Form 0920-25AU Sexual Contact Interview

Form Approved

OMB No. 0920-1446

Exp. Date: 3/31/2025

ATTACHMENT 7. SEXUAL CONTACT INTERVIEW FORM

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1446).

Before interview: visit this website to see which countries are listed as having recent human disease cases (as of 11/21/24: Bolivia, Brazil, Colombia, Cuba, Dominican Republic, Guyana, Panama, and Peru)

Complete before interviewing contact

Period of interest (from case interview): __________________________________________________

Date of first sexual encounter during period of interest: ______________________________________

Date of last sexual encounter during period of interest: ______________________________________

(provided by case during interview, confirm with contact)

Possible symptom onset window: Date of first sexual encounter with index case through 2 weeks after last sexual encounter during the period of interest.

Date of first sexual encounter with index case:	through	2 weeks after last sexual encounter during the period of interest:
(MM/DD/YY) ___/___/___		(MM/DD/YY) ___/___/___

[INTRO SCRIPT, ELIGIBILITY, CONSENT PROCESS]

Did you travel to [LIST COUNTRIES WITH RECENT OROPOUCHE VIRUS DISEASE CASES] since January 1, 2023?

o Yes o No

If yes, obtained dates of travel from (MM/DD/YY) ____/_____/_____ to _____/_____/_____ and location ________________________; if traveled to more than one location with recent Oropouche, record additional travel dates and location:______________________________________________

What is your sex?

o Female o Male

Pregnancy status (if applicable): o Yes o No o Unknown/Not sure

Between the dates of [possible symptom onset window], did you experience any of the following symptoms?

Symptom
o	Fever (subjective or objective)
o	Headache
o	Muscle aches
o	Joint pain/aches
o	Light sensitivity
o	Eye (retroorbital) pain
o	Rash over large parts of the body
o	Stiff neck
o	Confusion
o	Memory loss
o	Muscle weakness
o	Seizures
o	Other symptom(s): ___________________________________________________________ ___________________________________________________________________________
o	No symptoms experienced

If the respondent reports fever + at least one other listed symptom (NOT an “other” symptom ): Would you be willing to have a blood sample taken to test for signs of Oropouche virus infection? You would receive your results and information about what your test results mean.

o Yes, date of first symptoms (MM/DD/YY) ___/___/___ o No

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