Atlanta Hotel Pneumonia Illness Outbreak 
The Fulton County Board of Health and Georgia Department of Public Health are working to investigate a cluster of respiratory illnesses reported among people who stayed at the Sheraton in downtown Atlanta during late June and early July.
Please answer all questions that apply and know that all of your answers will be kept completely confidential. Please complete one survey per person. Responses from those who were not ill are also valuable to our investigation - it enables us to compare activities for those who got ill to those who did not. We estimate that it should take you 10 minutes per survey to complete. If you have any questions while you are taking the survey, please call the Fulton County Board of Health Epidemiology at 404-613-1391. Thank you so much for your cooperation.
1 . First Name
2 . Last Name
3 . Address
4 . City
5 . State
6 . Zip Code
7 . County
8 . Gender
9 . Date of Birth//
10 . Age
11 . Phone Number--
12 . Email Address
1 . Please indicate if you experienced the following:
 No   Yes   Not Sure 
Ill with symptoms of fever, cough, or shortness of breath DURING your stay or in the 14 days AFTER your visit to the Sheraton in downtown Atlanta
If you did not experience symptoms of illness during or following your visit to the Sheraton, please skip the following questions and proceed to the next section about hotel activities.
2 . On what date did your symptoms start?//
3 . At what time did your symptoms start?:AMPM
4 . Please check ALL of the following symptoms you experienced since checking into the Sheraton in downtown Atlanta.
 Yes   No   Not Sure 
Shortness of Breath
Body Aches
5 . Other symptoms.
6 . IF you reported pneumonia, how were you diagnosed with pneumonia? (Please check all that apply)
       Chest x-ray
7 . Other method of diagnosis
8 . Have your symptoms resolved or gotten better?Yes No 
9 . IF your symptoms have resolved, on what date did you feel better?//
10 . Did you visit a healthcare provider for this illness?
11 . IF YES, what type of healthcare provider? (please check any and all types of providers you saw)
       Primary Care Physician
       Health Clinic
       Urgent Care Center
       Hospital Emergency Department (did not stay overnight)
       Hospital (stayed at least one night)
12 . IF you were seen at a hospital, please provide the name and location (City, State)
13 . Did you submit any samples (urine, sputum, or other) for testing?Yes No Not Sure 
14 . Do you know the results of that testing? Or, did a healthcare practitioner give you a diagnosis and, if so, what was it?
15 . IF you are aware of others that have had similar illness, please provide their information here (this information will remain confidential).
  Hotel Activities
1 . Did you spend any nights at the Sheraton in downtown Atlanta? (i.e. Did you "check in" as a hotel guest?)Yes No 
2 . IF you stayed overnight at the hotel, on what date did you check in?//
3 . IF you stayed overnight at the hotel, on what date did you check out?//
4 . IF you did stay overnight at the Sheraton, in what room did you stay?
5 . IF you did not stay overnight at the hotel, please indicate on what dates you visited the hotel.
6 . Please indicate if you did any of the following at the Sheraton in downtown Atlanta.
 Yes   No   Not Sure 
Took a bath
Swam in the pool
Used the fitness facility
Entered whirlpool spa
Near (not entered) whirlpool spa
Near decorative fountain(s)
Near other water feature
Consumed ice from an ice machine
7 . Please indicate if you were in or near the pool on any of the following days. ("Near" the pool would be within the gated courtyard pool area)
 Entered   Near but did not enter   Neither near nor entered   Not sure 
Wed. June 12
Thurs. June 13
Fri. June 14
Sat. June 15
Sun. June 16
Mon. June 17
Tues. June 18
Wed. June 19
Thurs. June 20
Fri. June 21
Sat. June 22
Sun. June 23
Mon. June 24
Tues. June 25
Wed. June 26
Thurs. June 27
Fri. June 28
Sat. June 29
Sun. June 30
Mon. July 1
Tues. July 2
Wed. July 3
Thurs. July 4
Fri. July 5
Sat. July 6
Sun. July 7
Mon. July 8
Tues. July 9
Wed. July 10
Thurs. July 11
Fri. July 12
Sat. July 13
Sun. July 14
  Off-site Activities
Now we have some questions about things you may have done in and around the Atlanta hotel during your time there.
1 . Please indicate if you recall being in or near any of the following during your stay in Atlanta.
 Yes   No   Not Sure 
Healthcare Facilities
Senior or Assisted Living Facilities
Hot tub or whirlpool spa (entered)
Hot tub or whirlpool spa (near)
Jacuzzi tub
Pool (not at Sheraton)
Recreational misters
Steam room or wet sauna
Decorative fountain (not at Sheraton)
Gym facility (not at Sheraton)
Other areas with water
2 . IF you said "Yes" to any of the above, please provide more information here.
Again, thank you very much for your participation in this survey. All of the information provided will be used to describe the outbreak that occurred and hopefully determine the source of illness. When you are finished, please select "Save" and then "Finish" for your responses to be transmitted through our secure website.
1 . Please use this space for any additional comments.