City of Havre Illness Survey

City of Havre Illness Survey
Thank you for taking the time to participate in this survey. There have been some giardiasis cases reported in Hill County that may be related the City of Havre public water supply. Local and state public health are hoping to learn more about the number of potentially related illnesses in the community, and appreciate your help by answering the questions below.

Disclaimer: Please answer these questions about your water consumption routines PRIOR to the Boil Water Advisory sent out on April 19th.
Do you consume water from the City of Havre Public Water Supply in the place where you live?

YesNoUnsure
If unsure, leave a comment (optional)
Do you consume water from the City of Havre Public Water Supply in the place where you work?

YesNoUnsure
If unsure, leave a comment (optional)
Do you routinely perform any additional filtration or treatment on your water before consuming it? Please note, this question refers to your normal water consumption behaviors prior to the Boil Water Advisory that went into effect on April 19th.

YesNoOther
If yes, please describe steps taken:
Do you drink water from your refrigerator's filter?

YesNo
Do you drink water from a pitcher water filter (for example, a Brita filter)?

YesNo
Do you drink bottled water exclusively (that is, you only drink bottled water and not tap water)?

YesNo
If yes, please share the name of the brand of bottle water:
Have you had any new onset of gastrointestinal (GI) symptoms this year (2024)?

YesNo
Would you be willing to work with public health to test the filters from your refrigerator or pitcher filter, if you have not changed them since February of this year?

YesNo
Note: If yes, please provide a phone number and contact info in case public health needs to follow up with you.
What day did your symptoms start? Please estimate the date if you are not quite sure the exact date they started.

MonthDayYear
Date
Please select the symptoms you had below (please check as many as apply).

DiarrheaGasFoul-smelling greasy stools (poop) that tend to floatStomach cramps or painUpset stomach or nauseaVomitingDehydration (loss of fluids)Other
How long did your symptoms last (if you are still symptomatic, please include that below)?
Did you ever visit a doctor for these symptoms?

YesNo
If yes, did the doctor collect a stool (poop) sample for testing?

YesNo
If yes, please share the result of the testing:
If you are still sick, are you thinking about visiting your doctor and getting a stool (poop) sample tested?

YesNo
In the two weeks before you got sick, did you knowingly drink untreated water (for example, from a stream while hiking) or have recreational water exposure?

YesNo
If yes, please describe:
In the two weeks before you got sick, did you have close contact with someone who was sick with similar symptoms? Close contact could be you shared food with them, took care of them, live in the same house as them, etc.

YesNo
If yes, please describe:
Did you travel in the two weeks before your symptoms started?

YesNo
If yes, please explain:
Are there any additional details you would like to share about your illness?
OPTIONAL:

Demographic information, including age/date of birth and address will be helpful in figuring out more about this situation, if you are willing to share that information below. Public health may have some additional questions for you, based on the results of the survey, if you are willing to provide your name and phone number.

Please share your name, age, date of birth, address, and/or phone number below.
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Should be Empty: