Version: 10 Sep 2020 Participant Code: __________________

Cohort Participant Close Out Form

First Name(s): __________________________________________________________________________________
Surname(s): ____________________________________________________________________________________
Today’s date: (m/d/y) _____/_____/_____ Interviewer: ____________________________________
Date participant left the study (m/d/y): _____/______ /______

Reason for leaving the study:

( ) Participant is to return home or leaving for continued travel
( ) Participant withdrawal
( ) Excluded by investigatory team

The participant has agreed that it is all right to contact them in future to evaluate for long term symptoms
related to diarrhea.
( ) Agree to be contacted ( ) Have requested not to be contacted

___________________________________________________________ _____________________
Volunteer Study Participant (signature) Date (m/d/y)

___________________________________________________________ _____________________
Investigation Team Member (signature) Date (m/d/y)

Reason(s) for Leaving the Study: ________________________________________________________________________________________

______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

Suggestions for Improvement: __________________________________________________________________________________________

______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

General Comments: _______________________________________________________________________________________________________

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TRAVELERS’ DIARRHEA [ ] Not participating

Have Your Eating Habits Changed:
While eating in Perú, did you eat raw vegetables?
( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

While eating in Perú, did you eat raw fruits that have not been peeled?
( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

While living in Perú, did you drink the local water?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

While living in Perú, did you drink unbottled beverages or drinks with ice?
( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Appendix H
Version: 10 Sep 2020 Participant Code: __________________

Did you eat raw or undercooked meat or fish including ceviche while in Perú?
( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Did you add table sauces to your food while in Perú?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

How often did you wash your hand before eating while living in Perú?
( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

RESPIRATORY ILLNESS [ ] Not participating

Have Your Sick Habits Changed?
When you coughed or sneezed, did you cover your mouth?
( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

With your hands?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

With your elbow?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

With a tissue or hanky?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Did you wash your hands after coughing/sneezing?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Did you wash your hands after using the restroom?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Did you wash your hands before eating?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Did you use your mask while in Cusco?

( ) Always ( ) Almost always ( ) Sometimes ( ) Rarely ( ) Never

Do you plan on getting your annual flu vaccination next year?

( ) Definitely ( ) Most likely ( ) Maybe ( ) Not likely ( ) No

How often did you tend to touch your face (pick your nose or rub your eyes)?
( ) Very Frequently ( ) Frequently ( ) Sometimes ( ) Infrequently ( ) Rarely

Did you tend to have dry or itchy eyes while in Cusco? ( ) Yes ( ) No

Did you tend to have a runny nose while in Cusco? ( ) Yes ( ) No

Appendix H