Importance: High
Mike, | apologize for the delay regarding the attached FOIA’s and questionnaire.
The information that you shared during the conference call last week was very helpful. | have not received a response
yet from the April 2, FOIA.
Thank you
Jim Henry RS, MBA
Environmental Health Supervisor
630 S. Saginaw St., Suite 4
Flint, MI 48502-1540
Phone (810) 257-3618 Fax (810) 257-3125
*NOTICE: This e-mail, including attachments, is intended for the exclusive use of the addressee and may contain
proprietary, confidential or privileged information. If you are not the intended recipient, any disclosure, use,
distribution, copying, or taking of any action in reliance of the contents of this e-mail is strictly prohibited. If you have
received this e-mail in error, please notify me via e-mail and permanently delete the original and destroy all copies.
Thank you.
For a copy of the Health Department’s Notice of Information Practices, contact the Health Department or visit the Health
Department’s website at hite://www.gehd.us/
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MDSS ID
Legionellosis Questionnaire
Genesee County, 2014-2015
Interviewer Identification
Date of Interview: Interviewer’s Name:
Health Dept.: Phone Number: E-mail:
What was the patient’s outcome? [_RECOVERED [_] STILL ILL DIED [_] UNK
Patient Contact Information
Name: Age: Sex: |_JM F
Street address: City:
State: Zip: County:
Daytime Phone: Evening Phone:
Surrogate Contact Information <List surrogate contact information if patient is too unwell or has died>
Name:
Daytime Phone: Evening Phone:
Relationship to Patient:
Hello, my name is and I’m calling from (health department).
We are investigating a cluster of respiratory illnesses in Genesee County. At this point, the source of
these illnesses is still under investigation. We are hoping this interview will provide further
information and answers about the illnesses. I’d like to ask you a few questions about your home and
your exposures during the 2 weeks before you got sick. You do not have to answer any of the questions,
but any assistance you can provide is appreciated. Do you have about 30 minutes to talk? If not now,
when would be a good time for me to call back?
<lf the case is from more than 1 month prior, the following text may be used: >
It might be helpful for you to collect documents such as a calendar, receipts, credit card or bank
statements to jog your memory about your activities and where you were in the 2 weeks prior to getting
sick. The only information we would ask you to share from these are dates and locations. Would you like
me to call you back after you have time to collect these materials? When would be a convenient day and
time for me to call you back?
| have that your first symptom started on <insert onset date> . Is this correct?
[ves [JNo [_JNotsure
If no, what was the first date you started feeling sick? / /
List dates of exposure period: from vA L to vA ZL <The exposure period includes the
2 weeks before the date of illness onset>
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xxxEND_PAGE:deq16_b5_0892_4900_0920
Illness Information
1.) During your illness, did you have any of the foll
MDSS ID
Diagnosis of pneumonia
Fever
If yes, highest temp:
Chills
Cough
Nausea
Vomiting
Diarrhea
Aches or muscle pains
Chest pain
Shortness of breath
Sore throat
Headaches
Other symptoms (specify):
Exposure Information
2.) How long have you lived at your current residence?
<if they have moved since the listed exposure period, indicate that you are asking about the house
they lived in prior to becoming sick>
a.) If you moved after the exposure period/illness, what was your previous residence
address?
3.) Where did you get your tap (drinking and other household use) water from between [ [
and [ [ ? <Exposure period from above>
(Jt. City of Flint Water
[_] 2. City of Flint Township Water
in 3. Other municipal water system
in 4. Private well
CO] 5. Unknown
O 6. Other
4.) During the last year, has the water pressure at your residence changed? Lyes Jno [Not sure
a.) If yes, did the water pressure: EC] Increase in
b). If yes, when did the water pressure change occur?
Decrease
Page 2 of 6
xxxEND_PAGE:deq16_b5_0892_4900_0921
MDSS ID
5.) During the last year, has the water quality (appearance, taste, smell) at your residence changed?
L yes LINo []Not Sure
a.) If yes, please describe the change in the water quality:
b). If yes, when did the water quality change occur?
6.) Prior to your illness, did you make any recent plumbing changes or repairs at your residence?
LJyes [_JNo [_JNotsure
a.) If yes, please describe the changes/repairs and give the dates the work was done.
7.) Prior to your illness, were there any water main breaks or other water line issues that affected the
water at your residence, including boil water advisories? L]Yes [_]No [_\Not sure
a.) If yes, please describe the water main/line issues or boil water advisories and give the dates
they occurred.
I'd like to ask you some questions about what you did during the 2 weeks before you got sick.
The time period I’m asking about is between i [ and [ / .<Exposure period>
During this 2 week period, did you:
8.) Work or volunteer, either full or part time? Nes No |Not sure
) If yes, complete the following table:
9.) Spend any time in a hospital, doctor’s office, clinic, or dentist office as a patient, visitor, employee, or
volunteer? [_]Yes No [_]Notsure
a.) If yes, check all that apply:
Inpatient [_] | Admission
Discharge
Outpatient [J
Visitor C]
Employee [_]
Volunteer
10.) Visit, reside, or work in a long term care facility, nursing home, assisted living facility, or senior living
facility? les No INot sure
Page 3 of 6
xxxEND_PAGE:deq16_b5_0892_4900_0922
MDSS ID
a.) If yes, complete the following table:
08
Resident L]
Visitor ic
Employee in
11.) In the 2 weeks before you before you gotsick(__ / = / _to /__{ ___),did you spend any
nights away from home (excluding healthcare settings)? [Ves | No [JNot sure
a.) If yes, complete the following table: <prompts: hotel, campground, cabin, cruise, second
home, with family, etc.>
12.) Inthe 2 weeks before you before you gotsick(___/ —-/ _to /_{ _), did you visit any of
the following community venues?
Hote! (without |
staying overnight —
e.g. dinner, wedding)
| Auditorium | | |
Barbershop or Hair
salon
| Car wash |
Casino
Church or Place of.
worship
Gym or Work out
facility
Grocery store.
Home improvement
store
Spa or Nail salon a
Mall or Department
store
Movie theater
Other (specify)
13.) In the 2 weeks before you before you got sick (___/ {to / {__), did you have
exposure to any of the following water sources, either at home or while away from home?
Page 4 of 6
xxxEND_PAGE:deq16_b5_0892_4900_0923
MDSS ID
Shower
Use a detachable shower head or.
hose
Hot tub, whirlpool spa, Jacuzzi
tub
Sat NEAR a working hot tub or
whirlpool spa but did not get in
Steam room or wet sauna
Humidifier (whole house or If yes, specify type:
portable) If yes, what type of water is used in device?
uBottled uTap cOther:
Respiratory therapy machine If yes, specify type:
(e.g. nebulizer, CPAP, BiPAP, etc.) If yes, what type of water is used in device?
uBottled oTap cOther:
Other (specify)
Shower at gym, work, other
location
Use a detachable shower head or
hose
Hot tub, whirlpool spa, Jacuzzi
tub
Sat NEAR a working hot tub or
whirlpool spa but did not get in
Humidifier (whole house or If yes, specify type:
portable) If yes, what type of water is used in device?
oBottled oTap cOther:
Pool/splash pad/waterpark
Recreational or cooling misters
Steam room or wet sauna
Decorative fountain
Qutdoor watering hose or
sprinkler
Beach, lake, pond, river, creek,
etc.
Medical History
Now I’m going to ask a few questions about your medical history and health behaviors.
14.) Have you ever been told by a healthcare provider that you had any of the following conditions:
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xxxEND_PAGE:deq16_b5_0892_4900_0924
MDSS ID
Chronic kidney disease
Weakened immune system (due to cancer,
chemotherapy , radiation therapy,
immunosuppressive meds, HIV, organ transplant, etc.)
Diabetes
Chronic lung disease (COPD, emphysema)
Asthma or chronic bronchitis
Heart disease or congestive heart failure |
Liver disease
Other conditions (specify)
15.) Health behaviors:
Are you currently a smoker?
Are you a former smoker?
Do you drink alcohol?
16.) Do you know anyone else with similar symptoms? [_]Yes [_]No [_]Not sure
a.) If yes, complete the following table:
Additional Comments
Thank you so much for taking the time to answer these questions. Do you have any questions that |
can help answer? If you have any questions or remember any further details later, please contact the
(health department) at phone:
Page 6 of 6
xxxEND_PAGE:deq16_b5_0892_4900_0925