Sample - Epi case survey

Appendix D:

Epidemiologic Contact Assessment Symptom Exposure

EPI CASE SURVEY SAMPLE

Appendix D. Epidemiologic Contact Assessment Symptom Exposure (Epi CASE) Survey

Form Approved

OMB No. 0923-0051

Exp. Date 02/28/2021

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reading instructions, obtaining signatures, and completing interview. 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 (0923-0051)

Version 08262019

INCIDENT CODE:|___|___| SITE # |___|___| INTERVIEWER ID|___|___|___| DATE:|___|___| - |___|___ | - |___|___|___|___| Registrant ID _________________

TIME STARTED |___|___| : |___|___ | |___| TIME ENDED |___|___| : |___|___ | |___| M M D D Y Y Y Y

H H M M A/P H H M M A/P

IDENTIFICATION PROVIDED
Social Security _ _ _ - _ _- _ _ _ _ Driver’s license: State __ __ Number_________________exp __ / __/ __ ____	State ID: State __ __ Number________________exp __ / __/ __ ____ Other ID (describe)_________________________
REGISTRANT PERSONAL INFORMATION
1. Name _______________ , _________________ ___ Last First M.I. 2. Date of Birth (mm/dd/yyyy) _ _/_ _ /_ _ _ _		5. Social media account (check all that apply and specify) Facebook ______________________________________ Twitter _______________________________________ Instagram _______________________________________ Other _______________________________________ Refused 
3. A. Street ____________________________ City _________________ County_________________ State ________________ ZIP ____________________ B. How many children younger than 13 years were in your immediate care during the incident? _______ If 1 or more, complete Question 19 AFTER completing Questions 4–18.		6. What are the best telephone numbers to reach you? A. (_ _ _ ) _ _ _ -_ _ _ _ Cell  Home  Work  B. (_ _ _ ) _ _ _ -_ _ _ _ Cell  Home  Work 
4. Email _________________________________		7. Sex (circle one) Male Female Other (specify)_____________________________________ 8. If female, (circle one) Pregnant Not pregnant Don’t know/refused
EMERGENCY CONTACT INFORMATION (Must live at a different address than registrant)
9. Name ___________________ , ___________ , _____ (Last, First, M.I.)		11. Email _________________________________________
10. Street address ________________________________ City _________________ County_________________ State __ __ ZIP ____________________		12. What are the best telephone numbers to reach them? A. (_ _ _ ) _ _ _ -_ _ _ _ Cell  Home  Work  B. (_ _ _ ) _ _ _ -_ _ _ _ Cell  Home  Work 

EXPOSURE INFORMATION on [DATE] at [TIME]

13. Were you exposed to this incident as

(check all that apply):

 Facility employee (if applicable)

 Passerby  First responder

 Clean-up worker or volunteer

 Government official (including military)

 Resident Skip to Question 15

 Other _______________

14. A. Street address________________________________

City _________________ County_________________

State _________________ ZIP ____________________

B. Nearest intersection/building/landmark

_______________________________________________

15. Physical location (check all that apply)

 Inside building  Outside  Inside a car/vehicle

 Other ________________

HEALTH/NEED

16. As a result of this incident, did you get injured or ill? Refer to Epi CASE Symptom Checker for codes

 Yes

 No

 Don’t know/refused

17. As a result of this incident, are you personally in need of anything? (check all that apply)

 Medicine or medical supplies  Medical care

 Mental health care  Water  Shelter  Food

 Utilities  Transportation

 Other, specify _________________________________

 Don’t know/refused

18. For radiological and nuclear incidents only: If you had repeated vomiting AFTER the incident, how long after the incident [date and time] did it start? (circle one) less than 1 hour 1-2 hours 3-6 hours more than 6 hours Did not vomit Don’t know/Refused

CHILDREN YOUNGER THAN 13 YEARS IN YOUR IMMEDIATE CARE DURING THE INCIDENT

19. For each child, please provide the date of birth or age, sex, and injuries or illness that resulted from this incident. Refer to the Epi CASE Symptom Checker for codes.

	Date of birth (mm/dd/yyyy)	Age (years)	Sex (circle one)	Child’s injury or illness
1.	__/_ _ /_ _ _ _	_____	Male Female
2.	__/_ _ /_ _ _ _	_____	Male Female
3.	__/_ _ /_ _ _ _	_____	Male Female
4.	__/_ _ /_ _ _ _	_____	Male Female
5.	__/_ _ /_ _ _ _	_____	Male Female