Household Questionnaire

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM

Public reporting burden of this collection of information is estimated to average 15 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 D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
TEAM #: ________________

DATE: ______/_______/_________

Household ID (e.g., SJ-1-A): _______-______-_____

GPS Coordinates: _____.____________°N ______.______________°E
How many people live in this house? _______________people
List all members of household below put yourself first.

Name (First, Paternal, Maternal)

Age

Gender

Participate?

M/F

Yes / No

M/F

Yes / No

M/F

Yes / No

M/F

Yes / No

M/F

Yes / No

M/F

Yes / No

M/F

Yes / No

M/F

Yes / No

Place sticker here

1

2

3

4

5

6

7

8

Head of household contact number to facilitate return of test results:___________________________________________

CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
Household Characteristics
Housing type (check only one):

□Public housing

□ One story house

□ Two story house □

Apartment/condo building

□ Temporary shelter

Has anyone in your immediate household traveled outside of Puerto Rico in the past 3 months?
Has anyone in your household been sick in the past 3 months?

□ Yes

□ Yes

□ No

Does your home have screened windows and doors?

□ All rooms

Do you regularly use air conditioning in your home?

□ Yes, in all rooms □ Yes, but only in some rooms

Do you regularly leave your doors or windows open?

□ Daytime only

Do you use mosquito coils in your house or yard?

□

Notes:

Yes

□ No

□ Some rooms

□ No

□ No
□ No

□ Night-time only □ Always □ Never