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National Outbreak Reporting System
Foodborne Disease Transmission, Person-to-Person Disease Transmission, Animal Contact
This form is used to report enteric foodborne, person-to-person, and animal contact-related disease outbreak investigations. This form has 5 sections, General, Laboratory, Person to
Person, Animal contact, and Food, as indicated by tabs at the top of each page. Complete the General and Laboratory tabs for all modes of transmission and complete additional
sections as indicated by the mode of transmission. Please complete as much of all sections as possible.
CDC USE ONLY
CDC Report ID
State Report ID
General Section
Primary Mode of Transmission
Form Approved
OMB No. 0000-0000
(check one)
Food (Complete General, Lab, and Food tabs)
Person-to-person (Complete General, Lab, and Person-to-Person tabs)
Water (Complete CDC 52.12)
Environmental contamination other than food/water
Animal contact (Complete General, Lab, and Animal Contact tabs)
Indeterminate/Other/Unknown (Complete General and Lab tabs)
Investigation Methods
(Complete General and Lab tabs)
(check all that apply)
Interviews only of ill persons
Case-control study
Cohort study
Food preparation review
Water system assessment: Drinking water
Water system assessment: Nonpotable water
Treated or untreated recreational water venue assessment
Investigation at factory/production/treatment plant
Investigation at original source (e.g., farm, water source, etc.)
Food product or bottled water traceback
Environment/food/water sample testing
Other
Comments
Dates (mm/dd/yyyy)
Date first case became ill (required)
/
/
/
Date last case became ill
Date of initial exposure
Date of last exposure
/
/
Date of report to CDC (other than this form)
/
/
Date of notification to State/Territory or Local/Tribal Health Authorities
/
/
/
/
/
Geographic Location
Reporting state:
Exposure occurred in multiple states
Exposure occurred in a single state but cases resided in multiple states
Other states:
Reporting county:
Exposure occurred in multiple counties in reporting state
Exposure occurred in a single county but cases resided in multiple counties in reporting state
Other counties:
City/Town/Place of exposure:
Do not include proprietary or private facility names
Primary Cases
Sex (estimated percent of the primary cases)
Number of Primary Cases
# Lab-confirmed cases
(A)
# Probable cases
(B)
# Estimated total primary ill (if greater than sum A+B)
# Cases
Total # of cases for whom
info is available
Male
%
Female
%
Approximate percent of primary cases in each age group
# Died
<1 year
%
20–49 years
%
# Hospitalized
1–4 years
%
50–74 years
%
# Visited Emergency Room
5–9 years
%
≥ 75 years
%
10–19 years
%
Unknown
# Visited health care provider (excluding ER visits)
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General
Incubation Period, Duration of Illness, Signs or Symptoms for Primary Cases only
Incubation Period (circle appropriate units)
Duration of Illness (among recovered cases-circle appropriate units)
Shortest
Min, Hours, Days Shortest
Min, Hours, Days
Median
Min, Hours, Days Median
Longest
Total # of cases for whom info is available
Min, Hours, Days Longest
Total # of cases for whom info is available
Min, Hours, Days
Min, Hours, Days
Unknown incubation period
Signs or Symptoms
Unknown duration of illness
(*refer to terms from appendix, if appropriate, to describe other common characteristics of cases)
Feature
Vomiting
Diarrhea
Bloody stools
Fever
# Cases with signs or symptoms
Total # cases for whom info available
Abdominal cramps
HUS
Asymptomatic
*
*
*
Secondary Cases
Mode of Secondary Transmission (check one)
Number of Secondary Cases
Food
Water
Animal contact
Person-to-person
Environmental contamination other than food/water
Indeterminate/Other/Unknown
# Lab-confirmed secondary cases
(A)
# Probable secondary cases
(B)
Total # of secondary cases (if greater than sum A+B)
Total # of cases (Primary + Secondary)
Environmental Health Specialists Network (if applicable)
EHS-Net Evaluation ID: 1.)
2.)
3.)
Traceback (for food and bottled water only, not public water)
Please check if traceback conducted
Source name
(If publicly available)
Source type
(e.g. poultry farm, tomato
processing plant, bottled
water factory)
Location of source
State
Comments
Country
Recall
Please check if any food or bottled water product was recalled
Type of item recalled:
Comments:
Reporting Agency
Agency name:
E-mail:
Contact name:
Contact title:
Phone no.:
Fax no.:
Remarks
CDC 52.13 Rev. 03 2008
Briefly describe important aspects of the outbreak not covered above. Please indicate if any adverse outcomes occurred in special populations
(e.g., pregnant women, immunocompromised persons)
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Laboratory
Person-to-Person
Animal Contact
Laboratory Section
Etiology known?
Yes
No
Yes
If etiology is unknown, were patient specimens collected?
No
Unknown
If yes, how many specimens collected? (provide numeric value)
What were they tested for? (check all that apply)
Etiology
Bacteria
Chemicals/Toxins
Viruses
Parasites
(Name the bacterium, chemical/toxin, virus, or parasite. If available, include the serotype and other characteristics such as phage type,
virulence factors, and metabolic profile. Confirmation criteria available at http://www.cdc.gov/foodborneoutbreaks/guide_fd.htm or
MMWR2000/Vol. 49/SS-1/App. B)
Genus
Species
Serotype
Confirmed outbreak
etiology
Other
Characteristics
Detected in*
# Lab-confirmed
cases
yes
yes
yes
yes
*Detected in (choose all that apply): 1 - patient specimen 2 - food specimen 3 - environment specimen 4 - food worker specimen
Isolates
(For bacterial pathogens, provide a representative for each distinct pattern; provide lab ID for all specimens submitted for
viral sequencing)
State Lab ID
PulseNet Outbreak
Code
CDC PulseNet
Pattern Designation for
Enzyme 1
CDC PulseNet
Pattern Designation for
Enzyme 2
Other Molecular
Designation
Other Molecular
Designation
Person to Person
Major setting of exposure (choose one)
Camp
Child day care
Community-wide
Hospital
Hotel
Nursing home
Prison or detention facility
Other, please specify:
Private setting (residential home)
Religious facility
Restaurant
School
Ship
Workplace
Attack rates for major settings of exposure
Group (based on setting)
Estimated exposed in
major setting*
Estimated ill in
major setting
Crude attack
rate [(estimated ill /
estimated exposed) x 100]
residents, guests, passengers, patients, etc.
staff, crew, etc.
*e.g., number of persons on ship, number of residents in nursing home or affected ward
Other settings of exposure
Camp
Child day care
Community-wide
Hospital
(choose all that apply)
Hotel
Nursing home
Prison or detention facility
Other, please specify:
Private setting (residential home)
Religious facility
Restaurant
School
Ship
Workplace
Animals and their environment
Setting of exposure
CDC 52.13 Rev. 03 2008
Type of animal
Remarks
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Food
Food-specific data
Food vehicle undetermined
Total # of cases exposed to implicated food
Food
1
2
3
Yes, Country
Yes, Unknown
No
Yes, Country
Yes, Unknown
No
Yes, Country
Yes, Unknown
No
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Name of food
(excluding any preparation)
Ingredient(s)
(enter all that apply)
Contaminated ingredients
(enter all that apply)
Reason(s) suspected (enter all that
apply from list in appendix)
Method of processing (enter all that
apply from list in appendix)
Method of preparation (enter all from list in
appendix)
Level of preparation
(select from list in appendix)
Contaminated food imported to US?
Was product both produced under
domestic regulatory oversight and sold?
Location where food was prepared (Check all that apply)
Location of exposure (where food was eaten)
(Check all that apply)
Restaurant – ‘Fast-food’ (drive
up service or pay at counter)
Nursing home, assisted
living facility, home care
Restaurant – ‘Fast-food’ (drive
up service or pay at counter)
Nursing home, assisted
living facility, home care
Restaurant – Sit-down dining
Hospital
Restaurant – Sit-down dining
Hospital
Restaurant – Other or
unknown type
Child day care center
Restaurant – Other or
unknown type
Child day care center
Private home
School
Private home
School
Banquet Facility (food
prepared and served
on-site)
Prison, jail
Banquet Facility (food
prepared and served
on-site)
Prison, jail
Carterer (food prepared
off-site from where served)
Church, temple, religious
location
Carterer (food prepared
off-site from where served)
Church, temple, religious
location
Fair, festival, other temporary
or mobile services
Camp
Fair, festival, other temporary
or mobile services
Camp
Grocery store
Picnic
Grocery store
Picnic
Workplace, not cafeteria
Other (describe in remarks)
Workplace, not cafeteria
Other (describe in remarks)
Workplace cafeteria
Unknown
Workplace cafeteria
Unknown
Remarks:
CDC 52.13 Rev. 03 2008
Remarks:
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Food
Contributing Factors (Check all that contributed to this outbreak)
Contributing factors unknown
Contamination Factor
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11
C12
C13
P8
P9
P10
P11
P12
N/A
C14
C15
N/A
Proliferation/Amplification Factor (bacterial outbreaks only)
P1
P2
P3
P4
P5
P6
S3
S4
S5
N/A
P7
Survival Factor
S1
S2
The confirmed or suspected point of contamination (Check one)
Before preparation
If ‘before preparation’:
Preparation
Pre-Harvest
Processing
Unknown
Reason suspected (Check all that apply)
Environmental evidence
Laboratory evidence
Epidemiologic evidence
Prior experience makes this a likely source
Was food-worker implicated as the source of contamination?
If yes, please check only one of the following
Laboratory and epidemiologic evidence
Epidemiologic evidence
Laboratory evidence
Prior experience makes this a likely source
Yes
No
School Questions
(Complete this section only if school is checked in either sections “Location where food was prepared” or “Location of exposure (where food prepared)”)
1. Did the outbreak involve a single or multiple schools?
Single
Multiple (If yes, number of schools____)
2. School characteristics (for all involved students in all involved schools)
a. Total approximate enrollment
(number of students)
Unknown or undetermined
b. Grade level(s)
Preschool
Grade school (grades K-12)
Please check all grades affected:
College/university/technical school
Unknown or Undetermined
c. Primary funding of involved schools
Public
Private
Unknown
K
1st
3. Describe the preparation of the implicated item:
(check all that apply)
Heat and serve (item mostly prepared or cooked
off site, reheated on-site)
Served a-la-carte
Serve only (preheated or served cold)
Cooked on-site using primary ingredients
Provided by a food service management company
Provided by a fast-food vendor
Provided by a pre-plate company
Part of a club or fundraising event
Made in the classroom
Brought by a student/teacher/parent
Other ___________________
Unknown or Undetermined
CDC 52.13 Rev. 03 2008
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
12th
11th
4. How many times has the state, county or local health department inspected this school cafeteria or kitchen in the 12 months
before the outbreak?*
Once
Twice
More than two times
Not inspected
Unknown or Undetermined
5. Does the school have a HACCP plan in place for the
school feeding program?*
Yes
No
Unknown or Undetermined
*If multiple schools are involved, please answer according to the most affected school
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Food
6. Was implicated food item provided to the school through the
National School Lunch/Breakfast Program?
If yes, was the implicated food item donated/purchased by:
Yes
No
Unknown or Undetermined
USDA through the Commodity Distribution Program
The state/school authority
Other
Unknown or Undetermined
Ground Beef
1. What percentage of ill persons (for whom information is available) ate ground beef raw or undercooked?
%
2. Was ground beef case-ready? Yes
No
Unknown
(Case-ready ground beef is meat that comes from a manufacturer packaged for sale that is not altered or repackaged by the retailer)
3. Was the beef ground or reground by the retailer?
Yes
No
Unknown
If yes, was anything added to the beef during grinding (such as shop trim or any product to alter the fat content)?:
Additional Salmonella Questions
(Complete this section for Salmonella outbreaks)
1. Phage type(s) of patient isolates:
if RDNC* then include #
if RDNC* then include #
if RDNC* then include #
if RDNC* then include #
* Reacts, Does Not Conform
Eggs
1. Were eggs (check all that apply)
in shell, unpasteurized?
in shell, pasteurized?
packaged liquid or dry?
stored with inadequate refrigeration during or after sale?
consumed raw?
consumed undercooked?
pooled?
2. Was SE found on the farm?
Yes
No
Unknown
Comment (e.g. eggs and patients isolates matched by phage type):
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, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA, 30333, ATTN: PRA (xxxx-xxxx) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESSCDC 52.13 Rev. 03 2008
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File Type | application/pdf |
File Modified | 2008-04-30 |
File Created | 2008-04-29 |