Appendix 1: Example Cover Letter for Parents-Caregivers

Date

Your name

Your address

City, State Zip code

Telephone number

Dear parent-caregiver:

We have learned that some children attending the _______________________ (name of

child care center) have developed chickenpox. Although chickenpox is usually not a serious

illness, it is a common disease and often causes parents to miss work when they stay home to

care for their children. In some children, chickenpox may cause more serious illness and may

require hospitalization.

A vaccine which can prevent chickenpox has been made and the vaccine is safe for

children who are older than 12 months of age. This vaccine is recommended for children who

have never had chickenpox or have never had the chickenpox vaccine before. We would like to

recommend that you contact your child’s regular pediatrician or family physician as soon as

possible to see if the chickenpox vaccine is available for your child.

At the health department, we are trying to learn more about why children develop

chickenpox and how we can best prevent this disease. In the attached questionnaire, we ask a

few questions about your child and whether or not they have had chickenpox or the chickenpox

vaccine. If your child has had chickenpox in the past three months, we have asked you a few

questions regarding your child’s illness.

All information that you provide is strictly confidential and cannot be shared with other

persons within the health department who are not involved with this study, with other physicians,

parents or insurance carriers. In addition, your name and the name of your child will not be

recorded in our database and it will not appear on the questionnaire.

We thank you for your help in completing the attached questionnaire and please do not

hesitate to contact us at any time if you should have any questions.

_______________________ (Study Coordinator) Telephone number: ___________________

Appendix 2: Varicella in Child Care Centers Questionnaire for Parent/Caregiver

Questionnaire Number: ________(health department use only)

Date: ____/____/____

1. Age of child: ______ (circle one: years months)

2. Race (circle one): 1. white 2. black 3. Asian/pacific islander 4. Other

3a. Has your child ever received the chickenpox vaccine? Yes No DK

3b. If yes, please write date _______________

4a. Has your child had chickenpox? Yes No DK

4b. If yes, please write date: ____________ (Month and Year, if possible)

4c. Please write the name of your child’s usual clinic and doctor (if applicable):

Clinic or office name: _____________________________________

Doctor: _____________________ Telephone: (____)__________________

If child has never had chickenpox, please stop here.

If child had chickenpox in the last three months, please answer the following questions:

5. Please write date that you first noticed your child’s rash: ____/____/____(MM/DD/YY)

6. How many days did rash last (until all scabs crusted)? _____ (days)

7. At the most severe stage of the illness, how many lesions were present? (Please select one of

the following):

a. All pock marks could be counted them in 30 seconds or less (< 50 pock marks).

b. An average number of pock marks were found (50-500).

c. Many pock marks present and in some areas, you could not see normal skin between

areas where pock marks were found (>500 pock marks).

8a. Did child have fever at least once during illness?

Yes No Don’t know

8b. If known, please write the highest temperature that you measured:___ ( F, C)

8c. Did fever spike occur more than one time? Yes No DK

9a. Did your child visit a physician because of chickenpox or a complication of chickenpox?

Yes No DK

9b. If Yes, please write date of office visit: ____/____/____

10. Did your child have any skin infection during his episode of chickenpox? Yes No DK

11a. Was your child hospitalized because of chickenpox or one of its complications?

Yes No DK

11b. If your child was hospitalized, how long was the hospital stay: ____ (days)

12a. Did your child have other complications of chickenpox that did not require hospitalization?

Yes No DK

12b. If Yes, please name the complication, if possible:________________________________

14a. Did child receive any medication during the chickenpox illness:

Yes No DK

14b. If Yes, please mark any of the following medications that apply:

Antibiotics on skin lesions? Y N DK

Oral or injectable antibiotics? Y N DK

Zovirax (Acyclovir)? Y N DK

Benadryl? Y N DK

Medication(s) for fever?

Tylenol: Y N DK

Advil: Y N DK

Ibuprofen Y N DK

15. Did your child receive any other medications for chickenpox? (Please specify name)

_______________________________

16a. Does this child have any chronic health problems that began before he/she developed

chickenpox? Y N DK

16b. If Yes, please check any of the following conditions that apply:

Bronchitis:____ Asthma: ____ Cystic fibrosis: ____

Other lung problems: ___________________________________

Diabetes:____ Chronic ear infections: _____

Allergies:____ Epilepsy or seizures: _____

Heart disease: _____

Other (please specify): _____

17a. Is child taking any regular medications for any condition under the care of a physician?

Yes No DK

17b. If Yes, please name these regular medications:

________________________________________________________

General comments from parent-caregiver:

______________________________________________________________________________

Appendix 3: Health Care Provider Survey

1. Provider ID# P-______________ 2. City: ________ 3. County: _______

4. Practice volume: ____________ ( Please record average number of patients seen each day)

5. Proportion of children ages 12 months to 12 years in your practice?______%

6. Do you offer childhood immunizations in your clinic? Yes No

7a. Do you offer varicella vaccine to patients in your office? Yes No

7b. If Yes, to whom do you recommend use of the vaccine? (Circle all that apply)

1. All children under the age of 13 years

2. Children aged 12 to 18 months of age

3. Person greater than or equal to age 13 years

4. Health care workers

5. Family of immunocompromised persons

6. Child care employees

7. Residents or staff of institutional settings.

8. College students

9. Non pregnant women of childbearing age

7c. If No, please mark reasons why vaccine is not offered (mark all that apply):

1. Unable to meet freezer temperature requirements: ______

2. Vaccine not necessary for patients: ________

3. Cannot afford to purchase vaccine for patients: ________

4. Patients cannot afford to purchase vaccine: _______

5. Other reasons:________________________________________

8. Where do you store varicella vaccine in your office?

1. Refrigerator 2. Freezer 3. Other: _______

9a. Do you have a thermometer which records accurate temperature in your vaccine storage unit

(.e.g. freezer)? Yes No DK

9b. If Yes, what is the current temperature of cold storage area (e.g. freezer) where you store

varicella vaccine? ______ ( F, C)

10a. Have you been required to discard varicella vaccine due to any storage or handling

problems?: Yes No DK

10b. If yes, please state problems: ___________________________________

11a. Have you returned any doses of varicella vaccine to manufacturer due to any storage or

handling problems? Yes No DK

11b. If yes, please state problems: __________________________________

12. Approximately how many doses of vaccine do you administer each week (average #):

____________

13. On average, how many cases of varicella do you see each month in your practice? ________

14. Has the number of varicella cases that you have seen in your office in the past one month

been:

1. about normal

2. slightly above normal

3. greatly above normal

4. below normal

Appendix 4: Environmental Survey of Child Care Facility

1. Total number of child care attendees: _____

2. Total number of full-time staff: _____

3. Total number of part-time staff: _____

4. Total number of class rooms used everyday: _____

5. Number of classrooms used for part of day only: _____

6. List classrooms (record name of room which indicates activity) used for group activities

a. _________________________ b. _________________________

c. _________________________ d. _________________________

e. _________________________ f. _________________________

g. _________________________ h. _________________________

7. Please list class levels in child care center and age ranges of children in each level:

a. Level ___. Age range______ # of children ____ Classroom number: ____

b. Level ___. Age range______ # of children ____ Classroom number: ____

c. Level ___. Age range______ # of children ____ Classroom number: ____

d. Level ___. Age range______ # of children ____ Classroom number: ____

e. Level ___. Age range______ # of children ____ Classroom number: ____

f. Level ___. Age range______ # of children ____ Classroom number: ____

Comments:

____________________________________________________________________

Appendix 4: Environmental Survey of Child Care Facility (continued)

Graphical representation of child care center floor plan and room dimensions (record linear

dimensions of rooms when available):

Child care facility name:_________________________ Date recorded _____/_____/_____

Appendix 6: Line listing of Clients in Child Care Center Affected by Varicella Outbreak (For follow-up of clients only; names will not

be recorded in database)

Client

Number

Client’s

Name

(Last,First)

Parent-

Caregiver

Name

Telephone Age of

child

Class Staff in

charge

of class

Ill/Well Start date

of illness

Last day

of illness

Varicella

vaccine

(Yes,No)

Date of

Varicella

Vaccine