Hypothesis testing questionnaire script
An example of an interview questionnaire script is shown below:
Introductory statement:
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Hello, this is ............... from the..........................
You may have heard that a number of people became unwell
after..................
We are conducting an investigation to try and find out why. As part of that
we need to compare what people who were unwell were exposed to compared to
those people who were not unwell.
Could I ask you a few questions about this?
Any information you provide will be completely confidential
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Coding:
- Unique sequential identity number {ID} <IDNUM>
- {Case} status #
(Confirmed case=2, probable case=1, control=0)
•{Match} code (if matched study) ###
(1=self, 2=parent, 3=spouse, 4=other)
- Date of interview <dd/mm/yyyy>
Personal information data - this should be recorded separately with the identity number above
to link the information:
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What is your surname?
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What is your first name?
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What is your date of birth?
Demographic data
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What is your {age }? ###
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Male or female {sex }? <A> (M/F)
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{Postcode/zipcode} of residence? <A >
Exposures
This part of the questionnaire needs to be tailored according to the information obtained from
the descriptive epidemiology as to whether the source is suspected to be a cooling tower,
whirlpool or a hotel, where a number of different sources may be suspected like air
conditioning unit, showers and whirlpool. Dates should be specified based upon the information
in the descriptive epidemiology and whether a point source or continuous source was suspected
over a period of time.
I would like to ask you a few questions about your experience of this event (exposure).
Source 1 (Note that careful consideration should be given to description of potential exposure
site to interviewee; locations should be specified clearly and perhaps should be broadened to
geographical areas, as not all interviewees will be aware of locations of cooling towers and
other sources and material can be advected away from source.)
Were you exposed to (suspect source 1) in the 14 days prior to onset of symptoms
<Y>
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On what days were you exposed ? <DDMMYY>
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For how long were you exposed? ### (This can be divided into different time
categories)
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Were you exposed to this even t as a: #
(1=employee, 2=visitor, 3=other)
- Did you walk or drive near/past the site/event #
(1= walk, 2= inside a car or other vehicle)
Repeat series of questions for each potential exposure source (Note that these are dependent on
hypotheses being tested and should not be speculative/exhaustive):
- Exposure 2 specific questions (repeat above)
- Exposure 3 specific questions (repeat above)
- Exposure 4 specific questions (repeat above)
Health effects
• Before the event, did you have any of the following conditions?
{Diab}etes <Y>
{Resp}iratory disease <Y>
{Chronic r}enal disease <Y>
{Cardiac} disease <Y>
{Organ} Transplant <Y>
Malignancy / {cancer} <Y>
Do you take {immuno}suppressive medications? <Y>
Other illness _________________
• Do you {smoke}? <Y>
• Are you {pregnant}? <Y>
• Were you ill after the event? <Y>
• Did you have any of the following symptoms between <-specify dates and
times>?
Breathlessness <Y>
Cough <Y>
Fever <Y>
Chills <Y>
Dizziness <Y>
Lethargy <Y>
Myalgia <Y>
Confusion<Y>
Other symptoms _____________
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On what {date} did you first feel unwell? <dd/mm/yyyy>
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At what {time} of day did you first feel {unwell} ? ##.## (24 hour clock)
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Are you {still}{ ill} now? <Y>
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For how many {days} were you {unwell}? ##
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Were you admitted to {hospital} with this illness ? <Y>
- Case {died} <Y>
• Date of {death} <dd/mm/yy>
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