Form assigned Trichinosis

TRICHINOSIS SURVEILLANCE CASE REPORT

Form Approved

OMB NO. 0920-0009

S tate Reporting: First four letters of last name: Age: Sex: Date of birth:

Male Female

State abbreviation Mo Day Yr

Race/Ethnicity:

American Indian or Alaska Native Black or African American Native Hawaiian or other Pacific Islander Unknown

Asian Hispanic or Latino White

County: Physician’s Name: Physician’s Phone:

__ __

DATE OF ONSET OF ILLNESS: OUTCOME:

Recovered Died Unknown

Mo Day Yr

S IGNS AND SYMPTOMS:

Eosinophilia: Fever: Periorbital edema: Myalgia:

Yes Not Done Yes Unknown Yes Unknown Yes Unknown

No Unknown No No No

Specify absolute number or percentage: Specify temperature:

(#) _________ or (%) __________ _____________

M USCLE BIOPSY: SEROLOGIC FINDINGS: Positive Negative Not Done Unknown

Positive Test type (specify): ____________________________

Negative

Date of test: Test results: Positive Negative Unequivocal Unknown

Not Done Mo Day Yr

Date of test: Test results: Positive Negative Unequivocal Unknown

Mo Day Yr

S USPECT FOOD:

DATE CONSUMED:

Pork (specify type below): Non Pork (specify type below): Unknown

Store bought pork Bear meat

Pork from farm-raised pig Hamburger (ground meat)

Wild boar Other (specify): ______________ Mo Day Yr

Other (specify): ________________ Not specified

Not specified

LARVAE IN SUSPECT FOOD:

Not examined Present

Absent Unknown

WHERE MEAT OBTAINED: PREPARATION AFTER PURCHASE METHOD OF COOKING:

FURTHER PROCESSING:

Supermarket/grocery store No further processing Uncooked

Butcher shop Ground (i.e., hamburger) Fried

Restaurant or other public Smoked Open-fire roasting/BBQ

eating establishment Dried jerky Other cooking method (specify):

Direct from farm Marinated _________________________

Hunted or trapped Other (specify): _______________ Unknown

Other (specify): ____________________ Unknown

Unknown

PATIENT’S OCCUPATION: RELATED CASES:

Yes No Unknown

COMMENTS AND ADDITIONAL DATA

Investigator name and title: Date form completed:

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).