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820-nonDOH
Form ApprovedOMB No. 0920-1011
Exp. Date 01/31/2020
2019 Lung Injury Response Case Interview Form (CDC)September 11, 2019
Page 1
2019 LUNG INJURY RESPONSE
CASE INTERVIEW FORM (CDC)
September 11, 2019
Page 1 of 36Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).
820-nonDOH
Form ApprovedOMB No. 0920-1011
Exp. Date 01/31/2020
2019 Lung Injury Response Case Interview Form (CDC)September 11, 2019
Page 2
Page 2 of 36Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
CDC Case Questionnaire for E-cigarette Investigation SHORT FORMSeptember 11, 2019
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CDC Case Questionnaire for E-cigarette Investigation SHORT FORMSeptember 11, 2019
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Special note for entering the information in the Epi Info system:Epi Info data entry portal will have an additional page with the highest priority variables from throughout this document. The relevant fields are highlighted throughout the document for easy reference.
Interview FormINTERVIEW DETAILS[TO BE COMPLETED BY PUBLIC HEALTH DEPARTMENT PERSONNEL PRIOR TO INTERVIEW]
Patient or proxy (parent/guardian) interview?o Patiento Proxy
TRACKING [TO BE COMPLETED BY PUBLIC HEALTH DEPARTMENT PERSONNEL PRIOR TO INTERVIEW]
State or Territory STATE CASE ID (deidentified)(State-Case No.[5 digits] (i.e, IL-00001, CA-00057)
Case status
Confirmed Probable Not yet determined Not a case
Was CDC case definition used? Yes No Unknown
[If No or Unknown] Please describe case definition used:
How was this case first detected?
Direct report by a clinician, hospital, or other medical provider
Report by a non-clinician (patient, friend, relative, attorney, media, etc.)
Syndromic surveillance query of emergency department data
Syndromic surveillance query of poison control data
Other[IF YES] Specify other:
_____________________ Unknown
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CDC Case Questionnaire for E-cigarette Investigation SHORT FORMSeptember 11, 2019
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INTERVIEW ATTEMPT INFORMATION[TO BE COMPLETED BY PUBLIC HEALTH DEPARTMENT PERSONNEL PRIOR TO INTERVIEW]
Patient refused interview or was lost to follow-up o Yeso No
Number of interview attempts
PRODUCT SAMPLE ID NUMBER
List unique ID numbers for all product samples submitted for laboratory testing
If you are sending any products to FDA or a state lab for testing, enter the same sample IDs you shared with FDA or the state lab so that product test results can be linked to patient histories.
Product testing lab type (select all that apply):
FDA State public health lab Other (specify other: __________________________________)
FDA PRODUCT SAMPLE ID NUMBER
(List unique ID numbers for all product samples submitted for laboratory testing)
1. ___________________________
2. ___________________________
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CDC Case Questionnaire for E-cigarette Investigation SHORT FORMSeptember 11, 2019
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14. ___________________________
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42. ___________________________
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Biological specimen testing lab type (select all that apply):
FDA State public health lab Federal lab Other (specify other: __________________________________)
BIOLOGICAL SPECIMEN ID NUMBER
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(List unique ID numbers for all biological specimens submitted for testing)
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________
5. ___________________________
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28. ___________________________
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56. ___________________________
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64. ___________________________
***BEGIN INTERVIEW HERE***
Suggested script: Please read the following script if you are able to reach the patient or a proxy for an interview:
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.
Vaping includes the use of electronic devices that can vaporize a combination of nicotine, flavors, and/or other substances (e.g. marijuana, THC, THC concentrates, CBD, synthetic cannabinoids) for inhalation. Examples of these devices include electronic cigarettes or e-cigarettes, such as JUUL, SMOK, Suorin, Vuse, or blu. You also may know them as vapes, mods, e-cigs, e-hookahs, vape-pens, or some other electronic vapor product.
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
Sexo Maleo Female
How do you describe your ethnicity?o Hispanic or Latinoo Not Hispanic or Latino
How do you describe your race? (select all that apply) o White
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o Black or African Americano American Indian or Alaska Nativeo Asiano Native Hawaiian or Other Pacific
Islander
Age (in years)
Are you pregnant?
o Yeso Noo Do not know
ILLNESS HISTORY When did symptoms start (when did you first begin to feel ill)?
Date: (DD/MM/YYYY) Time: (HH:MM AM/PM) if available
What symptoms have you experienced since first becoming ill (select all that apply)?
Shortness of breath
o Yeso Noo Do not know
Chest pain
o Yeso Noo Do not know
Pain on breathing in or out
o Yeso Noo Do not know
Fever o Yeso Noo Do not know
Cough (any)
o Yeso Noo Do not know
Headache
o Yeso Noo Do not know
Nausea
o Yeso Noo Do not know
Vomiting o Yes
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o Noo Do not know
Diarrhea or loose stools
o Yeso Noo Do not know
Abdominal pain
o Yeso Noo Do not know
Other symptoms (open-ended)?
o Yeso Noo Do not know
[IF YES] Please list other symptom(s)Which symptom(s) began first?
Do you have any thoughts about why you may have become ill?Do you have any underlying medical conditions [prompt: asthma, COPD or other lung condition, heart disease, anxiety, depression]?
o Yeso No
[IF YES] Please list
JOB/SCHOOL
Do you have a job? o Yeso No
[IF YES] What is your occupation or job function? _____________Have you ever worked in a job in which you were regularly exposed to any of the following: coal, beryllium, silica, asbestos, or pesticides?
o Yeso Noo Do not know
[IF YES] Specify _____________VAPING PRODUCTS
The 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 symptoms began?
o Yeso No
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What substances did you use within the 3 months before symptoms started (select all that apply)?
For each substance used in the last 3 months before symptoms started, click the Device button to the right to describe the device used with the substance.
Nicotine (free-base or nicotine salts)
Yes (Y) (Fill the nicotine section on page 9 below) No (N) Unknown (U)
Marijuana, THC, THC Concentrates (e.g. dabs, dab wax, dab cards), hash oil, wax; includes Dank Vapes, Gorilla, and other THC brands
Yes (Y) (Fill the Marijuana, THC and related products section beginning on page 11 below) No (N) Don’t Know (U)
Synthetic cannabinoids (e.g. K2 or Spice)
Yes (Y) (Fill the Synthetic cannabinoids section on page 16) No (N) Don’t Know (U)
CBD or CBD oil
Yes (Y) (Fill the CBD or CBD oil section on page 18) No (N) Don’t Know (U)
Flavor extracts or additives added by the user
Yes (Y) (Fill the Flavors section on page 20) No (N) Don’t Know (U)
Other
Yes (Y) (Fill the Other section on page 22) No (N) Don’t Know (U)
Other specify: _______
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Do not know [ ]
[Repeat questions as necessary for each product/device or substance used in the 3 months before symptoms began.]Nicotine (Fill this section if Nicotine use was confirmed in the previous section)
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Substance Brands: _______________________________________________________________________
Please specify which flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Strength: _____________ [mg, mg/mL, %]
Free-base nicotine? [ ]
Nicotine salts? [ ]
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / weeko Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
Disposable e-cigarette or vape (First Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
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E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems) (Third Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Other (specify type(s)): _____________________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas station, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it from another person [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online [ ]
--Date of last purchase prior to symptom onset? ______________
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--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
End of Nicotine questions
Dank vapes (Fill this section if their use was confirmed in the earlier section)
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Dank Vapes:
Yes (Y) No (N) Don’t Know (DK)
[IF YES] Specify flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Strength: _____________ [mg, mg/mL, %]
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / weeko Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
Disposable e-cigarette or vape (First Generation)
Yes (Y)
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No (N) Don’t Know (U)
E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems)(Third Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Other (specify type(s)): _____________________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas station, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
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--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it from another person. [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
THC Brands or Types other than Dank Vapes (Fill this section if their use was confirmed in the earlier section)
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Dank Vapes:
Yes (Y) No (N) Don’t Know (DK)
Substance Brands: _______________________________________________________________________
Please specify which flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Strength: _____________ [mg, mg/ml, %]
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / week
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o Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
Disposable e-cigarette or vape (First Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems)(Third Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Other (specify type(s)): _____________________
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Product Type Used
Dabs Dab wax Dab cards Hash oil Wax Dry Herb Other
Specify: ______________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas station, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it from another person. [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
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End of Marijuana, THC and related products questions
Synthetic Cannabinoids
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Substance Brands: _______________________________________________________________________
Please specify which flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Strength: _____________ [mg, mg/ml, %]
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / weeko Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
Disposable e-cigarette or vape (First Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems)(Third Generation)
Yes (Y) No (N)
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Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Other specify type(s)): _____________________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas station, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it from another person. [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
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--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
End of Synthetic Cannabinoids questions
CBD or CBD oil (Fill this section if their use was confirmed in the previous section)
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Substance Brands: _______________________________________________________________________
Please specify which flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Strength: _____________ [mg, mg/ml, %]
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / weeko Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
Disposable e-cigarette or vape (First Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
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E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems)(Third Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Other specify type(s)): _____________________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas station, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it from another person. [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online. [ ]
--Date of last purchase prior to symptom onset? ______________
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--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
End of CBD or CBD oil questions
Flavor extracts or additives added by the user (Fill this section if their use was confirmed in the previous section)
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Substance Brands: _______________________________________________________________________
Please specify which flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / weeko Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
Disposable e-cigarette or vape (First Generation)
Yes (Y) No (N) Don’t Know (U)
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E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems)(Third Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Specify other types: _____________________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas station, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
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Bought it from another person. [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
End of Flavor Extracts or Additives added by the User questions
Other Substance Type (Fill this section if their use was confirmed in the previous section)
Within the 3 months before symptoms started ...
For the current substance used in the 3 months before symptoms started, what brands were used. Be as specific as possible for each substance currently used.
Substance Brands: _______________________________________________________________________
Please specify which flavors: _______________________________________________________________
Date of last use (MM/DD/YYY): ______________
Approximately how frequently did you use this substance?
o Monthly or lesso 2-4 times / montho 2-3 times / weeko 4-6 times / weeko Daily
What type of device(s) did you use with this substance within the 3 months before symptoms started? (Select all that apply.)
Select each device that you used in the 3 months before symptoms started:
(Y = Yes, the device was used; N = No, the device was not used; U = Unsure if the device was used or not.)
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Disposable e-cigarette or vape (First Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with refillable cartridge (Second Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a tank that you refill with liquids (including sub-ohm, mod or modifiable systems)(Third Generation)
Yes (Y) No (N) Don’t Know (U)
E-cigarette or vape with a prefilled or refillable pod (Fourth Generation)
Yes (Y) No (N) Don’t Know (U)
Other
Yes (Y) No (N) Don’t Know (U)
Other (specify type(s)): _____________________
Where was the substance purchased or obtained (please select all that apply)
Bought it at a vape shop or dispensary. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details: ____________________________________________________________________
Bought it at a different type of store (such as a convenience store, gas staton, supermarket) [ ]
--Date of last purchase prior to symptom onset? ______________
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--Specify details:_______________________________________________________________________
Bought it at a pop-up shop [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
Bought it from another person. [ ]
--Date of last purchase prior to symptom onset?_______________________
Bought it online. [ ]
--Date of last purchase prior to symptom onset? ______________
--Specify details:_______________________________________________________________________
It was given to me by another person. [ ]
--Date last given prior to symptom onset? ____________________
Other [ ]
--Date last acquired prior to symptom onset? ___________
--Specify details: _______________________________________________________________________
End of Other Substance Type questions
Dabbing:
Have you dabbed within the 3 months before symptom onset? [Y/N]
[IF YES for dabbing] What did you dab?: ___________
[IF YES for dabbing] How did you dab?: ___________
Modifications/Hacking:
In the 3 months before symptoms started, did you ever hack or modify your vaping device or liquid cartridge in any way [Y/N]?
[IF YES] Please describe what device and substance used (include brand of device and substance)? _________
In the 3 months before symptoms started did you buy e-juice, e-liquid or vaping liquid to put in your device
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[Y/N]? [IF YES]: What e-liquid or liquid do you use (include brand, substance used)? __________________________________
In the 3 months before symptoms started, did you make or mix your own e-liquid, e-juice, or vaping liquid [Y/N]?
[IF YES]: What ingredients did you use?: __________
Subsection: modifiable devices (“Mods”):Now I am going to ask you about each of the vaping or e-cigarette devices you used and how you used them in the 3 months before symptoms started. [Repeat as necessary for each mod device used in the 3 months before symptoms began.]
E-cigarettes or vape with a refillable tank with a modifiable system (Third Generation)Is the device modifiable ("mods")? [Y/N]
E.G.: A device where you can modify voltage; whether the user is adding additional equipment such as an atomizer for "dripping;" and/or if the user is tampering with the device to change settings (e.g. exposing heating coils to "drip" liquids directly on the heating device and get a bigger cloud of aerosol, etc.)
IF YES:What brand/type of coils did you use? _________What brand/type of atomizer did you use? ____________
Did you notice a build-up on the coil when using it? [Y/N/Don’t Know]What brand/type of wicks did you use? ____________In the 3 months before symptoms started, have you cleaned your mod device? [Y/N]
[IF YES] what do you use to clean your mod device? ____Do you use for device for dripping? [Y/N]
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E-cigarettes or vape with a refillable pod or cartridge with a modifiable system (Fourth Generation)Is the device modifiable ("mods")? [Y/N]
E.G.: A device where you can modify voltage; whether the user is adding additional equipment such as an atomizer for "dripping;" and/or if the user is tampering with the device to change settings (e.g. exposing heating coils to "drip" liquids directly on the heating device and get a bigger cloud of aerosol, etc.)
IF YES:What brand/type of coils did you use? _________What brand/type of atomizer did you use? ____________Did you notice a build-up on the coil when using it? [Y/N/Don’t Know]What brand/type of wicks did you use? ____________In the 3 months before symptoms started, have you cleaned your mod device? [Y/N]
[IF YES] what do you use to clean your mod device? ____Do you use for device for dripping? [Y/N]
VaporizersIs the device modifiable ("mods")? [Y/N]
E.G.: A device where you can modify voltage; whether the user is adding additional equipment such as an atomizer for "dripping;" and/or if the user is tampering with the device to change settings (e.g. exposing heating coils to "drip" liquids directly on the heating device and get a bigger cloud of aerosol, etc.)
IF YES:What brand/type of coils did you use? _________What brand/type of atomizer did you use? ____________Did you notice a build-up on the coil when using it? [Y/N/Don’t Know]What brand/type of wicks did you use? ____________In the 3 months before symptoms started, have you cleaned your mod device? [Y/N]
[IF YES] what do you use to clean your mod device? ____Do you use for device for dripping? [Y/N]
CHANGES IN VAPING BEHAVIORS
In the last 3 months before symptoms started, did you change where you purchased or got your product(s)? Please answer for each product used.
Device/Substance Changes in purchase? [Y/N]
If yes, what were the changes? (specify)
Device Used (overall)
e-liquid, e-juice, or liquid product used (overall)Check if not used: [ ]Nicotine (free-base or nicotine salts)
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Check if not used: [ ]Marijuana, THC, THC concentrates (e.g., dabs, dab wax, dab cards), hash oil, waxCheck if not used: [ ]Dank vapesCheck if not used: [ ]Synthetic cannabinoids (e.g., K2 or Spice)Check if not used: [ ]CBD or CBD oilCheck if not used: [ ]Flavors (list and complete for all): _______Check if not used: [ ]Something else (specify if relevant): _____Check if not used: [ ]
In the last 3 months before symptoms started, did you change the e-liquid, e-juice, liquid product, or device that you used? Please answer for each device or substance used.
Device/Substance Changes in type used? [Y/N]
If yes, what were the changes? (specify)
Device Used (overall)
e-liquid, e-juice, or liquid product used (overall)Check if not used: [ ]Nicotine (free-base or nicotine salts)Check if not used: [ ]Marijuana, THC, THC concentrates (e.g., dabs, dab wax, dab cards), hash oil, waxCheck if not used: [ ]Dank vapesCheck if not used: [ ]Synthetic cannabinoids (e.g., K2 or Spice)Check if not used: [ ]CBD or CBD oilCheck if not used: [ ]Flavors (list and complete for all): _______Check if not used: [ ]Something else (specify if relevant): ____Check if not used: [ ]
In the last 3 months before symptoms started, did you notice any changes in taste, texture, smell, clarity, or quality of the product(s)? Please answer for each substance used.
Device/Substance Notice changes in taste, texture, smell, clarity, or
If Yes: describe the change(s)?
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quality of the product [Y/N]?
Device Used (Overall)
Nicotine (free-base or nicotine salts)Check if not used: [ ]Marijuana, THC, THC concentrates (e.g., dabs, dab wax, dab cards), hash oil, waxCheck if not used: [ ]Dank vapesCheck if not used: [ ]Synthetic cannabinoids (e.g., K2 or Spice)Check if not used: [ ]CBD or CBD oilCheck if not used: [ ]Flavors (list and complete for all): _______Check if not used: [ ]Something else (specify if relevant): _______Check if not used: [ ]
In the last 3 months before symptoms started, did you notice any changes in how you feel after using the product e.g., cough, trouble breathing, dizziness, confusion, the buzz or high from use, or any other physical changes in symptoms or experiences)? Please answer for each product used.
Device/Substance Changes in how you feel after using? [Y/N]
If yes, what were the changes? (specify)
Device Used (overall)
e-liquid, e-juice, or liquid product used (overall)Check if not used: [ ]Nicotine (free-base or nicotine salts)Check if not used: [ ]Marijuana, THC, THC concentrates (e.g., dabs, dab wax, dab cards), hash oil, waxCheck if not used: [ ]Dank vapesCheck if not used: [ ]Synthetic cannabinoids (e.g., K2 or Spice)Check if not used: [ ]CBD or CBD oilCheck if not used: [ ]FlavorsCheck if not used: [ ]Something else (if so, specify): _____Check if not used: [ ]
PRODUCT TESTING SECTION (ELECTRONIC PRODUCTS ONLY):
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Do 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)?
o Yeso Noo Unknown
[IF YES] Can public health get it for testing?o Yeso No
Did you share your product(s) with anyone (e.g., friends, family) in the 3 months before symptoms started?
o Yeso Noo Unknown
[IF YES] Did that person(s) develop similar illness?
o Yeso Noo Unknown
GENERAL SUBSTANCE USE
Have you inhaled any of the following substances in the 3 months (90 days) before symptoms started? (select all that apply)
o Cigaretteso Cigars (regular cigars, little cigars,
cigarillos) o Hookah/Waterpipeo Pipe tobaccoo Roll-your-owno Bidiso Heated tobacco productso Non-vaped Cannabinoids (e.g.,
marijuana, hash, synthetic cannabinoids (K2 or Spice))
o Heroino Cocaineo Methamphetamineo Huffing (e.g., paint, glue, bath salts)o Something else ______
If something else, specify:__________________________
Non-vaped Cannabinoids (e.g., marijuana, hash, synthetic cannabinoids (K2 or Spice) Details:
IF YES TO USE IN 3 MONTHS BEFORE SYMPTOMS STARTED:Approx. date last used (MM/DD/YYYY)What type of cannabinoids did you use (select all that apply)?
Marijuana, hash [Y/N] Synthetic cannabinoids (e.g., K2 or Spice) [Y/N] Dabbed marijuana (e.g., oils or waxes) [Y/N] Dabbed CBD concentrate [Y/N]
What brand(s) did you use (within the 3 months before symptoms started)?: ______
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For each substance that you smoked or dabbed, how frequently did you use this substance in the 3 months before symptoms started?
Non-daily Daily
Marijuana, hashCheck if not used: [ ]Synthetic cannabinoids (e.g., K2 or Spice)Check if not used: [ ]Dabbed marijuana (e.g., oils or waxes) Check if not used: [ ]Dabbed CBD concentrateCheck if not used: [ ]
OTHER EXPOSURES For the last 6 months before symptoms started, have you been exposed to any of the following?
Moldy hay, grain, cheese, or wood bark?o Yeso Noo Do not know
Animal droppings or urine? o Yeso Noo Do not know
Birds in your home, as part of a hobby, or at work?o Yeso Noo Do not know
Humidifiers, hot tubs, or saunas?o Yeso Noo Do not know
Soil or compost (e.g., frequent handling of soil)?o Yeso Noo Do not know
Spray paints or polyurethane foam?o Yeso Noo Do not know
Did you spend time in an infrequently used space or structure (e.g., attic, cabin)?
o Yeso Noo Do not know
Did you inhale chemicals or toxins (e.g., cleaning products, o Yes
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occupational exposures)?o Noo Do not know
OTHER MEDICATIONS/SUPPLEMENTS (ask about frequency of being taken in the last three months)Over the counter medications [list all] Prescription medications [list all] (clarify if they took any prescription medications that were not prescribed to them). Include route of administration (oral, inhaled, topical, etc.)Did you take any prescription medications that were not prescribed to you?
o Yeso No
[IF YES] Which?Vitamins and supplements, including things that you’ve purchased online [list all] OTHER NOTES (include details of any conversation with parent or guardian)
***END INTERVIEW HERE***
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