Outbreak-Specific Questionnaire

The Alabama Department of Public Health, Immunization Division, is investigating an outbreak of pertussis in your community. The current outbreak spans two counties. We are conducting a survey to help identify additional individuals who may have been exposed, those who may be ill, and those who may need treatment or preventative medicine.

You have been selected to participate in this survey either because of your illness or because you are listed as having been potentially around one of the ill individuals.

The survey should take no more than 10 minutes and your answers will be extremely helpful to us. Please note, your participation is completely voluntary and all information you give will be kept confidential to the extent legally possible. You may refuse to answer any question at any time. Neither your name nor any identifying information will appear on any report.

Date of Submission:

M-D-Y

Person's First Name:

* must provide value

Person's Last Name:

* must provide value

Person's Age Group:

* must provide value

If <18 years of age, parent's or guardian's name:

* must provide value

Person's Street Address of Residence:

Person's City of Residence:

Person's State of Residence:

* must provide value

Person's County of Residence:

* must provide value

Person's Zip Code of Residence:

Which facility or event did ______ visit or attend?

* must provide value

Shades Valley Community Church (June 1 - July 15)

YMCA Legacy Day Camp (June 4 - June 8)

Church of the Highlands - Grants Mill (June 27 - July 22)

Church of the Highlands - Greystone (June 28 - July 19)

YMCA Greystone (July 4 - July14)

Mount Laurel Elementary Summer Singers Camp (July 9 - July 13)

Mount Laurel Library (July 16)

Winshape Camp at Double Oak Community Church (July 16 - July 20)

Did not visit or attend any of these facilities or events

Has ______ had a cough, made a high-pitched whoop sound, stopped breathing while sleeping, or vomited after coughing that began after June 27, 2018?

* must provide value

When did ______'s cough begin?

* must provide value

M-D-Y

About how many days has the cough lasted?

* must provide value

Person's Date of Birth:

* must provide value

M-D-Y

Person's Sex:

* must provide value

Person's Race:

* must provide value

If other race, please specify:

Person's Phone Number:

* must provide value

Did ______ travel after developing a cough on ______?

If yes to travel, please specify dates and locations:

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Did ______ attend any group gatherings or activities after developing a cough on ______?

If yes to group gatherings or activities, please specify event, dates, and locations:

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.