Form CDC 52.12 CDC 52.12 Waterborne Disease Outbreak Report

General

National Outbreak Reporting System
Waterborne Disease Transmission

This form is used to report waterborne disease outbreak investigations. This form has 6 parts, indicated by tabs at the top of each page. Part 1 asks for the minimum or basic information
about the outbreak investigation. Part 2 asks for epidemiological data and clinical specimen test results. Parts 3, 4, 5 and 6 collect information about types of water exposure (treated
recreational water, untreated recreational water, drinking water, and water not intended for drinking/unknown intent). Only 1 of these 4 water exposure parts should be completed for an
outbreak investigation report.
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 CDC 52.13)

Person-to-person (Complete CDC 52.13)

Water (Complete tabs for General, Water-General and type

Environmental contamination other than food/water

of water exposure)

(Complete CDC 52.13)

Animal contact (Complete CDC 52.13)

Indeterminate/Other/Unknown (Complete CDC 52.13)

Investigation Methods

(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 duration of illness

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 52.12 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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Water-General

Waterborne Disease and Outbreaks - General

Type of Water Exposure (check ONE box)
Water intended for recreational
purposes – treated venue
(e.g., pool, spa/whirlpool/hot
tub, spray pad)

Water intended for
recreational purposes –
untreated venue (e.g.,
freshwater lake, hot spring,
marine beach)

Water intended for drinking
(includes water used for
bathing/showering)

Geographic Location

Symptoms

Percent of primary cases living in reporting state :

Was exposure associated with a specific event or gathering?
No

Route of Entry

For each category, indicate # of
persons with:

%

Associated Events

Yes

Water not intended for
drinking or water of unknown
intent (e.g., cooling/industrial,
occupational, decorative/
display)

Unknown

Gastrointestinal symptoms/
conditions

Ingestion

Respiratory symptoms/
conditions

Contact

Skin symptoms/conditions

If Yes, what type of event or gathering was involved?

Inhalation

Ear symptoms/conditions
Other, specify:
Eye symptoms/conditions
Neurologic symptoms/
conditions

If outbreak occurred during a defined event, dates of event:

Unknown

Wound infections
Start date:

/
/
(mm/dd/yyyy)

End date:

/
/
(mm/dd/yyyy)

Other, specify (e.g.,
hepatitis A, leptospirosis):

Epidemiologic Data
1. Estimated total number of persons with primary exposure:
2. Were data collected from comparison groups to estimate risk?
If No or Unknown, was water the only common source
shared by persons who were ill?
Exposure (Vehicle/Setting)
(e.g., pool—waterpark;
hot spring; well water)

Total #
Exposed
(A)

# Ill
Exposed
(B)

Yes (specify in table below)

No

Unknown

Yes

No

Unknown

Total # Not # Ill Not
Exposed
Exposed

Attack rate for residents of reporting state:

%

Attack
Rate (%)
(B/A)

Odds
Ratio

Relative
Risk

p-Value

(provide exact
value, if known)

Attack rate for non-residents of reporting state:

95% Confidence
Interval

%

Clinical Specimens - Laboratory Results (refer to the laboratory findings from the outbreak investigation)
1. Were clinical diagnostic specimens taken from persons?

Yes

No (go to next tab)

Unknown (go to next tab)

If Yes, from how many persons were specimens taken?

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Water-General
Specimen Type*

Specimen Subtype**

Tested for § (list all that apply)

* Specimen Type: 1- Autopsy Specimen (specify subtype), 2-Biopsy (specify), 3-Blood, 4-Bronchial Alveolar Lavage (BAL), 5-Cerebrospinal Fluid (CSF), 6-Conjunctiva/Eye Swab, 7-Ear Swab,
8-Endotracheal Aspirate, 9-Saliva, 10-Serum, 11-Skin Swab, 12-Sputum, 13-Stool, 14-Urine, 15-Vomitus, 16-Wound Swab, 17-Unknown
** Specimen Subtype: 1-Bladder, 2-Brain, 3-Dura, 4-Hair, 5-Intestine, 6-Kidney, 7-Liver, 8-Lung, 9-Nails, 10-Skin, 11-Stomach, 12-Wound, 13-Other, 14-Unknown
§ Tested for: 1-Bacteria, 2-Chemicals/Toxins, 3-Fungi, 4-Parasites, 5-Viruses

Enter positive findings in the table below. If tests for a specific pathogen/agent were negative, please also list that pathogen/agent and fill
in the Specimen Type, Specimen Subtype, Test Type, Total # of People Tested and Total # of People Positive.
Clinical Specimen Genus/ Chemical/ Toxin
Row Number

Species

Serotype/ Serogroup/ Serovar

Genotype/ Subtype

1
2
3
4
5

Clinical Specimen Confirmed as
Row Number
Etiology ?
1

yes

2

yes

3

yes

4

yes

5

yes

Concentration
(number)

Unit (e.g., oocysts, CFU) Specimen Type *

Clinical Specimen Test Type §
Row Number

Specimen Subtype **

Total # People
Tested

Total # People
Positive

1
2
3
4
5
* Specimen Type: 1- Autopsy Specimen (specify subtype), 2-Biopsy (specify), 3-Blood, 4-Bronchial Alveolar Lavage (BAL), 5-Cerebrospinal Fluid (CSF), 6-Conjunctiva/Eye Swab, 7-Ear Swab,
8-Endotracheal Aspirate, 9-Saliva, 10-Serum, 11-Skin Swab, 12-Sputum, 13-Stool, 14-Urine, 15-Vomitus, 16-Wound Swab, 17-Unknown
** Specimen Subtype: 1-Bladder, 2-Brain, 3-Dura, 4-Hair, 5-Intestine, 6-Kidney, 7-Liver, 8-Lung, 9-Nails, 10-Skin, 11-Stomach, 12-Wound, 13-Other, 14-Unknown
§ Test Type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing,
6-Chemical Testing, 7-Tissue Culture Infectivity Assay

Isolates
State Lab Isolate ID

CDC 52.12 Rev. 03 2008

Specimen Profile 1 (e.g., PFGE, MLVA, or genotype)

National Outbreak Reporting System

Specimen Profile 2 (e.g., PFGE, MLVA, or genotype)

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Rec Water-Treated

Recreational Water – Treated Venue
Recreational Water Vehicle Description
Water Vehicle Number
(e.g., 1, 2, 3)

Water Vehicle Number
(e.g., 1, 2, 3)

Water Subtype

Water Type

(select indoor, outdoor, or
unknown)

USUAL Water Treatment
Provided at Venue

Venue Treatment Subtype

Chlorination Subtype

Fill Water Type

IF PUBLIC WATER WAS USED
TO FILL, USUAL Water Treatment
Provided for Fill Water Before
Coming to the Venue

IF PUBLIC WATER WAS USED TO FILL,
Fill Water Treatment Subtype

(e.g., no treatment; coagulation; disinfection; flocculation; filtration (pool);
unknown)

Water Vehicle Number
(e.g., 1, 2, 3)

Setting of Exposure

(e.g., spa/whirlpool/hot tub;
pool- swimming pool; pool- waterpark)

(e.g., public water supply; sea water;
untreated ground or surface water;
unknown)

(e.g., club, requiring membership;
hotel/motel/lodge/inn; waterpark)

(disinfection or pool filtration: e.g., UV;
chlorine dioxide; bag filter; cartridge filter;
unknown)

(chlorine disinfection only- e.g., gaseous;
sodium hypochlorite; cyanurates /stabilized
chlorine)

(disinfection or pool filtration: e.g., UV; chlorine
dioxide; bag filter; cartridge filter; unknown)

(e.g., no treatment; disinfection;
filtration (treatment plant); unknown)

Recreational Water Quality
Did the venue meet state or local recreational water quality regulations?

Yes

No

Unknown

Yes

No

Unknown

Not applicable

If No, explain:
Was there a pool operator on the payroll with state-approved
training or certification?
Laboratory Section - Recreational Water Samples from Treated Venues
Was water from treated recreational water venues tested?
Results
1

Sample
Source of Sample

Yes (specify in table below)
2

3

No
4

Unknown
5

(e.g., swimming pool, hot tub)

Additional Description of Source of Sample

(e.g., specific location, time of day, backwash sample, etc.)
Date (mm/dd/yyyy)

Volume Tested
Temperature
Residual/Free Disinfectant Level

(if total and combined disinfectant levels
given, total - combined = free)

Combined Disinfectant Level

(if total and free disinfectant levels given,
total - free = combined)

Number
Unit
Number
Unit
Number
Unit
Number
Unit

pH
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Rec Water-Treated

Microbiology or Chemical/Toxin Analysis (refer to the laboratory findings from the outbreak investigation)
Sample Number Genus/ Chemical/ Toxin Species

Serotype/ Serogroup/ Serovar Genotype/ Subtype

PFGE Pattern

Sample Number Test Results Positive?

Unit

Test Method (reference: National

Concentration
(number)

(e.g., oocysts, CFU)

Test Type*

Environmental Methods Index:
http://www.nemi.gov)

yes
yes
yes
* Test Type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing,
6-Chemical Testing, 7-Tissue Culture Infectivity Assay

Factors Contributing to Recreational Water Contamination and/or Increased Exposure in Treated Venues
Documented/
Observed***

POLICY AND
MANAGEMENT

MAINTENANCE

FACILITY
DESIGN

PEOPLE

Factors (check all that apply)**

Suspected***

Out of compliance with bather load/density requirements
Primary intended use of water is by diaper/toddler-aged children (e.g., kiddie pool)
Heavy use by child care center groups
Fecal/vomitus accident
Patrons continued to swim when ill or within 2 weeks of being ill
Operator error
Intentional contamination (explain in remarks)
Combined pool filtration systems led to cross-contamination
Hygiene facilities inadequate or distant (e.g., no toilets, no diaper changing facilities)
Spray feature water demand higher than treatment system capacity so water returns to features and bypasses
filtration/treatment system
No supplemental disinfection installed that would have inactivated pathogen (e.g., Cryptosporidium)
Water temperature ≥30°C (≥86°F)
Cross-connection with wastewater or non-potable water
Disinfectant control system malfunctioning, inadequate, or lacking (e.g., hand feed)
Incorrect settings on disinfectant control system
pH control system malfunctioning, inadequate, or lacking (e.g., hand feed)
Incorrect settings on pH control system
Filtration system malfunctioning or inadequate (e.g., low flow rate)
Supplemental disinfection system malfunctioning (e.g., ultraviolet light, ozone)
Insufficient system checks so breakdown detection delayed
No preventive maintenance programs to reduce breakdowns
Remote monitoring system in use
Ventilation insufficient for indoor aquatic facilities
Chemical handling error (e.g., chemical hookup, improper mixing or application)
Maintenance chemicals not flushed from system before opening to swimmers
Low or zero water flow combined with continuous feed of chemicals resulted in excess chemicals in water
Extensive slime/biofilm formation
Recent construction
Cyanurate level excessive
Lack of draining/cleaning
Stagnant water in spa piping was aerosolized
No aquatics operators on payroll who have received state/local certified training
Untrained/inadequately trained staff on duty
Unclear communication chain for reporting problems
Inadequate water quality monitoring (e.g., inadequate test kit, inadequate testing frequency)
Employee illness policies absent or not enforced
Missing or poor chemical handling policies, practices, and training
No operator on duty at the time of incident
Facility falls outside aquatic health code
No shock/hyperchlorination policy
Other, specify:
Unknown

** Only check off what was found during investigation
*** “Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for
which no documentation (as defined previously) is available.

Remarks

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Rec Water-Untreated

Recreational Water – Untreated Venue
Recreational Water Vehicle Description
Water Type
(e.g., canal; lake; river/stream; ocean)

IF SPRING OR HOT SPRING, Water Subtype
(select indoor, outdoor or unknown)

Setting of Exposure
(e.g., beach- public; camp/cabin/recreational area)

Recreational Water Quality
Did the venue meet state or local recreational water quality regulations?

Yes

No

Unknown

Not applicable

If No, explain:
Did the venue meet Environmental Protection Agency (EPA) recreational water quality standards?
Yes

No

Unknown

Not applicable

If No, explain:
Laboratory Section - Recreational Water Samples from Untreated Venues
Was water from untreated recreational water venues tested?
Results

1

Sample
Source of Sample

Yes (specify in table below)
2

3

No

Unknown

4

5

(e.g., lake or stream)

Additional Description of Source of Sample
(e.g., specific location, time of day, etc)
Date (mm/dd/yyyy)

Number
Unit
Number
Unit

Volume Tested
Temperature

Water Quality Indicator
Sample Number Type (e.g., fecal coliforms)

Concentration (number)

Unit (e.g., CFU)

Microbiology or Chemical/Toxin Analysis (refer to the laboratory findings from the outbreak investigation)
Sample Number Genus/ Chemical/ Toxin Species

Serotype/ Serogroup/ Serovar

Genotype/ Subtype

PFGE Pattern

Sample Number Test Results Positive?

Unit

Test Type*

Test Method (reference: National

Concentration
(number)

(e.g., oocysts, CFU)

Environmental Methods Index:
http://www.nemi.gov)

yes
yes
yes
yes
* Test Type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing,
6-Chemical Testing, 7-Tissue Culture Infectivity Assay
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Rec Water-Untreated

Factors Contributing to Recreational Water Contamination and/or Increased Exposure in Untreated Venues
Documented/
Observed**

POLICY AND
MANAGEMENT

WATER QUALITY

SWIM AREA
DESIGN

PEOPLE

Factors (check all that apply)*

Suspected**

Out of compliance with bather load/density requirements
Primary intended use of water is by diaper/toddler aged children (e.g., kiddie pool)
Heavy use by child care center groups
Fecal/vomitus accident
Patrons continued to swim when ill or within 2 weeks of being ill
Operator error
Intentional contamination (explain in remarks)
Hygiene facilities inadequate or distant (e.g., no toilets, no diaper changing facilities)
Malfunctioning or inadequate onsite wastewater treatment system *** ≠
Poor siting/design of onsite wastewater treatment system *** ≠
Stagnant or poorly circulating water in swim area
Heavy rainfall and runoff
Sanitary sewer overflow (SSO) impact ***
Combined sewer overflow (CSO) impact ***
Domestic animal contamination (e.g., livestock, pets)
Wildlife contamination - Birds
Wildlife contamination - Mammals
Wildlife contamination - Fish kill
Wastewater treatment plant effluent flows past swim area
Wastewater treatment plant malfunction ***
Sewer line break ***
Nearby biosolid/land application site (e.g., human or animal waste application)
Contamination from agricultural chemical application (e.g., fertilizer, pesticides)
Contamination from chemical pollution not related to agricultural application
Water temperature ≥30°C (≥86°F)
Seasonal variation in water quality (e.g., lake/reservoir turnover events)
Inappropriate dumping of sewage into water body (e.g., boat, RV)
Algal bloom
Dumping of ballast water
Tidal wash (i.e., tide exchange or influence by inland water)
Aquatics operator has not received state/local certified training
Untrained/inadequately trained staff on duty
Unclear communication chain for reporting problems
Employee illness policies absent
No operator on duty at the time of incident
Other, specify:
Unknown

* Only check off what was found during investigation
** “Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.
*** The release of sewage does not have to occur on the property in which persons have become ill. The sewage release may have occurred at a distant site but still affected the property in question.
≠ “Onsite wastewater treatment system” refers to a system designed to treat and dispose of wastewater at the point of generation, generally on the property where the wastewater is generated (e.g.,
septic systems or other advanced on site systems). However, contamination that originates from these systems can still occur off the property where treatment and disposal takes place due to
migration of contaminants from malfunctioning systems or poor siting and design.

Remarks

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Drinking Water

Drinking Water Vehicle Description
Drinking Water Vehicle Description
Water Type*

Public Water

(e.g., commercially-bot- System EPA
tled water, community ID Number**
water system, individual
water system)

Water Source

(select ground water,
surface water or
unknown)

Water Source
Description

(e.g., spring; well;
lake)

Setting of
Exposure

(e.g., airport,
mobile home
park)

USUAL Water
Treatment Provided
(e.g., no treatment,
disinfection, home
filtration)

Water Treatment
Subtype

(disinfection or filtration: e.g.,
boiling; chlorine; rapid sand
filter; reverse osmosis)

*Water system definitions: Community and noncommunity water systems are public water systems that have that have ≥ 15 service connections or serve an average of ≥ 25 residents for ≥ 60 days/year.
A community water system serves year-round residents of a community, subdivision, or mobile home park. A noncommunity water system serves an institution, industry, camp, park, hotel, or business
and can be nontransient or transient. Nontransient systems serve ≥ 25 of the same persons for > 6 months of the year but not year-round (e.g., factories and schools), whereas transient systems provide water to places in which persons do not remain for long periods (e.g., restaurants, highway rest stations, and parks). Individual water systems are small systems not owned or operated by a water
utility that have < 15 connections or serve < 25 persons.
** Number used for EPA reporting that uniquely identifies the water system within a specific state. The water system ID number can be found at http://www.epa.gov/safewater/dwinfo/index.html by first
selecting a state and then selecting a county.

Drinking Water Quality
Did the drinking water system have any monitoring violations in the 1 month prior to the outbreak?
Yes

No

Unknown

Not applicable

If Yes, explain:
Did the drinking water system have any maximum contaminant level (MCL) violations in the 1 month prior to the outbreak?
Yes

No

Unknown

Not applicable

No

Unknown

Not applicable

If Yes, explain:
Did the drinking water system have any violations in the 12 months prior to the outbreak?***
Yes

If Yes, explain:
***Sources of information about past violations can be obtained from utility records, consumer confidence reports (water quality reports), or violation
records from state or local health departments

Laboratory Section - Drinking Water
Was drinking water tested?

Yes (specify in table below)

Results

1

Sample

2

3

4

No

Unknown
5

Source of Sample
Additional Description of Source of Sample
(e.g., kitchen faucet, well, reservoir)
Date (mm/dd/yyyy)

Volume Tested
Temperature
Residual/Free Disinfectant Level

(if total and combined disinfectant levels
given, total - combined = free)

Number
Unit
Number
Unit
Number
Unit

pH
Turbidity (NTU)
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Drinking Water

Water Quality Indicator
Sample Number Type (e.g., fecal coliforms)

Concentration (number)

Unit (e.g., CFU)

Microbiology or Chemical/Toxin Analysis (refer to the laboratory findings from the outbreak investigation)
Sample Number Genus/ Chemical/ Toxin Species

Serotype/ Serogroup/ Serovar Genotype/ Subtype PFGE Pattern

Sample Number Test Results Positive?

Unit

Concentration
(number)

Test Type*

(e.g., oocysts, CFU)

Test Method (reference: National
Environmental Methods Index:
http://www.nemi.gov)

yes
yes
yes
* Test Type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing,
6-Chemical Testing, 7-Tissue Culture Infectivity Assay

Factors Contributing to Drinking Water Contamination and/or Increased Exposure to Contaminated Drinking Water
Did a problem with the source water (i.e., ground water or surface water) contribute to the disease or outbreak?
Yes (specify in table below)

No

Unknown

Documented/
Observed***

Source Water Factors (check all that apply)**

Suspected***

Sanitary sewer overflow (SSO) ****
Combined sewer overflow (CSO) ****
Malfunctioning on-site wastewater treatment system **** ≠
Sewage treatment plant malfunction ***
Sewer line break ***
Poor siting/design of on site wastewater treatment system **** ≠
Nearby biosolid/land application site (e.g., human or animal waste application)
Contamination from agricultural chemical application (e.g., fertilizer, pesticides)
Contamination from chemical pollution not related to agricultural application
Contamination by a chemical that the current treatment methods were not designed to remove
Domestic animal contamination (e.g., livestock, concentrated feeding operations, pets)
Wildlife contamination - Birds
Wildlife contamination - Mammals
Wildlife contamination - Fish kill
Flooding/heavy rains
Algal bloom
Seasonal variation in water quality (e.g., lake/reservoir turnover events, resort community with seasonal loading)
Low water table (e.g., drought, over-pumping)
Ground water under direct influence of surface water (e.g., shallow well)≠ ≠
Contamination through limestone or fissured rock (e.g., karst)
Contaminated recharge water
Use of an alternate source of water by a water utility
Mixing of raw water from different sources
Improper construction or location of a well or spring
Water system intake failure (e.g., cracked well casing, cracked intake pipe)
Intentional contamination (explain in remarks)
Other, specify:
Unknown
** Only check off what was found during investigation
*** “Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.
**** The release of sewage does not have to occur on the property in which persons have become ill. The sewage release may have occurred at a distant site but still affected the property in question.
≠ “On site wastewater treatment system” refers to a system designed to treat and dispose of wastewater at the point of generation, generally on the property where the wastewater is generated (e.g.,
septic systems or other advanced on site systems). However, contamination that originates from these systems can still occur off the property where treatment and disposal takes place du to migration of contaminants from malfunctioning systems or poor siting and design.
≠ ≠ Any water beneath the surface of the ground with substantial occurrence of insects or other macrooganisms, algae, or large-diameter pathogens (e.g., Giardia intestinalis or
Cryptosporidium), or substantial and relatively rapid shifts in water characteristics (e.g., turbidity, temperature, conductivity, or pH) that closely correlate with climatologic or surface water conditions.
Direct influence must be determined for individual sources in accordance with criteria established by the state.

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Drinking Water

Factors Contributing to Drinking Water Contamination and/or Increased Exposure to Contaminated Drinking Water
Did a problem with the water treatment prior to entry into a house or building contribute to the disease or outbreak?
Yes (specify in table below)

No

Unknown

Documented/
Observed**

Treatment Factors (check all that apply)*
Change in treatment process
No disinfection
Temporary interruption of disinfection
Chronically inadequate disinfection
No filtration
Inadequate filtration
Deficiencies in other treatment processes
Corrosion in or leaching from pipes or storage tanks
Pipe/component failure or break (e.g., pipes, tanks, valves)
Contamination during construction or repair of pipes/components
Construction or repair of pipes/components without evidence of contamination
Operator error
Other, specify:
Unknown

Did a problem with the distribution system contribute to the disease or outbreak?

Yes (specify in table below)

Suspected**

No

Unknown

(NOTE: For a community water system, the distribution system refers to the pipes and storage infrastructure under the jurisdiction of the water utility
prior to the water meter (or property line if the system is not metered). For noncommunity and nonpublic water systems, the distribution system refers to
the pipes and storage infrastructure prior to entry into a building or house)
Documented/
Observed**

Distribution and Storage Factors (check all that apply)*

Suspected**

Cross-connection of potable and nonpotable water pipes resulting in backflow
Low pressure or change in water pressure in the distribution system
Change in water flow direction in the distribution system
Mixing of treated water from different sources
Pipe/component failure or break (e.g., pipes, tanks, valves)
Corrosion in or leaching from pipes or storage tanks
Contamination of mains during construction or repair
Construction or repair of mains without evidence of contamination
Scheduled flushing of the distribution system
Contamination of storage facility
Aging water distribution components (e.g., pipes, tanks, valves)
Water temperature ≥30°C (≥86°F)
Intentional contamination (explain in remarks)
Other, specify:
Unknown

Did a problem occur after the water meter or outside the jurisdiction of a water utility that contributed to the disease or outbreak?
(e.g., in a service line leading to a house/building, in the plumbing inside a house/building, during shipping/hauling, during storage
other than in the distribution system, at the point of use, involving commercially-bottled water)
Yes (specify in table below)
Factors Not Under the Jurisdiction of a Water Utility or Factors at the Point of Use (check all that apply)*

No
Documented/
Observed**

Unknown
Suspected**

Legionella species in water system
Cross-connection of potable and nonpotable water pipes resulting in backflow
Lack of backflow prevention in plumbing
Low pressure or change in water pressure in the plumbing
Change in water flow direction in the plumbing
Corrosion in or leaching from pipes or storage tanks
Pipe/component failure or break (e.g., pipes, tanks, valves)
Aging plumbing components (e.g., pipes, tanks, valves)
Contamination of plumbing during construction or repair
Construction or repair of plumbing without evidence of contamination
Deficiency in building/home-specific water treatment after the water meter or property line
Deficiency or contamination of equipment/devices using or distributing water
Contamination during commercial bottling
Contamination during shipping, hauling, or storage
Contamination at point of use – Tap
Contamination at point of use – Hose
Contamination at point of use – Commercially-bottled water
Contamination at point of use – Container, bottle, or pitcher
Contamination at point of use – Unknown
Water temperature ≥30°C (≥86°F)
Intentional contamination (explain in remarks)
Other, specify:
Unknown
* Only check off what was found during investigation
** “Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.
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Drinking Water

Remarks

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WNID/WUI

Water Not Intended for Drinking or Water of Unknown Intent (WNID/WUI)
Intent for Use
What was the intended use for the implicated water? (check all that apply)
Cooling/Air Conditioning (e.g., cooling tower, swamp cooler)
Mister (e.g., produce in grocery store, public cooling system)
Ornamental (e.g., a decorative non-interactive fountain intended for public display and not designed for swimming or
recreational use)
Industrial/Occupational (e.g., steam cleaner)
Agricultural Irrigation
Waste water
Other (specify):
Unknown
Water Description
Water Type

(e.g., cooling tower; drainage ditch;
fountain- ornamental)

Setting of Exposure

(e.g., airport; hospital/health care facility,
nursing home; park- state park)

USUAL Water Treatment Provided
(e.g., no treatment; disinfection;
settling/sedimentation)

Water Treatment Subtype

(disinfection or filtration: e.g., boiling;
chlorine; rapid sand filter; reverse
osmosis)

Laboratory Section
Was the implicated water tested?

Yes (specify in table below)

Results

1

Sample

2

3

No

4

Unknown
5

Source of Sample
Additional Description of Source of Sample

(e.g., stream not intended for drinking, main A/C unit)
Date (mm/dd/yyyy)

Number
Unit
Number
Unit

Volume Tested
Temperature
Residual/Free Disinfectant Level

(if total and combined disinfectant levels
given, total - combined = free)

Number
Unit

Turbidity (NTU)
pH

Water Quality Indicator
Sample Number

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Type (e.g., fecal coliforms)

Concentration (number)

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Unit (e.g., CFU)

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WNID/WUI

Microbiology or Chemical/Toxin Analysis (refer to the laboratory findings from the outbreak investigation)
Sample Number Genus/ Chemical/ Toxin Species

Serotype/ Serogroup/ Serovar

Genotype/ Subtype PFGE Pattern

Sample Number Test Results Positive?

Unit

Test Type*

Concentration
(number)

(e.g., oocysts, CFU)

Test Method (reference: National
Environmental Methods Index:
http://www.nemi.gov)

yes
yes
yes
yes
* Test Type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing,
6-Chemical Testing, 7-Tissue Culture Infectivity Assay

Factors Contributing to Contamination and/or Increased Exposure to Contaminated Water
Documented/
Observed**

Factors (check all that apply)*

Suspected**

Cooling tower/evaporative condenser – shutdown for >3 days without draining to waste
Cooling tower/evaporative condenser – lack of a maintenance program
Cooling tower/evaporative condenser – lack of a qualified water quality specialist
Cooling tower/evaporative condenser – presence of scale or corrosion
Cooling tower/evaporative condenser – presence of dirt, organic matter, or other debris in the cold water basin
Cooling tower/evaporative condenser – absence of drift eliminators
Cooling tower/evaporative condenser – presence of damaged drift eliminators
Cooling tower/evaporative condenser – history of recent repairs to the device
Cooling tower/evaporative condenser – siting of device near building air intakes
Cooling tower/evaporative condenser – siting of device near windows that can be opened
Cooling tower/evaporative condenser – siting of device in immediate area of kitchen exhaust fans, live plants,
truck bays, or other sources of organic matter
Cooling tower/evaporative condenser – construction on the premises of the device within 6 months before the
index case
Cooling tower/evaporative condenser – construction within 100 meters of the premises of the device within 6
months before the index case
Ornamental fountain – presence of submerged lighting
Ornamental fountain – lack of a written cleaning and maintenance program
Ornamental fountain – presence of dirt, organic matter, or other debris in the water basin
Broken/damaged sewer pipe
Recycling of water
Water temperature ≥30°C (≥86°F)
Other, specify:
Unknown
* Only check off what was found during investigation
** “Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.

Remarks

Epidemic and laboratory assistance for the investigation of a waterborne disease outbreak is available upon request by the State Health Department to the Centers for Disease Control and Prevention. Please enter this
report into the National Outbreak Reporting System (NORS). State/Local investigation reports and questionnaires can also be attached to the report in the electronic system. Communications and requests for epidemic
and laboratory assistance may be directed to: Waterborne Disease and Surveillance Coordinator. Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, Coordinating Center for
Infectious Diseases, CDC 4770 Buford Highway, NE, MS F-22, Atlanta, GA, 30341-3724 or (770) 488-7775
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 52.12 Rev. 03 2008

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