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Appendix III:B-4. Epidemiological Questionnaire

Appendix III:B-4. Epidemiological Questionnaire
Background

Employee's Name: (last)___________________, (first) __________________

Age: _____

Gender: _____

Home address: (city)____________________, (zip)__________________


Race/Ethnicity (circle all that apply):
    African American, Asian, Caucasian, Latino/Hispanic, Native American, Pacific Islander, Other

Are you currently taking any oral steroid medications?: Yes / No


On what date did you first become ill?: ____ /____ /____

How many days were you ill?: _______

Was anyone else in your family ill?: Yes / No
    If Yes, who? ______________________________________

    What symptoms did they have? ______________________________
Since ___________, have any of your family, friends, or coworkers been diagnosed with pneumonia?:
    Yes / No. If Yes, who? __________________________, (relationship)____________________

Work Exposure
(During the 10 days prior to your illness)

Job Description: ________________________________________________

Primary work area: ______________________________________________

List all areas in _______ building where you spent any time:


Area

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

Hours per week

_______________________________

_______________________________

_______________________________

_______________________________

_______________________________

Did you shower at work?: Yes / No
    If Yes, where and how may times per week?: _________________
List all places you eat lunch: ____________________________________

List all places where you take a break: ____________________________

List all restrooms you use: ________________________________________

Do you smoke in the restrooms (or spend "extra" time, i.e., if a lounge is present): Yes / No
    If Yes, which restroom(s)?: _______________________________
Did you attend any training courses outside of the building?: Yes / No
    If Yes, where were they held? _______________________________
Do you have a second job?: Yes / No
    If Yes, what job and where:

    ____________________________________________________________________
Any other places that you have not mentioned where you spent time while on the job?:
    ____________________________________________________________________

Community Exposure

(During the two weeks prior to your illness)

Did you use any health clubs?: Yes / No
    If Yes, which ones?: ________________________________________

    How many times?: ______________________________________________
Did you use any hot tubs (whirlpool spas)?: Yes / No
    If Yes, list which hot tubs and when used:

    _____________________________________________________________
Did you attend any churches?: Yes / No
    If Yes, where ________________________________________________

    How many times? ____________
Have you had any dental work performed?: Yes / No
    If Yes, where _________________________________________

    How many times? ____________
Which grocery stores did you go to?: _____________________________
    How often? __________________
Did you go to the movies?: Yes / No
    If Yes, which one? ________________________________

    How often? ____________
Did you go to any shopping malls?: Yes / No
    If Yes, which one(s)? __________________________
Did you go to any other public places which you feel might be significant (i.e. public meetings, schools etc.)?: Yes / No
    If Yes, where? ___________________________________________
Did you engage in any activities that exposed you to water sprays or mists?: Yes / No
    If yes, which one(s)?__________________________________________________________

    How often? ___________________________
Did you travel or stay overnight somewhere other than usual residence?: Yes / No
    If yes, give cities, dates, and lodging.

    __________________________________________________________________________

    __________________________________________________________________________

    __________________________________________________________________________

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