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CYCLOSPORIASIS SURVEILLANCE CASE REPORT FORM
ICR 201003-0920-010 · OMB 0920-0009 · Object 16615901.
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| File Type | application/msword |
|---|---|
| File Title | CYCLOSPORIASIS SURVEILLANCE CASE REPORT FORM |
| Author | ail7 |
| Last Modified By | Writer |
| File Modified | 2006-04-05 |
| File Created | 2026-09-27 |
| Conversion State | complete |
Extracted Text
CYCLOSPORIASIS SURVEILLANCE CASE REPORT FORM
Form Approved
OMB NO. 0920-0009
Demographic Data:
Patient’s name: __________________________________________________________________________________
Last First
State of residence: ______________________________________ County: ______________________________
Sex: Male Female Age:______ Date of birth (mm/dd/yy):____/____/____
Race/Ethnicity (select one or more):
American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander
Asian Hispanic or Latino White
Unknown
Physician’s Name:___________________________________________ Phone:__ __ __-__ __ __-__ __ __ __
Physician’s Email: ___________________________________________
Clinical Data: (NOTE: for dates, be as specific as possible. However, approximations (e.g., mm/yy) are okay.)
Date of illness onset (mm/dd/yy): ___/___/____ Unknown
Signs and symptoms:
Diarrhea: Yes No Unknown Fatigue: Yes No Unknown
Maximum number stools per day:__________ Anorexia: Yes No Unknown
(unknown = 999) Nausea: Yes No Unknown
Weight loss: Yes No Unknown Vomiting: Yes No Unknown
Baseline weight: __ __ __ lbs. (unknown = 999) Abdominal cramps: Yes No Unknown
Number of pounds lost: ___________ Other symptoms (specify): _________________
Fever: Yes No Unknown _______________________________________
Temperature (if measured):_______degrees F (unknown = 999)
Hospitalized (at least overnight): Yes No Unknown
If yes, list name of hospital: _________________________________ Date of admission: ___/___/___
Stool collection date: ___/___/___ Results: Positive Negative Unknown
Confirmed by state lab? Yes No Unknown Confirmed by CDC lab? Yes No Unknown
Was the case-patient treated for cyclosporiasis? Yes No Unknown
If yes, what medication was provided? trimethoprim/sulfamethoxazole (e.g., Bactrim, Septra, Cotrim)
Other (specify): _________________________ Unknown
Is case-patient sulfa-allergic? Yes No Unknown
Epidemiologic Data: (NOTE: for dates, be as specific as possible. However, approximations (e.g., mm/yy) are okay.)
Public reporting burden of this collection of information is estimated to average 15 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).
History of Travel (during the 2 weeks before onset of illness): Yes No Unknown
International travel (country): Unknown dates (check here if dates are unknown)
(1)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___
(2)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___
(3)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___
Travel in the United States (state): Unknown dates (check here if dates are unknown)
(1)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___
(2)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___
(3)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___
Exposures (during the 2 weeks before onset of illness):
Ate fresh berries: Yes (if yes, specify types below; check all that apply) No Unknown
Strawberries Blackberries Blueberries
Raspberries Black raspberries Golden raspberries Unknown type of berry
Other type of berry (specify):_________________________________
Ate fresh herbs: Yes (if yes, specify types below; check all that apply) No Unknown
Cilantro Oregano Thyme Mint Dill Parsley Rosemary
Basil (specify types): Sweet basil Thai basil (i.e., green leaves and purple stems)
Purple basil (i.e., purple leaves and stems)
Other type of herb (specify): ___________________________________________________________
Unknown type of herb
Ate lettuce: Yes (if yes, specify types below; check all that apply) No Unknown
Mesclun (a.k.a., spring mix, field greens, baby greens, & gourmet salad mix)
Arugula
Other type of lettuce (specify): ____________________________________________________________
Unknown type of lettuce
Ate other types of fresh produce: Yes (if yes, specify types below; check all that apply) No Unknown
Fruit, other than berries (specify types): _______________________________________________________
Unknown type of fruit
Other type(s) of fresh produce (specify): _____________________________________________________
___________________________________________________________________________________
Unknown type of fresh produce
Did the case-patient attend any events (e.g., wedding reception) during the 2 weeks before symptom onset? Yes No Unknown
If yes, specify type of event: ___________________________________________________________________
Event date: ___/___/___
Does the case-patient know of any other ill persons? Yes No Unknown
If yes, did health department collect contact information about other ill persons and investigate further (provide comments below)?
Yes No Unknown
Comments and additional data:
Name (person filling out form):______________________________________ Title:____________________________
Phone: __ __ __-__ __ __-__ __ __ __ FAX: __ __ __-__ __ __-__ __ __ __
Email: ____________________________________________
Name of investigating health department: ____________________________________________________________
Date form completed: ___/___/___
Revised 9/3/02