0920-0004 Foodborne Outbreak 52.13

Form approved OMB No. 0920-0004

Electronic
Foodborne
Outbreak
Reporting
System

Investigation of a Foodborne Outbreak
This form is used to report foodborne disease outbreak investigations to CDC. It is also
used to report Salmonella Enteritidis and E. coli O157:H7 outbreak investigations
involving any mode of transmission. A foodborne outbreak is defined as the occurrence
of two or more cases of a similar illness resulting from the ingestion of a common food
in the United States. This form has 6 parts. Part 1 asks for the minimum or basic
information needed and must be completed for the investigation to be counted in the
CDC annual summary. Part 2 asks for additional information for any foodborne
outbreak, while Parts 3 – 6 ask for information concerning specific vehicles or
etiologies. Please complete as much of all parts as possible.

CDC Use Only

__-___________
State Use Only

______________

Part 1: Basic Information
1. Report Type
A.
□ Please check if this a final report

3. Dates
Please enter as many dates as possible
Date first case became ill __ __/__ __/__ __ __ __
Month

B.

□ Please check if data does not support a
FOODBORNE outbreak

Day

Year

Date last case became ill __ __/__ __/__ __ __ __
Month

Day

Year

Date first known exposure __ __/__ __/__ __ ____
Month

2. Number of Cases

Day

Year

Date last known exposure __ __/__ __/__ __ __ __
Month

Day

Year

Lab-confirmed cases______(A)
Including _______ secondary cases

Estimated total ill__________
(If greater than sum A + B)

<1 year _____% 20-49 yrs _____%
1-4 yrs _____% ≥50 yrs _____%
5-19 yrs ____% Unknown _____%

Reporting state ________________
If multiple states involved:
□ Exposure occurred in multiple states
□ Exposure occurred in single state, but cases
resided in multiple states
Other states: __________________
_____________________________
_____________________________

Reporting county_______________
If multiple counties involved:
□ Exposure occurred in multiple counties
□ Exposure occurred in one county, but cases
resided in multiple counties
Other counties: ________________
_____________________________
_____________________________

Probable cases______(B)
Including _______ secondary cases

5. Approximate Percentage of
Cases in Each Age Group

4. Location of Exposure

6. Sex

7. Investigation Methods (Check all that apply)

(Estimated percent of
the total cases)

□ Interviews of only cases
□ Food preparation review
□ Investigation at factory or production plant
□ Investigation at original source

Male___________%
Female___________%

□ Case-control study
□ Cohort study

(farm, marine estuary, etc.)

□ Food product traceback
□ Environment / food sample cultures

8. Implicated Food(s): (Please provide known information)
Name of Food
e.g., Lasagna

Main Ingredient(s) Contaminated Ingredient(s)
e.g., Pasta, sauce,
eggs, beef

e.g., Eggs

Reason(s) Suspected
(See codes just below)
e.g., 4

Method of Preparation
(See attached codes)
e.g., M1

1)
2)
3)

□ Food vehicle undetermined
Reason Suspected (List above all that apply)
1 - Statistical evidence from epidemiological investigation
2 - Laboratory evidence (e.g., identification of agent in food)
3 - Compelling supportive information

4 - Other data (e.g., same phage type found on farm that supplied eggs)
5 - Specific evidence lacking but prior experience makes it likely source

CDC 52.13 revised November, 2004
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 (0920-0004).

9. Etiology: (Name the bacteria, virus, parasite, or toxin. 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/SS1/App. B)
Etiology

Serotype

1)

Other Characteristics
(e.g., phage type)

Detected In
(See codes just below)

□ Confirmed
□ Confirmed
□ Confirmed

2)
3)

□ Etiology undetermined
Detected In (List above all that apply)
1 - Patient Specimen(s)
2 - Food Specimen(s)

3 -Environment specimen(s)
4 - Food Worker specimen(s)

10. Isolate Subtype
State Lab ID

PFGE (PulseNet designation)

PFGE (PulseNet designation)

1)
2)
3)
11. Contributing Factors (Check all that apply. See attached codes and explanations)
□ Contributing factors unknown
Contamination Factor

□C1 □C2 □C3 □C4 □C5 □C6 □C7 □C8 □C9 □C10 □C11 □C12 □C13 □C14 □C15 (describe in Comments) □ N/A
Proliferation/Amplification Factor (bacterial outbreaks only)

□P1 □P2 □P3 □P4 □P5 □P6 □P7 □P8 □P9 □P10 □P11 □P12 (describe in Comments) □ N/A
Survival Factor (microbial outbreaks only)

□S1 □S2 □S3 □S4 □S5 (describe in Comments) □N/A
□ Was food-worker implicated as the source of contamination? □ Yes □ No
If yes, please check only one of following
□ laboratory and epidemiologic evidence
□ epidemiologic evidence (w/o lab confirmation)
□ lab evidence (w/o epidemiologic evidence)
□ prior experience makes this the likely source (please explain in Comments)

CDC 52.13 revised November, 2004

Part 2: Additional Information
12. Symptoms, Signs and Outcomes
Cases with
Total cases for whom
Feature
outcome/
feature

you have information
available

Healthcare provider
visit
Hospitalization
Death

13. Incubation Period
(Circle appropriate units)
Shortest______(Hours, Days)
Longest______(Hours, Days)
Median ______(Hours, Days)
□ Unknown

Vomiting

14. Duration of Illness
(Among those who recovered)
(Circle appropriate units)
Shortest______(Hours, Days)
Longest______(Hours, Days)
Median ______(Hours, Days)
□ Unknown

Diarrhea
Bloody stools

∗ Use the following terms, if appropriate, to describe other common

Fever

characteristics of cases

Abdominal cramps

Anaphylaxis
Arthralgia
Bradycardia
Bullous skin lesions
Coma
Cough
Descending paralysis
Diplopia
Flushing

HUS or TTP
Asymptomatic

*
*
*

Headache
Hypotension
Itching
Jaundice
Lethargy
Myalgia
Paresthesia
Septicemia
Sore throat

Tachycardia
Temperature reversal
Thrombocytopenia
Urticaria
Wheezing

15. If Cohort Investigation Conducted:
Attack rate* = __________/ __________________________________ x 100 = ________%
Exposed and ill

Total number exposed for whom you have illness information

* The attack rate is applied to persons in a cohort who were exposed to the implicated vehicle. The numerator is the number of persons who were exposed and became ill;
the denominator is the total number of persons exposed to the implicated vehicle. If the vehicle is unknown, then the attack rate should not be calculated.

16. Location Where Food Was Prepared

17. Location of Exposure or Where Food Was Eaten

(Check all that apply)
□Restaurant or deli
□ Nursing home
□ Day care center
□ Prison, jail
□ School
□ Private home
□ Office setting
□ Workplace, not cafeteria
□ Workplace cafeteria
□ Wedding reception
□ Banquet Facility
□ Church, temple, etc
□ Picnic
□ Camp
□ Caterer
□ Contaminated food imported into U.S.
□ Grocery Store
□ Hospital
□ Fair, festival, other temporary/ mobile services
□ Commercial product, served without further preparation
□ Unknown or undetermined
□ Other (Describe) ________________________________

(Check all that apply)

□ Restaurant or deli
□ Nursing Home
□ Day care center
□ Prison, jail
□ School
□ Private home
□ Office Setting
□ Workplace, not cafeteria
□ Workplace cafeteria
□ Wedding Reception
□ Banquet Facility
□ Church, temple, etc.
□ Picnic
□ Camp
□ Grocery Store
□ Hospital
□ Fair, festival, temporary/ mobile service
□ Unknown or undetermined
□ Other (Describe) _____________________________________

18. Trace back
□ Please check if trace back conducted
Source to which trace back led:

Source
(e.g., Chicken farm, Tomato processing plant)

CDC 52.13 revised November, 2004

Location of Source
State

Comments
Country

19. Recall
□ Please check if any food product recalled
Recall Comments
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

20. Available Reports (Please attach)
□ Unpublished agency report
□ Epi-Aid report
□ Publication (please reference if not attached)
__________________________________________________________
__________________________________________________________

21. Agency reporting this outbreak
___________________________________________

22. Remarks

Contact person:
Name _____________________________________
Title ______________________________________
Phone _____________________________________
Fax _______________________________________
E-mail ____________________________________

________________________________________________________

Briefly describe important aspects of the outbreak not covered above
(e.g., restaurant closure, immunoglobin administration, economic impact, etc)

____________________________________________
____________________________________________
____________________________________________
____________________________________________

Part 3: School Questions
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) (Please check all grades affected)
□ Preschool
□ Grade School (grades K-12)
Please check all grades affected: □K □1st
□ College/University/Technical School
□ Unknown or Undetermined

□2nd □3rd □4th □5th □6th □7th □8th □9th □10th □11th □12th

c. Primary funding of involved school(s)
□ Public □ Private □ Unknown or Undetermined

3. Describe the preparation of the implicated
item:
□ 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/ fundraising event
□ Made in the classroom
□ Brought by a student/teacher/parent
□ Other ___________________
□ Unknown or Undetermined

CDC 52.13 revised November, 2004

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 there are multiple schools involved, please answer according to the most
affected school

6. Was implicated food item provided to the
school through the National School
Lunch/Breakfast Program?
□ Yes
□ No
□ Unknown or Undetermined

If Yes, Was the implicated food item donated/purchased
by :

□ USDA through the Commodity Distribution Program
□ Purchased commercially by the state/school authority
□ Other_____________________________
□ Unknown or Undetermined

Part 4: 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? (Ground beef that comes from a manufacturer packaged for sale and not altered or repackaged by the retailer)
□ Yes
□ No
□ Unknown or Undetermined
3. Was the beef ground or reground by the retailer?
□ Yes
□ No
□ Unknown or Undetermined
If yes, was anything added to the beef during grinding (e.g., shop trim or any product to alter the fat
content)____________________________________________________________________________

Part 5: Mode of Transmission
(Enterohemorrhagic E. coli or Salmonella Enteritidis only)
1. Mode of Transmission (for greater than 50% of cases)
Select one:
□ Food
□ Person to person
□ Swimming or recreational water
□ Drinking water
□ Contact with animals or their environment
□ Unknown or Undetermined

Part 6: Additional Egg Questions
1. Were Eggs: (Check all that apply)
□ in-shell, un-pasteurized?
□ in-shell, pasteurized?
□ liquid or dry egg product?
□ stored with inadequate refrigeration during or after sale?
□ consumed raw?
□ consumed undercooked?
□ pooled?
2. If eggs traced back to farm, was Salmonella Enteritidis found on the farm?
□ Yes
□ No
□ Unknown or Undetermined
Comment:_____________________________________________________________________________________________
_____________________________________________________________________________________________

CDC 52.13 revised November, 2004

Contamination Factors:1
C1 - Toxic substance part of tissue (e.g., ciguatera)
C2 - Poisonous substance intentionally added (e.g., cyanide or phenolphthalein added to cause illness)
C3 - Poisonous or physical substance accidentally/incidentally added (e.g., sanitizer or cleaning compound)
C4 - Addition of excessive quantities of ingredients that are toxic under these situations (e.g., niacin poisoning in bread)
C5 - Toxic container or pipelines (e.g., galvanized containers with acid food, copper pipe with carbonated beverages)
C6 - Raw product/ingredient contaminated by pathogens from animal or environment (e.g., Salmonella Enteriditis in
egg, Norwalk in shellfish, E. coli in sprouts)
C7 - Ingestion of contaminated raw products (e.g., raw shellfish, produce, eggs)
C8 - Obtaining foods from polluted sources (e.g., shellfish)
C9 - Cross-contamination from raw ingredient of animal origin (e.g., raw poultry on the cutting board)
C10 - Bare-handed contact by handler/worker/preparer (e.g., with ready-to-eat food)
C11 - Glove-handed contact by handler/worker/preparer (e.g., with ready-to-eat food)
C12 - Handling by an infected person or carrier of pathogen (e.g., Staphylococcus, Salmonella, Norwalk agent)
C13 - Inadequate cleaning of processing/preparation equipment/utensils B leads to contamination of vehicle (e.g.,
cutting boards)
C14 - Storage in contaminated environment B leads to contamination of vehicle (e.g., store room, refrigerator)
C15 - Other source of contamination (please describe in Comments)

Proliferation/Amplification Factors:

1

P1 - Allowing foods to remain at room or warm outdoor temperature for several hours (e.g., during preparation or
holding for service)
P2 - Slow cooling (e.g., deep containers or large roasts)
P3 - Inadequate cold-holding temperatures (e.g., refrigerator inadequate/not working, iced holding inadequate)
P4 - Preparing foods a half day or more before serving (e.g., banquet preparation a day in advance)
P5 - Prolonged cold storage for several weeks (e.g., permits slow growth of psychrophilic pathogens)
P6 - Insufficient time and/or temperature during hot holding (e.g., malfunctioning equipment, too large a mass of food)
P7 - Insufficient acidification (e.g., home canned foods)
P8 - Insufficiently low water activity (e.g., smoked/salted fish)
P9 - Inadequate thawing of frozen products (e.g., room thawing)
P10 - Anaerobic packaging/Modified atmosphere (e.g., vacuum packed fish, salad in gas flushed bag)
P11 - Inadequate fermentation (e.g., processed meat, cheese)
P12 - Other situations that promote or allow microbial growth or toxic production (please describe in Comments)

Survival Factors:1
S1 - Insufficient time and/or temperature during initial cooking/heat processing (e.g., roasted meats/poultry, canned
foods, pasteurization)
S2 - Insufficient time and/or temperature during reheating (e.g., sauces, roasts)
S3 - Inadequate acidification (e.g., mayonnaise, tomatoes canned)
S4 - Insufficient thawing, followed by insufficient cooking (e.g., frozen turkey)
S5 - Other process failures that permit the agent to survive (please describe in Comments)

Method of Preparation:2
M1 - Foods eaten raw or lightly cooked (e.g., hard shell clams, sunny side up eggs)
M2 - Solid masses of potentially hazardous foods (e.g., casseroles, lasagna, stuffing)
M3 - Multiple foods (e.g., smorgasbord, buffet)
M4 - Cook/serve foods (e.g., steak, fish fillet)
M5 - Natural toxicant (e.g., poisonous mushrooms, paralytic shellfish poisoning)
M6 - Roasted meat/poultry (e.g., roast beef, roast turkey)
M7 - Salads prepared with one or more cooked ingredients (e.g., macaroni, potato, tuna)
M8 - Liquid or semi-solid mixtures of potentially hazardous foods (e.g., gravy, chili, sauce)
M9 - Chemical contamination (e.g., heavy metal, pesticide)
M10 - Baked goods (e.g., pies, éclairs)
M11 - Commercially processed foods (e.g., canned fruits and vegetables, ice cream)
M12 - Sandwiches (e.g., hot dog, hamburger, Monte Cristo)
M13 - Beverages (e.g., carbonated and non-carbonated, milk)
M14 - Salads with raw ingredients (e.g., green salad, fruit salad)
M15 - Other, does not fit into above categories (please describe in Comments)
M16 - Unknown, vehicle was not identified
1

Frank L. Bryan, John J. Guzewich, and Ewen C. D. Todd. Surveillance of Foodborne Disease III.
Summary and Presentation of Data on Vehicles and Contributory Factors; Their Value and Limitations.
Journal of Food Protection, 60; 6:701-714, 1997.
2
Weingold, S. E., Guzewich JJ, and Fudala JK. Use of foodborne disease data for HACCP risk
assessment. Journal of Food Protection, 57; 9:820-830, 1994.

CDC 52.13 revised November, 2004