Effingham County Chemical Spill September 2023 
  INTRODUCTION
The Coastal Health District is conducting surveillance after a chemical spill in Effingham County on September 26th, 2023.

All information provided to public health will remain confidential in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  DEMOGRAPHIC INFORMATION
1 . First Name
2 . Last Name
3 . Address (Home)
4 . City
5 . State
6 . Zip Code
7 . County
(If you live outside of Georgia, select "Unknown".)
8 . Date of Birth//
9 . Age years
10 . GenderFemale Male Other 
11 . Race
12 . Ethnicity
13 . Phone Number--
14 . E-mail
  ILLNESS AND SYMPTOMS
1 . Have you experienced any symptoms you don't normally experience since September 26th, 2023?Yes No Not Sure 
2 . On what date did your first symptoms start?//
3 . Did you experience any of the following general symptoms?
       Fever
       Fatigue
       Muscle aches
       Body aches
       Headache
       Dizziness/Vertigo
       Confusion/Lethargy
       Malaise
       Rapid heart rate
       Other general symptoms
4 . Other general symptoms
5 . Did you experience any of the following skin symptoms?
       Itching
       Redness
       Burns
       Blisters
       Rash/Hives
       Other skin symptoms
6 . Other skin symptoms
7 . Did you experience any of the following respiratory symptoms?
       Runny nose
       Cough
       Sneezing
       Sore throat
       Dry/Scratching/Burning Throat
       Wheezing
       Shortness of breath
       Rapid breathing
       Other respiratory symptoms
8 . Other respiratory symptoms
9 . Did you experience any of the following gastrointestinal symptoms?
       Abdominal Pain
       Nausea
       Vomiting
       Diarrhea
       Dark-colored urine
       Dehydration
       Weight loss
       Loss of appetite
       Other GI symptoms
10 . Other gastrointestinal symptoms
11 . Did you experience any of the following ocular symptoms?
       Redness in eyes
       Burning eyes
       Constant tear production
       Mucous discharge from tear ducts
       Blurred vision
       Blindness (partial or complete)
       Double vision
       Other ocular symptoms
12 . Other ocular symptoms
13 . Have you recovered from this illness?Yes No 
14 . How long did your illness last? (If you're still sick, skip this question.) days
15 . Did you visit a healthcare provider for this illness?Yes No 
16 . IF YES, what type of healthcare provider? (please check any and all types of providers you saw)
       Primary Care Physician
       Urgent Care
       Health Clinic
       Hospital Emergency Department (did not stay overnight)
       Hospital (stayed at least one night)
17 . Did you submit any samples (stool, urine, blood, or other) for testing?Yes No Unknown 
18 . Do you know the results of that testing? Or, did a healthcare practitioner give you a diagnosis and, if so, what was it?
19 . If any testing was done or a diagnosis was provided to you, provide healthcare facility name (e.g., hospital or urgent care name) and address.
  THANK YOU!
Thank you so much for taking the time to fill out this survey! All of the answers you have provided will remain confidential.

If anyone in your household is sick with vomiting, diarrhea, or fever, please make sure that person stays home from school or work until they have been vomiting, diarrhea, and fever free for 24 hours without the use of medication.

Please click the "Save" button below when you are finished. You will have an opportunity to review your responses before clicking "Finish" to submit your completed survey. Thank you again for your time.
.
1 . Please leave any other comments you have here.
SendSS System Message:
#msgtext#
SendSS System Message:
#msgtext#