Form 9 Form 9 NARMS SIRI Module 5

Form Approved

OMB No: 0XXX-XXXX

Expires: XX/XX/20XX

Module 5: Typhoid/Paratyphoid

Section 1: Interviewer & Patient Information Questions 1-13 to be completed by interviewer prior to questionnaire administration. Note to interviewer: Review available information from the case report form or other investigation form prior to interview.
PulseNet ID #: ________________________ and/or WGS ID: ______________________			State/Local/Other ID #: _____________________
NARMS specimen ID: __________________ ☐ Don’t know		NORS ID: __________________ ☐ No NORS ID ☐ Don’t know
List any other laboratory IDs linked to this episode or person: _____________________________________________________________________
Date of Interview:	__ __ / __ __ / __ __ __ __ M M D D Y Y Y Y
Interviewer Agency or Organization: _____________________________________________________________
Language interview conducted in ☐ English ☐ Spanish ☐ Other (specify): _______________
Respondent was: ☐ Self ☐ Parent ☐ Spouse or domestic partner ☐ Other (specify): _______________
Before this interview, was the patient (or their surrogate) interviewed about their illness by a local or state public health official? ☐ Yes ☐ No ☐ Don’t know
Was follow up culture or other testing done to confirm infection cleared from stool? ☐ Yes ☐ No ☐ Don’t know If yes, describe type of test(s), results, and dates: _____________________________________________________________________________________________________________________

Hello, my name is <interviewer name>. I am calling on behalf of the <state health department name>. Is this [name]? We are contacting you about a recent illness. You may have already been contacted by the health department. I would like to ask you a few additional questions about your (the patient’s) illness and about any exposures you (the patient) may have had before becoming ill. Your help in the investigation is very important and may help prevent others from getting sick. 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 20 minutes. Are you willing to participate? Make sure the patient is over 18. If they are a minor, you need parental consent to interview.

☐ Yes

Thank you. Before we begin, can you confirm your date of birth for me? This is done to protect their security and make sure you are talking to the correct person.

Now that I have confirmed your identity, I can tell you that we are talking about your recent Salmonella <Typhi or Paratyphi> diagnosis. <Typhoid or Paratyphoid> fever was detected after you provided your health care provider with a specimen, such as stool or blood.

☐ No

Thank you for your time. Can I answer any questions for you? If you wish at any time to complete the questionnaire, please call <phone number>.

Section 2: Clinical Information and Risk Factors: Now I have a few questions about your (the patient’s) illness, any medical conditions you (the patient) have or have had, and any procedures you (the patient) have had.

1. Describe your (the patient’s) clinical course (progression of symptoms from start to finish):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Did your illness result in any of the following?

☐ Sepsis ☐ Liver failure ☐ Kidney failure ☐ Enlarged liver ☐ Enlarged spleen ☐ Bowel perforation ☐ Abdominal surgery

Note to interviewer: Review available information from case report form or other investigation form. If the patient was admitted to hospital, ask questions 3 and 4. If they were not admitted to hospital, skip to question 5.

3. How many nights did you (the patient) spend in the hospital? _____________ ☐ Don’t know

Yes

Maybe

No

Don’t Know

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4. Did you (the patient) stay overnight in an Intensive Care Unit (ICU) or Critical Care Unit (CCU)?

1. How many nights in ICU or CCU? _______________

2. Why were you (the patient) admitted to ICU? ___________________________________________________________________________________

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5. Did you (the patient) take any antibiotics for this illness? If yes, I will be asking more questions about the antibiotic, so it may be helpful to get the pill bottles or packages if available.

Examples of antibiotics are azithromycin (called Zithromax), amoxicillin (Amoxil), amoxicillin/clavulanic acid (Augmentin), ciprofloxacin (Cipro) cephalexin (Keflex), trimethoprim-sulfamethoxazole (Bactrim or Septra).

1. Please list the name, start date and duration for every antibiotic.

Antibiotic name

Start date (MM/DD/YYYY; for any part of the date not known, enter ‘99’ or ‘9999’)

Duration (days)

1

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

2

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

3

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

4

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

5

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

6

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

7

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

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If the patient is not a female of childbearing age, skip question 7.

6. At the time your illness began, were you pregnant?

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7. In the year before illness, did you (the patient) visit, work, or volunteer in doctor’s office or clinic, urgent care, emergency department, hospital, or other healthcare setting?

Doctor’s office or clinic?	☐ Yes	☐ No	☐ Maybe	☐ Don’t Know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
Urgent care?	☐ Yes	☐ No	☐ Maybe	☐ Don’t Know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
Emergency department?	☐ Yes	☐ No	☐ Maybe	☐ Don’t Know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
Hospital?	☐ Yes	☐ No	☐ Maybe	☐ Don’t Know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
If visit, where you (the patient) admitted overnight to the hospital?	☐ Yes	☐ No	☐ Maybe	☐ Don’t Know
If yes, describe indication, dates, and duration	_______________________________________________________________________________________________________________________________________
Other health care setting?	☐ Yes	☐ No	☐ Maybe	☐ Don’t Know
If yes, specify setting:	_____________________________________________
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know

In the 3 months before illness, did you (the patient)

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8. Take an antibiotic by mouth or injection?

Please list the name, start date (at least the month) and duration for every antibiotic.

Antibiotic name

Start date (MM/DD/YYYY; for any part of the date not known, enter ‘99’ or ‘9999’)

Duration (days)

1

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

2

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

3

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

4

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

5

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

6

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

7

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

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9. Take any medication to block stomach acid (e.g., proton pump inhibitors, histamine antagonists, antacids)?

If yes, what type?

☐ Proton pump inhibitors (e.g., Dexlansoprazole/Dexilant, Esomeprazole/Nexium, Lansoprazole/Prevacid, Omeprazole/Prilosec, Omeprazole-sodium bicarbonate/Zegerid, Pantoprazole/Isopan, Rabeprazole/AcipHex)

☐ Histamine antagonist (e.g., Cimetidine/Tagamet, Famotidine/Pepcid, Nizatidine/Axis, Ranitidine/Zantac)

☐ Antacids (e.g., Amphojel, Dialume, Genaton, Maalox, Di-Gel, Gelusil, Mylanta, Rulox, Tempo, Gaviscon, Ami-Lac, Pepto, Caltrate, Tums, Rolaids, Gas-X with Maalox, Riopan, Milk of Magnesia, Ri-Mag, Ron-Acid)

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10. Take any antidiarrheal or antimotility medication (e.g., Pepto-Bismol, Kaopectate, Immodium, Lomotil)?

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11. Take any probiotics (e.g., yogurts and other fermented dairy products, capsules, pills, powders, any foods or drinks labeled as containing ‘live and active capsules’ or ‘probiotics’)?

If yes, what type:

Capsule or Pill?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Powder?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Drink?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Yogurt (non-drinkable)?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Other?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
If yes, please specify:		____________________________________________________

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12. Take any laxatives of stool softeners (e.g., Senna, Docusate, Bisacodyl, Lactulose)?

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13. Have you (the patient) been diagnosed with typhoid or paratyphoid fever in the past?

1. When? ___/___/_____

Have you (the patient) ever been told by a physician that you (the patient) have or had any of the following conditions:

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14. Immune deficiency or a condition that could lead to immune deficiency (e.g., complement deficiency, antibody or immunoglobulin deficiency, asplenia)?

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15. Sickle cell disease?

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16. Cancer (including leukemia/lymphoma)?

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17. Diabetes?

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18. Irritable bowel syndrome?

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19. Peptic ulcer disease?

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20. Gastroesophageal reflux disease?

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21. Liver cirrhosis or liver failure?

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22. Other chronic health condition?

1. Specify: ___________________________________________________________

Have you (the patient) ever had any of the following procedures or treatments:

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23. Immunosuppressive medicine, such as medicines you would take for an autoimmune disease, cancer or organ transplant?

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24. Radiation therapy?

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25. Bariatric surgery (e.g., gastric bypass, gastric banding)?

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26. Other abdominal surgery (e.g., removal of appendix, removal of gall bladder, any surgery of the stomach, small intestine or large intestine)?

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27. Organ transplant (e.g., kidney)?

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28. Bone marrow transplant?

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29. Have you (the patient) ever received a dose of typhoid conjugate vaccine?

1. When was it administered? __ __ / __ __ __ __

M M Y Y Y Y

2. Country administered? _______________________________________

Section 2 Comments.

Section 3: Epidemiological Data: Now I have a few questions about your (the patient’s) occupation, household, and travel.

1. What is your occupation? (specify): ________________________________________________________________________  ☐ Declined to answer

1. Did you work, volunteer, or attend any of the following in the 30 days (typhoid fever) or 10 days (paratyphoid fever) before illness began?

☐ Daycare ☐ School ☐ Aged care ☐ Preparing or handling food

1. If yes, specify:

________________________________________________________________________

2. What were the dates attended?

________________________________________________________________________

Yes

Maybe

No

Don’t Know

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2. Do others live in the same household as you (the patient)?

1. How many other household members are there? _____________ Don’t Know

2. List the relationship, age, sex, and whether they had a similar illness for each household member.

Relationship	Age (years)	Sex	Similar illness?	If yes, when did they first become ill?	If yes, confirmed typhoid/ paratyphoid diagnosis?
		☐ Male ☐ Female	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know	☐ Before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t Know	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know
		☐ Male ☐ Female	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know	☐ Before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t Know	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know
		☐ Male ☐ Female	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know	☐ Before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t Know	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know
		☐ Male ☐ Female	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know	☐ Before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t Know	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know
		☐ Male ☐ Female	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know	☐ Before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t Know	☐ Yes ☐ No ☐ Maybe ☐ Don’t Know

For interviewer only:

6. If household member(s) has a confirmed typhoid/paratyphoid fever, what is their PulseNet or WGS ID(s)? _____________________________________________

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3. Did you (the patient) have close contact with someone with a similar illness in the 30 days (typhoid fever) or 10 days (paratyphoid fever) before your (the patient’s) illness began who does not live in your household?

1. Did they have a confirmed typhoid/paratyphoid fever diagnosis?

☐ Yes ☐ Maybe ☐ No ☐ Don’t know

For interviewer only:

1. If yes, what is their PulseNet or WGS ID? ____________________________

2. What is your relationship to them? ______________________________________________

___________________________________________________________________________

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3. Did anyone else become ill after contact with you (the patient) (i.e., any known secondary cases in the US)?

1. Specify ________________________________________________________________

________________________________________________________________

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3. Did you (the patient) travel or live outside the United States in the 12 months before illness began?

1. Please provide details for each travel location:

• City and Country	Date of Arrival	Date of Departure	Accommodation Type & Name	Reason(s) for Travel
  				Tourism Business or work Visiting friends or relatives Other:________________
  				Tourism Business or work Visiting friends or relatives Other:________________
  				Tourism Business or work Visiting friends or relatives Other:________________
  				Tourism Business or work Visiting friends or relatives Other:________________
  				Tourism Business or work Visiting friends or relatives Other:________________

  If the patient did not travel in the 30 days before illness (typhoid fever) or 10 days before illness (paratyphoid fever), skip to question 6.

• If the patient spent all 30 (typhoid fever) or 10 (paratyphoid fever) days before illness began outside of the U.S., answer questions 5b-5g and skip to Section 7: Race, Ethnicity, and Languages.

• If the patient spent some of the 30 days (typhoid fever) or 10 (paratyphoid fever) days before illness began outside of the U.S., answer all questions below.

During your (the patient’s) international travel in the 30 days (typhoid fever) or 10 days (paratyphoid fever) before illness began:

2. Were there traveling companions that became ill? Yes No Don’t know

i. If yes, describe: ___________________________________________________________

3. Did you (the patient) eat food from any of the following?

   Restaurants?	Yes No Maybe Don’t know
   Street foods?	Yes No Maybe Don’t know
   Grocery stores or bodegas?	Yes No Maybe Don’t know
   Prepared by friends or relatives?	Yes No Maybe Don’t know
   Other sources? ________________________________

4. Where did the water you (the patient) drank came from?

Municipal / tap Well water Bottled water Other, specify_______________ Don’t know

5. Did you (the patient) swim in, wade in, or enter a pool, ocean, lake, pond, river, stream, or natural spring? Yes No Maybe Don’t know

If yes, specify: _____________________________________________________________

6. Was any food brought back to the US? Yes No Maybe Don’t’ know

i. If yes, describe food item(s): _______________________________________________

ii. If yes, did you (the patient) eat this food(s)? Yes No Maybe Don’t know

7. Was any healthcare sought during the trip, or were health facilities visited for any reason?

Yes No Don’t know

i. If yes, describe names/locations: _____________________________________________

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6. Did a close contact travel or live outside the United States during the 90 days before your (the patient’s) illness began?

1. What is your (the patient’s) relationship to this person? _____________________________

2. Where did this person travel?

3. City and Country	Date of Arrival	Date of Departure	Accommodation Type & Name	Reason(s) for travel
   				Tourism Business or work Visiting friends or relatives Other
   				Tourism Business or work Visiting friends or relatives Other
   				Tourism Business or work Visiting friends or relatives Other
   				Tourism Business or work Visiting friends or relatives Other

   Did this person become ill? Yes No Don’t know

4. Were there traveling companions that became ill? Yes No Don’t know

i. If yes, describe (e.g., relationship to the patient, age, sex, symptom onset): ______________________________________________________________________________________________________________________________________________________

5. Did the close contact eat food from any of the following?

   Restaurants?	Yes No Maybe Don’t know
   Street foods?	Yes No Maybe Don’t know
   Grocery stores or bodegas?	Yes No Maybe Don’t know
   Prepared by friends or relatives?	Yes No Maybe Don’t know
   Other? ________________________________

6. Where did the water the close contact drank came from?

Municipal / tap Well water Bottled water Other, specify_______________ Don’t know

7. Did the close contact swim in, wade in, or enter a pool, ocean, lake, pond, river, stream, or natural spring? Yes No Maybe Don’t know

If yes, specify: _____________________________________________________________

8. Did the close contact bring any food back? Yes Maybe No Don’t know

i. If yes, describe food item(s): _______________________________________________

ii. If yes, did you (the patient) or anyone who became ill eat this food(s)?

Yes No Maybe Don’t know

Did the close contact travel anywhere else internationally in the last year?

Yes No Maybe Don’t know

i. If yes, describe locations and dates: ___________________________________________

In the 30 days (Typhoid) or 10 days (Paratyphoid) before your (the patient’s) illness began, did you (the patient):

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7. Travel to another state in the US?

City and State	Date of Arrival	Date of Departure	Accommodation Type & Name

List all cities and states inside the United States where you (the patient) might have purchased or eaten foods. This includes foods eaten at airports, bus, or train stations.

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8. Attend a gathering outside of your home (e.g., wedding, religious, sporting, entertainment, or cultural event)?

1. What was the gathering? ______________________________________________________

2. Where was the gathering? ______________________ (If outside the US, specify the country)

3. When was the gathering? _______________________

Section 3 Comments.

SUSPECTED FOOD
Yes	Maybe	No	Don’t Know
☐	☐	☐	☐	Was there a particular food or drink that you (the patient) had in the 30 days (Typhoid) or 10 days (Paratyphoid) before illness began that you think could have led to the illness?
				Please specify: ______________________________________________________________________

Section 4: Sources of food prepared at home: Now I have a few questions about where the food you (the patient) ate came from that was prepared at home in the 30 days before your illness began (10 days for paratyphoid fever). This isn’t necessarily where you shopped during that week, but where the food you (the patient) ate came from, which could include older shopping purchases. This could include grocery stores, warehouse stores, farmers’ markets, home delivery, delis, swap meets, ethnic or specialty markets, butchers, live animal markets, food or meal subscription services, or groceries that were bought several weeks ago but consumed in the 30 days (10 days for paratyphoid) before you (the patient) got sick. I’m going to ask a few questions about stores you (the patient) may have shopped at, as well as any shopper card numbers you (the patient) may have. Store shopper or membership information can help provide detailed information, such as brands, varieties, purchase date, that you may not know or remember. You may also be able to access your own purchase history through an online account. We can then compare it with other people’s purchase histories to see if the same food is reported or identified. Your purchase history will only be shared on a need-to-know basis with local, state, or federal staff during the investigation. This information could help prevent additional illnesses. Additionally, I’ll also ask a few questions about dietary practices and restrictions.

1. Do you (the patient) keep Halal? ☐ Yes ☐ No ☐ Don’t’ know

2. Do you (the patient) keep Kosher? ☐ Yes ☐ No ☐ Don’t know

3. Do you (the patient) follow any other type of diet or have other dietary restrictions? ☐ Yes ☐ No (if yes, specify) _________________________________________________________________________________________________________________

4. Please specify all locations you (the patient) may have shopped at (please list store names, address/location, and shopper card # (if applicable) mentioned by the interviewee below: Remember to collect all shopper cards used for the household. Sometimes shopper card numbers can be phone numbers.)

Store/Supermarket/ Subscription Services	Address/Location	Purchase/Shopping Method	Store Shopper or Membership Information	Records of Online/App Orders (if applicable)
		☐ In-Person ☐ Online/App & Pick-Up or delivery		☐ Yes ☐ No
		☐ In-Person ☐ Online/App & Pick-Up or delivery		☐ Yes ☐ No
		☐ In-Person ☐ Online/App & Pick-Up or delivery		☐ Yes ☐ No
		☐ In-Person ☐ Online/App & Pick-Up or delivery		☐ Yes ☐ No
		☐ In-Person ☐ Online/App & Pick-Up or delivery		☐ Yes ☐ No
		☐ In-Person ☐ Online/App & Pick-Up or delivery		☐ Yes ☐ No

5. Did you (the patient) consume groceries purchased online or through an app such as Instacart, Amazon, Whole Foods, etc.? ☐ Yes ☐ No (if yes, specify in the table above)

6. Did you (the patient) consume food provided by online meal kit or meal delivery services such as Hello Fresh, Blue Apron, etc.? ☐ Yes ☐ No (if yes, specify in the table above)

7. May we have permission to retrieve purchase history based on your (the patient’s) store shopper or membership information and share with other public health officials to help with this investigation? Although we will collect your purchase history, we will not release any further information about you (the patient) or your (the patient’s) illness. Please modify wording to fit your state’s needs ☐ Yes ☐ No

Section 4 Comments: Additional Store/Retail Names and Locations.

Section 5: Sources of food prepared outside the home: Now I have a few questions about the food that you (the patient) ate outside your (the patient’s) home or that was prepared outside your home such as restaurants, fast food chains, or take out. It could be helpful to check credit card statements or receipts or phone photos to refresh your memory. I’m going ask about each place you (the patient) would have eaten food from during the 30 days (10 days for paratyphoid fever) before you were sick.

1. Please specify all restaurants/stores you (the patient) may have eaten at (please list names, address/location, meal dates, and food ordered/eaten by the interviewee below)

Location Name	Address/Location	Meal Date(s)	Food Ordered/Eaten

To make sure we’ve covered all the possible restaurants/stores you (the patient) may have eaten at, did you (the patient):

2. Eat ready-to-eat foods from a grocery store salad bar, hot bar, or deli? ☐ Yes ☐ No (if yes, specify in table)

3. Eat foods from a food truck or food stand ☐ Yes ☐ No (if yes, specify in table)

4. Eat any food from catered events such as a parties, conferences, weddings, etc.? ☐ Yes ☐ No (if yes, specify in table)

5. Eat any food items from a school, work, or hospital cafeteria? ☐ Yes ☐ No (if yes, specify in table)

6. Eat any foods prepared by friends or relatives? ☐ Yes ☐ No (if yes, specify in table)

7. Eat any foods that friends or family brought back or sent from another country? ☐ Yes ☐ No

If yes, what was the food? __________________________________________________________________________

Where was the food from? ____________________________________________________________________

How was it stored? ___________________________________________________________________________

8. For the restaurant and fast food locations identified, did you order from delivery service such as Uber Eats, Grub Hub, or Door Dash? ☐ Yes ☐ No (if yes, specify in table)

Section 5 Comments: List Additional Restaurant/Retail Names and Locations.

Section 6: Water Exposure: Now I have a question about the water that you (the patient) drank in the 30 days (typhoid fever) or 10 days (paratyphoid fever) before your (the patient’s) illness began and a question about any swimming in the 30 days (typhoid fever) or 10 days (paratyphoid fever) before your (the patient’s) illness began in the United States.
Where did the water that you (the patient) drank in the United States 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 in the United States?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes, specify: ________________________
Section 6 Comments.

Section 7: Race, Ethnicity, and Languages: In this section, we will ask questions about your (the patient’s) race, ethnicity, and languages spoken at home. We are collecting this information from all ill people. By knowing more about your (the patient’s) race, ethnicity, and languages we can get a better idea of health risks you (the patient) may have and foods you might eat, that might help us identify what caused you to become sick. You (the patient) may belong to more than just one race or ethnicity; please check all that apply to you (the patient). These questions are optional, and you may choose not to answer them.

American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc. _______________________________	Asian Chinese Asian Indian Filipino Vietnamese Korean Japanese Enter, for example, Pakistani, Hmong, Afghan, etc. _______________________________	Black or African American African American Jamaican Haitian Nigerian Ethiopian Somali Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congalese, etc. _______________________________
Hispanic or Latino Mexican Puerto Rican Salvadoran Cuban Dominican Guatemalan Enter, for example, Colombian, Honduran, Spaniard, etc. _______________________________	Middle Eastern or North African Lebanese Iranian Egyptian Syrian Iraqi Israeli Enter, for example, Moroccan, Yemeni, Kurdish, etc. _______________________________	Native Hawaiian or Pacific Islander Native Hawaiian Samoan Chamorro Tongan Fijian Marshallese Enter, for example, Chuukese, Palauan, Tahitian, etc. _______________________________
White English German Irish Italian Polish Scottish Enter, for example, French, Swedish, Norwegian, etc. _______________________________

1. What is your race and/or ethnicity? (Select all that apply and enter additional details in the spaces below)

2. What languages are spoken at home? ________________________________________________________________________ Declined to answer

Public reporting burden of this collection of information is estimated to average 20 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