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Appendix III:B-3. Health Surveillance Questionnaire - Legionellosis

Appendix III:B-3. Health Surveillance Questionnaire - Legionellosis
We at, ________________________(identify agency) are investigating a cluster of respiratory infections at _________________________(location), Records show that you took sick leave for three consecutive days or more. We would like to ask a few questions about your work absence.
  1. Name: (last)____________________, (first)__________________

    Age:______

    Gender: ______

    Work Location: ____________________

    Home Phone:___________

    Work Phone:________________________

  2. Dates of absence(s):______________________________________

  3. Stated reason for absence:________________________________
Ask about the following symptoms:
  1. Fever: Yes____ No____ Unsure____

    If yes, highest temperature _____.

  2. Cough: Yes____ No ____. If yes, was the cough productive? Yes____ No____

  3. Headache: Yes_____ No_____

  4. Diarrhea: Yes_____ No_____

  5. Shortness of breath: Yes ____ No ____

  6. Chest pain: Yes ____ No ____

  7. Did you see a physician about these symptoms? Yes ___ No ___

    Was a chest x-ray taken? Yes_____ No_____

    Were you tested for legionellosis? Yes_____ No_____ Don't Know______

    Were you diagnosed as having pneumonia? Yes _____ No _____. If no, what was the diagnosis? _____________________________________

    Physician's name:______________________ Phone:_____________

    Physician's Address:______________________________________

  8. Were you admitted to a hospital? Yes ____ No ____

    If yes, which hospital? ________________________(name) ____________________(location)

    Admission Date: _____/______/______

    Date released: _____/______/______

  9. Interviewer:________________________________

    Date:_____/______/______

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