PLEASE COMPLETE ONLY ONE SURVEY PER HOUSEHOLD
Dear Swine Exhibitor,
A recent diagnosis of [SWINE VARIANT] influenza in a [PIG/PERSON] at the [COUNTY FAIR] on [DATES] has raised concern for the health and welfare of the people exposed to swine at the county fair, as well as any pigs that may still be on your farm.
Symptoms of swine variant influenza infections in humans are similar to those of seasonal flu and may cause severe illness in some people. It is important to inform your family doctor if anyone in your family has come down with a fever, cough, body aches, or other respiratory symptoms. Please contact the [LOCAL HEALTH JURISDICTION] or the Michigan Department of Health & Human Services (MDHHS) if you or anyone in your family has been sick with these symptoms.
In addition, the [LOCAL HEALTH JURISDICTION] and MDHHS are gathering information on any potential human illness and/or contact with swine at the [COUNTY FAIR]. We are asking all exhibitors to please fill out this survey, regardless of health status.
Swine influenza in pigs is not a food safety concern. Therefore, you cannot get influenza by eating cooked pork or pork products.
Thank you for your time!
[LHD CONTACT INFORMATION]
Directions:
Your answers will remain anonymous unless you choose to provide your name and contact information.
The survey is to be completed by an adult member of the household. Please complete only one survey per household.
Household members are defined as people who slept in the household more than half the time from [DATE RANGE].
Please mark a response for each question. If the question does not apply, please check (N/A).
Please answer for each individual in the same order for each question. For example, if you consider 'Joe Smith' to be Individual 1, please continue to keep 'Joe Smith' as Individual 1 throughout the entire survey.
1. What is your County of residence? ____________________
2. May we contact you if we have additional questions? If so, please provide your name and phone number. _____________________________
3. Did you or anyone in your household attend the [COUNTY FAIR] between [DATE RANGE]?
Yes No (SKIP to end if No)
4. Please select the appropriate age range for you and the members of your household:
You Age Range 0-4 years 5-17 years 18-65 years > 65 years
Individual 1 Age Range 0-4 years 5-17 years 18-65 years > 65 years
Individual 2 Age Range 0-4 years 5-17 years 18-65 years > 65 years
Individual 3 Age Range 0-4 years 5-17 years 18-65 years > 65 years
Individual 4 Age Range 0-4 years 5-17 years 18-65 years > 65 years
Individual 5 Age Range 0-4 years 5-17 years 18-65 years > 65 years
Individual 6 Age Range 0-4 years 5-17 years 18-65 years > 65 years
5. Did you or any of your household members become ill with any of the following symptoms since [DATE]?
|No Illness |Fever |Sore Throat |Cough |Muscle Ache |Diarrhea |Short of Breath |Vomiting |Headache |Eye Redness |N/A | |You |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 1 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 2 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 3 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 4 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 5 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 6 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |
Please list any other symptoms below for each individual ______________________
6. Did you or anyone in your household become ill but did NOT attend the [COUNTY FAIR]?
You Yes No Unknown N/A
Individual 1 Yes No Unknown N/A
Individual 2 Yes No Unknown N/A
Individual 3 Yes No Unknown N/A
Individual 4 Yes No Unknown N/A
Individual 5 Yes No Unknown N/A
Individual 6 Yes No Unknown N/A
7. When did you or your household member first become ill?
Please approximate if exact date is unknown.
You _____/_____/_______ (MM/DD/YYYY)
Individual 1 _____/_____/_______ (MM/DD/YYYY)
Individual 2 _____/_____/_______ (MM/DD/YYYY)
Individual 3 _____/_____/_______ (MM/DD/YYYY)
Individual 4 _____/_____/_______ (MM/DD/YYYY)
Individual 5 _____/_____/_______ (MM/DD/YYYY)
Individual 6 _____/_____/_______ (MM/DD/YYYY)
8. Are you or is anyone in your household still sick?
You Yes No N/A
Individual 1 Yes No N/A
Individual 2 Yes No N/A
Individual 3 Yes No N/A
Individual 4 Yes No N/A
Individual 5 Yes No N/A
Individual 6 Yes No N/A
9. If not still ill, please list when you or your household member felt better. Please approximate if exact date is unknown or leave blank if the quest does not apply.
You _____/_____/_______ (MM/DD/YYYY)
Individual 1 _____/_____/_______ (MM/DD/YYYY)
Individual 2 _____/_____/_______ (MM/DD/YYYY)
Individual 3 _____/_____/_______ (MM/DD/YYYY)
Individual 4 _____/_____/_______ (MM/DD/YYYY)
Individual 5 _____/_____/_______ (MM/DD/YYYY)
Individual 6 _____/_____/_______ (MM/DD/YYYY)
10. Did you or anyone in your household seek medical care for the illness? If that person was hospitalized, please check the “Hospitalized” box
You Yes No Hospitalized N/A
Individual 1 Yes No Hospitalized N/A
Individual 2 Yes No Hospitalized N/A
Individual 3 Yes No Hospitalized N/A
Individual 4 Yes No Hospitalized N/A
Individual 5 Yes No Hospitalized N/A
Individual 6 Yes No Hospitalized N/A
11. Did you or anyone in your household have any direct contact with pigs at the [COUNTY FAIR]. Direct contact includes touching, feeding, washing, or performing similar activities with pigs. Please select all dates that apply.
|[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |N/A | |You |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 1 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 2 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 3 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 4 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 5 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 6 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |
12. Did you or anyone in your household have any indirect contact with pigs at the [COUNTY FAIR]. Indirect contact means coming within 6 feet of pig without known direct contact. Please select all dates that apply.
|[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |[DATE] |N/A | |You |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 1 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 2 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 3 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 4 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 5 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |Individual 6 |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ |δ | |
13. Did you or anyone in your household attend or participate in any of the swine showmanship, hog or swine shows, swine auction, or swine judging events at the [COUNTY FAIR]?
You Yes No Unknown N/A
Individual 1 Yes No Unknown N/A
Individual 2 Yes No Unknown N/A
Individual 3 Yes No Unknown N/A
Individual 4 Yes No Unknown N/A
Individual 5 Yes No Unknown N/A
Individual 6 Yes No Unknown N/A
14. On average, how much time per day did you spend in the swine barns while you were at the [COUNTY FAIR]?
You none ................
................
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