Centers for Disease Control so they can share it with the location where you obtained your puppy, which might help in identifying your puppy's breeder. Please note that this information you provided might make it possible for the location where you purchased your puppy to identify you. Are you in agreement that this information can be shared with the CDC and the location where you purchased your puppy? ☐ Yes ☐ No ☐ Don’t know
☐		☐	☐		☐		Do you have a loyalty/shopper card for Petland or other pet store where the dog or puppy was purchased, and would you be willing to provide the number? We will use this number to help gather information about dogs or puppies purchased?
							Store name: ________________________________________ Number: ___________________________________________ Store name: ________________________________________ Number: ___________________________________________
☐		☐	☐		☐		Do you have a microchip number for your dog or puppy, and would you be willing to provide the number? We may use this number to help determine where the dog came from, such as breeder.
							Microchip number: __________________________________
Section Comments.

Dog exposure details (Outside The Home): Just a few more questions about any interaction you (the patient) may have had with dogs or puppies outside of your home in the 7 days before illness began.
Yes	Maybe	No	Don’t Know	Did you (the patient):
☐	☐	☐	☐	Touch any dogs or puppies in a pet store, at a friend’s house, or other location?
				Where did you (the patient) have contact with a dog or puppy or its cages or areas? ☐ Another person’s home ☐ Pet Store ☐ Other: _______________________ ☐ Don’t know If at a pet store, please provide more information. Name of store: ___________________________________________ Address of store: _________________________________________ When did you (the patient) have contact with a dog or puppy outside your home? _____/_____/______ _____/_____/______ ☐ Don’t know What was the age of the youngest dog or puppy you (the patient) were in contact with? ☐ <6 months ☐ 6 months – 1 year ☐ >1 year ☐ Don’t know What was (were) the breed(s) of dog or puppy you (the patient) had contact with? Breed 1: _____________________________ Breed 2: ____________________________ Breed 3: _____________________________ ☐ Don’t know
If “No” or “Don’t know” to question 1, skip to question 4
☐	☐	☐	☐	Hold or snuggle the dog or puppy?
				How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after touching the dog or puppy? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after touching the dog or puppy? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐	☐	☐	Kiss the dog or puppy?
☐	☐	☐	☐	Touch any dog or puppy cages or other areas where dogs or puppies were present?
				Where did you (the patient) have contact with a dog or puppy or its cages or areas? ☐ Another person’s home ☐ Pet Store ☐ Other: _______________________ ☐ Don’t know If at a pet store, please provide more information. Name of store: ___________________________________________ Address of store: _________________________________________ When did you (the patient) have contact with a dog or puppy outside your home? _____/_____/______ _____/_____/______ ☐ Don’t know What was the age of the youngest dog or puppy you (the patient) were in contact with? ☐ <6 months ☐ 6 months – 1 year ☐ >1 year ☐ Don’t know What was (were) the breed(s) of dog or puppy you (the patient) had contact with? Breed 1: _____________________________ Breed 2: ____________________________ Breed 3: _____________________________ ☐ Don’t know
If “Yes” or “Maybe to question 1 and “No” or “Don’t know” to question 4, skip to question 6 If “No” or “Don’t know” to both questions 1 and 4, skip to next section
☐	☐	☐	☐	Clean the dog’s or puppy’s cage or enclosure?
				How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after touching the cage/enclosure? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after touching the dog or puppy? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐	☐	☐	Feed or give water to the dog or puppy?
				How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after touching the cage/enclosure? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after touching the dog or puppy? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐	☐	☐	Pick up the dog’s or puppy’s poop?
				How often do you (does the patient) wash your (their) hands such as with soap and water or use hand sanitizer after picking up the poop? ☐ Always or almost always ☐ Sometimes ☐ Rarely ☐ Never What do you (the patient) use to clean your (their) hands after picking up the poop? ☐ Soap and water ☐ Alcohol-based hand sanitizer ☐ Both ☐ Other ☐ Nothing/Do not wash hands
☐	☐	☐	☐	In the 7 days before your (the patient’s) illness began, did the dog or puppy have diarrhea (defined as unformed or loose stools, usually occurring in larger amounts and/or more often than usual)?
				How many of the dogs or puppies had diarrhea? _______ Did any of the dogs or puppies die? ☐ Yes ☐ No ☐ Don’t know If yes, how many of the dogs or puppies died? _________
Section Comments.

Awareness and Education: The next questions have to do with your awareness of the connection between dogs and Campylobacter
Yes	Maybe	No	Don’t Know
☐	☐	☐	☐	Before this illness, were you aware of the connection between dogs or puppies and Campylobacter infection?
				How did you find this information? (Check all that apply) ☐ Magazine/newspaper ☐ Website/blog ☐ Employee at retail store ☐ Sign at retail store ☐ Friend/family ☐ Television ☐ Veterinarian ☐ Healthcare provider ☐ Other: ___________________________
Is there any other information you would like to share about this illness or about contact with dogs or puppies?

Eggs, Dairy, and Cheese: Now I have a few questions about eggs, dairy, and cheese products you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) could have eaten these either in your home or away from home, such as in a restaurant, take-out, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	Did you (the patient):
☐	☐	☐	☐	Eat any eggs or egg-containing dishes prepared at home? Type, variety, brand: ____________________________________________________ ☐ Don’t know Place purchased from (names, locations): ____________________________________ ☐Don’t know
☐	☐	☐	☐	Eat any eggs or egg-containing dishes prepared outside the home? Place purchased from (names, locations): ____________________________________ ☐Don’t know Dish Eaten: ____________________________________________________________ ☐Don’t know
☐	☐	☐	☐	Eat anything made with raw eggs that was not fully cooked (cookie dough, cake batter, sauces, homemade ice cream, homemade mayo, homemade salad dressing etc.)? Please describe: _______________________________________________________ ☐Don’t know
☐	☐	☐	☐	Drink or use any raw (unpasteurized) milk?
				How did you use the raw milk? ☐ Drink ☐ Cook ☐ Other _______________________ What type of milk (cow, goat, other)? __________________________________________ Where did you get the raw milk from? (store name, dairy, relative, friend, online purchase, etc.): __________________________________ Location (cross-streets, city): _______________________________________ Date(s) purchased: _____________________________________ Brand name (if purchased from a store): ________________________ Any leftover milk for testing? ☐ Yes ☐ No ☐ Don’t Know
☐	☐	☐	☐	Eat any cheese made from unpasteurized or raw milk, including homemade, farm-fresh, and door-to-door cheeses?
				Type, variety, brand: _______________________________________________________ ☐Don’t know
Section Comments.

Poultry: Now I have a few questions about chicken and other poultry that you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. This does not include canned items, but the poultry could have been fresh, frozen, or could have been eaten as part of dish. You (the patient) could have eaten these either in your home or outside the home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
Yes		Maybe	No		Don’t Know		Did you (the patient) eat any:
☐		☐	☐		☐		Whole chicken, including rotisserie or roasted chicken?
							If eaten at home: How was the chicken purchased? ☐ Raw, fresh ☐ Raw, frozen ☐ Already cooked ☐ Don’t know What was the type, variety, brand? ____________________________________ ☐ Don’t know Was it organic? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Place purchased from (names, locations): ________________________________ ☐ Don’t know Purchase date: _____/_____/_____ ☐ Don’t know If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: _____/_____/_____ USDA Establishment # P___________________ (the establishment # starts with “P”) Is a receipt available from this purchase? ☐ Yes ☐ No ☐ Don’t Know Is any of the chicken purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Would you be willing to have the leftover product collected by health officials for testing if needed? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Did you handle the chicken after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know ☐ Did not eat chicken at home
							If eaten outside the home, where? List name(s) and location(s): _______________________________________________ Meal date: ______/______/______ ☐ Don’t know Describe the dish: _____________________________________________________ ☐ Did not eat chicken outside the home
☐		☐	☐		☐		Pre-cut chicken parts or pieces, such as just breasts, drumsticks, thighs, wings?
							a. If eaten at home: How was the chicken purchased? ☐ Raw, fresh ☐ Raw, frozen ☐ Already cooked ☐ Don’t know What kind of chicken parts/pieces was purchased? ☐ Chicken breasts ☐ Thighs ☐ Wings ☐ Drumsticks ☐ Other:_______________ Were the parts/pieces boneless or bone-in? ☐ Boneless ☐ Bone-in ☐ Don’t know What was the brand?:_________________________________________ ☐ Don’t know Was it organic? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Place purchased from (names, locations):__________________________________ Purchase date: _____/_____/_____ ☐ Don’t know If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: _____/_____/_____ USDA Establishment # P___________________ (the establishment # starts with “P”) Is a receipt available from this purchase? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Is any of the chicken purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Would you be willing to have the leftover product collected by health officials for testing if needed? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Did you handle the chicken after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know ☐ Did not eat chicken at home
							b. If eaten outside the home, where? List name(s) and location(s): _______________________________________________ Meal date: ______/______/______ ☐ Don’t know Describe the dish: _____________________________________________________ ☐ Did not eat chicken outside the home
☐		☐	☐		☐		Ground chicken?
							If eaten at home: How was the chicken purchased? ☐ Raw, fresh ☐ Raw, frozen ☐ Already cooked ☐ Don’t know What was the percent fat/lean? ________________ ☐ Don’t know What was the brand?:_________________________________________ ☐ Don’t know Was it organic? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Place purchased from (names, locations):__________________________________ Purchase date: _____/_____/_____ ☐ Don’t know If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: _____/_____/_____ USDA Establishment # P___________________ (the establishment # starts with “P”) What was the size of chicken package you purchased? ______ lbs ☐ Don’t know Is a receipt available from this purchase? ☐ Yes ☐ No ☐ Maybe ☐ No ☐ Don’t know Is any of the chicken purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Would you be willing to have the leftover product collected by health officials for testing if needed? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Did you handle the chicken after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know ☐ Did not eat ground chicken at home
							If eaten outside the home, where? List name(s) and location(s): _______________________________________________ Meal date: ______/______/______ ☐ Don’t know Describe the dish: _____________________________________________________ ☐ Did not eat ground chicken outside the home
☐	☐			☐		☐	Other chicken products such as livers, gizzards, hearts, sausage, meatballs, deli meat, etc.?
							If eaten at home, what was the: Type (liver, sausage, etc.), variety: __________________________________ ☐ Don’t know Brand? ____________________________________________________ ☐ Don’t know Place purchased from (names, locations): ____________________________________ Purchase date: _____/_____/_____ ☐ Unknown Is a receipt available from this purchase? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: ______/______/______ USDA Establishment #: P_____________ (the establishment # starts with “P”) Is any of the chicken purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Would you be willing to have the leftover product collected by health officials for testing if needed? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Did you handle the chicken after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know ☐ Did not eat other chicken products at home
							If eaten outside the home, where? List name(s) and location(s): _______________________________________________ Meal date: ______/______/______ ☐ Don’t know Describe the dish: _____________________________________________________ ☐ Did not eat other chicken products outside the home
☐	☐			☐		☐	Even if you (the patient) didn’t eat it yourself, did you (the patient) touch, handle, or prepare any chicken?
							What was the brand? __________________________________________________ What was the type, variety? _____________________________________________ Place purchased from (names, locations): _____________________________________ Purchase date: _____/_____/_____ ☐ Don’t know Is a receipt available from this purchase? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: _____/_____/_____ USDA Establishment # __P_________ (the establishment # starts with “P”) Is any of the chicken purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Would you be willing to have the leftover sample collected by health officials for testing if needed? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Did you handle the chicken after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know
☐	☐			☐		☐	Whole turkey or cut turkey pieces or parts, not including deli meats or other processed meat?
							a. If eaten at home, what was the: Type, variety, brand? ________________________________________________ Place purchased from (names, locations): _____________________________________ ☐ Did not eat turkey at home
							b. If eaten outside the home, where? List name(s) and location(s): ____________________________________________ ☐ Did not eat turkey outside the home
☐	☐			☐		☐	Ground turkey?
							a. If eaten at home, what was the: Type, variety, brand? :_________________________________________________ Place purchased from (names, locations): ____________________________­­­­­­­_____ ☐ Did not eat ground turkey at home
							b. If eaten outside the home, where? List name(s) and location(s): ____________________________________________ ☐ Did not eat ground turkey outside the home
☐	☐			☐		☐	Other poultry, like duck, game hen, or squab?
							Type, variety, brand: _______________________________________
Section Comments.

Water Exposure: Now I have questions about water exposure. In the 7 days before your (the patient’s) illness began,
Where did the water that you (the patient) drank come from?	☐ Municipal / tap ☐ Well water ☐ Bottled water ☐ Other, specify: __________________________________________________ ☐ Don’t know
Did you (the patient) swim in, wade in, or enter a pool, ocean, lake, pond, river, stream, or natural spring?	☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, specify:_____________________________________________________
Section Comments.

RECENT SEXUAL ACTIVITY [Proceed if participant is ≥ 18 years of age and answering survey on behalf of themself. Otherwise skip section] Finally, I would like to ask about your recent sexual activity because Campylobacter can be spread through sexual contact. People can get campylobacteriosis 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 campylobacteriosis. 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 Campylobacter infection these questions. Your answers to these questions will be kept private and may help us to identify how you became sick with a Campylobacter infection. This may also help us to prevent others from getting sick. Do you wish to proceed with the next section? If yes: Thank you If no: That is OK. We appreciate the information you have given us. ☐ Refused/Prefer Not to Complete
Which of the following best represents how you think of yourself?    ​​☐​ Lesbian or gay    ​☐​ Straight, that is not lesbian, gay, or bisexual    ​☐​ Bisexual     ​☐​ Something else (specify): _______________      ​​☐​  I don’t know      ​☐​ Prefer not to answer
Yes	No	Prefer not to answer
☐	☐	☐	Are you currently sexually active? (if no skip to question 3)
☐	☐	☐	If yes to question 2, since your illness started, have you had sexual contact with another person? Sexual contact would include genital sex, anal sex, oral sex, or any other sexual contact.
☐	☐	☐	If yes to question 2, in the 7 days before your illness started, did you have sexual contact with another person? Sexual contact would include genital sex, anal sex, oral sex, or any other sexual contact.
☐	☐	☐	If yes to question 2b, in the 7 days before your illness started did any of your sex partners have diarrhea or symptoms similar to your own?
			If yes to question 2b, 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.
			In the 7 days before your illness started, what kind of sexual contact did you have?
☐	☐	☐	Genital sex (for example, penis in the vagina)?
☐	☐	☐	Anal sex (for example, penis in the anus)?
☐	☐	☐	Oral sex (for example, mouth on penis or vagina)?
☐	☐	☐	Anilingus or rimming (meaning mouth on anus)?
☐	☐	☐	Other sexual contact (for example touching your partner’s anus with your hands, your partner touching your anus with their hands, or sharing of sex toys)?
☐	☐	☐	If yes to question 2b, in the 7 days before your illness started did you use drugs or alcohol during or immediately before sex?
			If yes to question 2biv, what did you use? ☐ Alcohol ☐ Viagra or similar ☐ Cannabis (marijuana) ☐ Ecstasy ☐ GHB/GBL (liquid ecstasy) ☐ Methamphetamine (crystal meth, Tina) ☐ Mephedrone (4-MMC, meow, methylone) ☐ Ketamine (K/Special K) ☐ Cocaine ☐ Poppers ☐ LSD (acid) ☐ Other (specify): ___________________________________ ☐ Prefer Not to Answer
			If yes to question 2biv, how did you use? ☐ Oral (by mouth) ☐ Inhalation ☐ Smoked ☐ Patch ☐ Skin popping/non-venous injection ☐ IV injection ☐ Other (specify): ______________________________ ☐ Prefer Not to Answer
			If yes to question 2biv, in what setting did you use? ___________________________ _____________________________________________________________________
			In the 7 days before your illness, how many sex partners did you have? specify):_________
☐	☐	☐	If yes to question 2b, were any of these partners new?
			If yes to question 2bv1, in the 7 days before your illness started, did you meet your new sex partner(s) at any of the following places?
☐	☐	☐	Bar, restaurant, or club? (specify): _______________________
☐	☐	☐	Bathhouse? (specify): _______________________
☐	☐	☐	Bookstore? (specify): _______________________
☐	☐	☐	Gym? (specify): _______________________
☐	☐	☐	Park? (specify): _______________________
☐	☐	☐	Social media sites? (specify): _______________________
☐	☐	☐	Dating or hookup sites? (specify): ______________________
☐	☐	☐	Party, conference, or other type of event? (specify): ______________
☐	☐	☐	Cruise ship? (specify name of ship and dates): ______________________
☐	☐	☐	Sex club or sex party? (specify): _______________________
☐	☐	☐	Other location I didn’t ask about? (specify): _______________
☐	☐	☐	In the past 12 months have you been told by a doctor that you have a sexually transmitted infection?
			If yes to question 2, which infection? (select all that apply) ☐Chlamydia ☐ Gonorrhea ☐ Syphilis ☐ Genital warts ☐ Herpes ☐ Other (specify):_____________

Public reporting burden of this collection of information is estimated to average 25 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0XXX-XXXX