Interview Form - SOM - State of Michigan



MDHHS Vaping/lung injury CASE INTERVIEW FORM Revised 3/2/2020Instructions to interviewer: This questionnaire has been revised and shortened based on a revised interview created by CDC. When completed, upload the questionnaire as a PDF in the notes section of the patient’s MDSS file and notify Rita Seith (seithr@).We are no longer using OMS for data management. MDHHS will do data entry of the questionnaire into an MDHHS created and stored database.Interview FormINTERVIEW Patient or proxy (parent/guardian) interview?PatientProxyName of person completing this interview and phone number: _____________________________________ ________________________________________________________________________________________Local Health Department: _____________________________Date interview completed: _________________________***BEGIN INTERVIEW HERE***Suggested script to introduce yourself to the patient or a proxy:I'm calling from the [jurisdiction] Health Department. I'm calling because you might be part of a group of people who have gotten sick after vaping. Most people who have gotten sick have been hospitalized overnight with several ending up in the intensive care unit. We are working with hospitals, doctors and other health departments to try to understand what is causing this illness so that we can keep other people from getting sick. We heard about your illness from your health care provider. We would like to learn more about your symptoms and to understand if something you vaped might have made you sick. Do you have a few minutes to share your experience with this illness?Your responses will help us better understand what may be causing illness. PATIENT DEMOGRAPHICS ?SexMaleFemaleOtherHow do you describe your ethnicity?Hispanic or LatinoNot Hispanic or LatinoOtherHow do you describe your race? (select all that apply)WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderOtherAge (in years)?VAPING PRODUCTSThe next several questions are about vaping or e-cigarette use, such as JUUL, SMOK, Suorin, Vuse, or blu. You also may know them as vapes, vaporizers, mods, e-cigs, e-hookahs, dab pens, rigs, vape-pens, or electronic nicotine delivery systems (ENDS).Please consider the vaping of any substance:Did you vape or use e-cigarettes in the 3 months before you got sick?YesNoRefused to answerOther than vaping, in the last three months did you: [Select all that apply]Smoke tobacco products (for example, cigarettes, cigars)Smoke marijuana Use other tobacco products (like smokeless tobacco or hookah)Use other marijuana products (for example, edibles)The rest of the questions apply if the person answered yes.What substances did you vape within the 3 months before you got sick? [select all that apply]NicotineMarijuana, THC, THC Concentrates (e.g. dabs, dab wax, dab cards), hash oil, wax; includes Dank Vapes, Gorilla, and other THC brands CBD or CBD oil (also called cannabidiol)Synthetic cannabinoids (e.g. K2 or Spice)Flavors alone Other substances (specify___________________________________________________________)Don’t knowNicotine [Ask if nicotine was checked yes above] All questions apply to the three months before illness onset. When was the date of last use of a nicotine vaping/dabbing product: ______________ Approximately how frequently did you vape nicotine products?Daily (estimate how many times a day on average___________)A few times a week (specify how often ______________)A few times a month (specify how often_____________)Monthly or lessWere the nicotine-containing vape product(s) flavored?YesNoHow many different brands of nicotine vaping products did you use? ______List brand names and flavors________________,___________________,_____________________,_______________, ____________________,__________________,_________________Where was/were the nicotine e-cigarettes or vaping products purchased or obtained [select all that apply]Recreational dispensary Specify name(s) of facility and location(s)__________________________Vape or smoke shopSpecify name(s) of facility and location(s)__________________________Pop-up shopSpecify name(s) of facility and location(s)__________________________Grocery store/drugstore/convenience storeSpecify name(s) of facility and location(s)__________________________Family or friendDealerOnlineOther (Describe______________________________________________________What kind(s) of device(s) did you use to vape nicotine within the 3 months before you got sick? [Select all that apply.]Disposable e-cigarettes or vaping deviceE-cigarettes with pre-filled or refillable cartridges (e.g. using battery pens, Ego, EVO, Ooze pen, Caliplug, 510 battery)E-cigarettes with a tank that you refill with liquids (including sub-ohm or modifiable systems)E-cigarettes with prefilled or refillable “pods” or pod cartridges (for example JUUL, Suorin)Other (describe/specify type(s)________________________________________________Don’t Know Were any of the devices you used a “mod” device (a device that allows the user to choose higher/lower temperatures)? YesNoDon’t knowDid you modify or add a substance to the device(s) that was not intended by the manufacturer?Yes (explain___________________________________________________________NoDon’t knowDo you know anyone else who became ill from vaping nicotine?YesNo If yes, did you share your nicotine vape products with that person?YesNoDon’t knowIf yes, are you willing to share their name or pass along contact information for the EVALI team at the Michigan Department of Health and Human Services (MDHHS)?Record name & contact info of other person: __________________________________________________Or share Rita Seith’s email and phone number: SeithR@ 517-243-2426End of Nicotine questionsTHC or THC oil [Ask if THC was checked yes on p. 3.] All questions apply to the three months before illness onset.When was the date of last use of a THC vaping/dabbing product: ______________ Approximately how frequently did you vape THC?Daily (estimate how many times a day on average___________)A few times a week (specify how often ______________)A few times a month (specify how often_____________)Monthly or lessDid the THC-containing products you used contain flavors?YesNoHow many different brands of THC vaping products did you use in the past three months? ______ Which THC substance(s) were used in your e-cigarette, vaping device, vaporizer, or dab rig? [Select all that apply]Marijuana herbTHC oilsButane hash oilTHC concentrate (for example wax, batter/budder, crumble, shatter, pull and snap)THC powder (for example dry sift)Other (describe_______________________________________________________Where was/were the THC product(s) purchased or obtained? [Select all that apply and list by brand, flavors, and where obtained]THC Product Source CategoryBrandFlavorsFacility name(s) and location(s) where obtained Medical dispensary Recreational dispensary (retail cannabis/marijuana shop)Vape or smoke shop Pop-up shop Grocery store/Drugstore/Convenience storeDescribe how obtained Family or friend Illicit dealer Online OtherWhat kind(s) of device(s) were used with the THC products? [Select all that apply]Disposable deviceDevice with pre-filled cartridges Device with tank that you refill with liquids (e.g. mods)Device with pre-filled or refillable “pods” or pod cartridges (e.g. JUUL, Suorin)Dab rigVaporizer (for dry herbs etc.)Other (specify______________________________________________What kinds of THC cartridges(s) used with your devices(s)? [Select all that apply]RoveDank VapesGolden GorillaSmart CartOther (specify_____________________________________________)Were any of the devices you used a “mod” device (a device that allows the user to choose higher/lower temperatures)? YesNoDon’t knowDid you modify or add a substance to the device(s) that was not intended by the manufacturer?Yes (explain__________________________________________NoDon’t knowDo you know anyone else who became ill from vaping THC?YesNo If yes, did you share your THC products or devices with that person?YesNoIf yes, are you willing to share their name or pass along contact information for the EVALI team at the Michigan Department of Health and Human Services (MDHHS)?Record name & contact info of other person: __________________________________________________Or share Rita Seith’s email and phone number: SeithR@ 517-243-2426End of THC and related products questionsCBD or CBD oil [Ask if CBD was checked yes on p. 3.] All questions apply to the three months before illness onset. When was the date of last use of a CBD product: ______________ Approximately how frequently did you vape CBD?Daily (estimate how many times a day on average___________)A few times a week (specify how often ______________)A few times a month (specify how often_____________)Monthly or lessDid the CBD-containing products you used contain flavors?YesNoHow many different brands of CBD vaping products did you use? ______List brand names and flavors________________,___________________,_____________________,_______________, ____________________,__________________,_________________Where was/were the CBD vaping product(s) purchased or obtained [Select all that apply]Medical dispensary Specify name(s) of facility and location(s)__________________________Recreational dispensary Specify name(s) of facility and location(s)__________________________Vape or smoke shopSpecify name(s) of facility and location(s)__________________________Pop-up shopSpecify name(s) of facility and location(s)__________________________Grocery store/drug store/convenience store/Specify name(s) of facility and location(s)__________________________Family or friendDealerOnlineOther (Describe______________________________________________________What type(s) of device(s) did you use to vape CBD within the 3 months before you got sick? [Select all that apply.]Disposable e-cigarettes E-cigarettes with pre-filled cartridgesE-cigarettes with a tank that you refill with liquids (for example mods)E-cigarettes with prefilled or refillable “pods” or pod cartridges (for example JUUL, Suorin)Other (describe/specify type(s)________________________________________________Don’t KnowWere any of the devices you used a “mod” device (a device that allows the user to choose higher/lower temperatures)? YesNoDon’t knowDid you modify or add a substance to the devices that was not intended by the manufacturer?Yes (explain______________________________________________________NoDon’t knowDo you know anyone else who became ill from vaping CBD?YesNo If yes, did you share your CBD products or devices with that person?YesNo If yes, are you willing to share their name or pass along contact information for the EVALI team at the Michigan Department of Health and Human Services (MDHHS)?Record name & contact info of other person: __________________________________________________Or share Rita Seith’s email and phone number: SeithR@ 517-243-2426End of CBD or CBD oil questionsPRODUCT TESTING SECTION – (ELECTRONIC PRODUCTS ONLY):FOR CASES WITH BAL FLUID ONLYDo you have any device(s), substance(s), product(s), or product packaging left for any of the substances or products you used in the last 90 days (3 months)? YesNoUnknown[IF YES] Would you be willing to provide what you have for laboratory testing? [If yes]: please put products in a safe place and someone will get back to you about this.]YesNoOTHER NOTES (include other details of conversation with person interviewedDo you have a medical marijuana card? YesNoDeclined[IF YES] Would you be willing to provide your medical marijuana card number so MDHHS can look at purchases prior to hospital admission?Read the following to the patient:The Food and Drug Administration (FDA) is working with public health to try to figure out which products and devices are making people sick. The FDA’s goal is to ensure that the products that are making people sick are not available to anyone else. ? Would you be willing to talk to the FDA about the products and devices you used? Can we release your name and contact information to FDA? Yes, I give permission to release my name and contact information to the FDA.No, do not release my name to the FDA.Additional comments or concerns? ................
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