Now I'm going to ask you some questions about your community and home.
Q 3.1 For how long have you lived in your current town or city of residence?[Answer should be reported in years, months, weeks and/or days . [Interviewer, please fill in the appropriate line.]
Years_____________ Months_____________ Weeks______________ Days_______________ Q3.2 Do you live on a farm?
o Yes
o No
o Don’t know
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Q3.3 What type of farm do you live on? Your choices are: [Interviewer, read choices]
A farm that grows plants or crops
A farm that grows animals
Don't know
Refused to answer
Q3.4 Do the animals on the farm that you live on spend all of their time in confinement or in a house?
Yes
No
Don't know
Refused to answer
Q3.5 On average, how often do you smell odors from a livestock farm when you are at home, if ever?
Daily
Several times each week
Several time each month
Less than once a month
Never
Don't know
Refused to answer
Q3.6 How many of the following pets do you have living inside your home?
0 1-3 4-5 6-10 > 10 Don't know Refused to answer
Dogs
Cats
Q3.7 Which of these animals that lives inside your home also goes outside?
Dogs
Cats
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Q4.1 Outside of work, how often do you currently have direct contact with any of the following animals, if ever? Direct contact means that you touch the animals with your hands. [ Interviewer-ask each animal category and if there is contact check all the boxes that apply.]
No contact Less than
once/month About once/month Several times/month Several times each week Daily contact Pigs Chickens Turkeys Cows Horses Goats Dogs Cats PART FIVE
In the next two questions I will ask you about antibiotic use by you and by any member of your household. Q5.1 Starting the day before you were admitted to Pitt County Memorial Hospital, have you taken antibiotics:
a.) in the past 4 weeks? b.) in the past 6 months? c.) in the past year?
[Interviewer: If the participant answers yes to 4 weeks, then you do not need to ask about 6 months and the past year. If the participant answers yes to 6 months, then you do not need to ask about the past year.]
Yes No Don't know Refused to answer
In the past 4 weeks
In the past 6 months
In the past year
Q5.2 Starting the day before you were admitted to Pitt County Memorial Hospital, has someone in your household other than yourself taken antibiotics: a.) in the past 4 weeks? b.) in the past 6 months? c.) in the past year?
[Interviewer: If the participant answers yes to 4 weeks, then you do not need to ask about 6 months and past year. If the participant answers yes to 6 months, then you do not need to ask about the past year.]
Yes No Don't know Refused to answer
In the past 4 weeks
In the past 6 months
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In these next questions I am going to ask about recent hospitalizations of you or of any member of your household. Hospitalization means being admitted to or seen by a provider in a hospital for at least 8 hours. Q5.3 Other than this hospital visit, have you been hospitalized at any point:
a.) in the past 4 weeks? b.) in the past 6 months? c.) in the past year?
[Interviewer-if you the participant answers yes to four weeks, then you do not need to ask about 6 months or past year. If they answer yes to six months then you do not need to ask about the past year.]
Yes No Don't know Refused to answer
In the past four weeks
In the past six months
In the past year
Q5.4. Has anyone in your household been hospitalized at any point: a.) in the past 4 weeks? b.) in the past 6 months? c.) in the past year?
Again, a household member is someone who has lived in the same house as you most of the time for at least the last 3 months.
Yes No Don't know Refused to answer
in the past 4 weeks
in the past 6 months
in the past year
Q5.5 Starting the day before you were admitted to Pitt County Memorial Hospital, have you been treated for a Methicillin resistant Staphylococcus aureus (or MRSA) infection:
a.) in the past 4 weeks? b.) in the past 6 months? c.) in the past year?
Yes No Don't know Refused to answer
in the past four weeks
in the past six months
in the past year
PART 6. [Interviewer: Let the participant know that we are almost finished with the interviewer here.] Q6.1 What is your current age?
AGE: __________________ Q6.2 What is your gender?
Male
Female
Other
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Q6.3 Which of the following best describes your racial background and ethnicity? Choose all that apply.
[Interviewer, read the choices ]
Black/African American
White
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Hispanic, Latino or of Spanish origin
Other ____________________
Refused to answer
Q6.4 What is the highest degree that you earned in school? [Interviewer, read choices]:
Less than high school
High School Diploma
Associate Degree (GED)
Bachelor's Degree
More than Bachelor's Degree
Other ____________________
Refused to answer
Q6.5 In the two weeks before the day you were admitted to Pitt County Memorial Hospital, have you: [Select all that apply]
Yes No Don't know Refused to answer
Gone hunting?
Gone fishing?
Participated in sports such as football, soccer, or basketball?
Gone swimming or wading in a recreational body of water such as an
ocean, lake, or stream, but not a swimming pool?
Q6.6 In the two weeks before the day you were admitted to Pitt County Memorial Hospital, in what city or town & state did you go:
[Interviewer: ask about the location for each of the recreational activities that the participant indicated having done in the past year]
City/Town and state
City/town State
Hunting Fishing Swimming or wading
Q6.7 In the two weeks before the day you were admitted to PCMH, how often do you estimate that you visited a gym to work-out or exercise in?
6-7 days each week
2-5 days each week
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Less than one day each week
Not at all
Don't know
Refused to answer
Q6.8 In the two weeks before the day you were admitted to Pitt County Memorial Hospital, about how often do you estimate that you touched or handled raw meat? Raw meat is defined as chicken, pork, beef, or goat that hasn't been cooked.
6-7 days each week
2-5 days each week
about 1 day each week
Less than 1 day each week
Never
Don't know
Refused to answer
Q6.9 Starting the day before you were admitted to PCMH, when is the last time that you smoked tobacco cigarettes?
Less than one day before I was admitted to PCMH
More than a day but less than one week before I was admitted to PCMH
More than a week but less than one month before I was admitted to PCMH
More than a month but less than a year before I was admitted to PCMH
More than a year before I was admitted to PCMH
I have never smoked tobacco cigarettes
Don't know
Refused to answer
PART 7.
Q7.1 In this section I am going to ask you for your home address. We will use your address to explore whether there are associations between the location of your home and whether or not you have been exposed to MRSA. We will keep your address confidential, and we will never publish it or share it with anyone.
What is your home address (Street address, town and zip) ? STREET_______________________________________
CITY________________________________ STATE ___________
ZIP________________
Q7.2 Are you willing to be contacted in the mail about participating in follow-up studies?If you consent to be contacted about possible follow studies we will mail you a letter using only your study number and we will identify you only as “Dear Participant”.
Yes
No
Q7.3 Is your mailing address the same as your home address?
Yes
No
Q7.4 What is your mailing address?
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CITY________________________ STATE________________ ZIP___________
Q8.1 This is the end of the survey. Thank you for your time and for your participation. Do you have any questions or comments regarding this survey or our research?
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