0920-0004 Listeria Case Form

LISTERIA CASE FORM

Completed by ______________ Date completed _____________
Form Approved
OMB No. 0920-0004

BOX 1: CASE-PATIENT INFORMATION
Case-patients = adults and children >1 month of age. For fetal or neonatal infections, the MOTHER is the case-patient.
Patient’s name: _________________________________ Surrogate’s name: ________________________________
Patient’s street address: ___________________________________________________________________________
City: ________________________________ State: ____________ Zip: ____________
Phone numbers: (h) ____________________ (w) _____________________ (m) ________________________
Hospital name(s): _____________________________ Hospital contact name(s): ______________________________
_____________________________
_______________________________
Hospital contact numbers: ________________________ ________________________ _________________________
---------------------------------------------------------------------------------------------------------------------------------------detach here to remove personal identifiers if necessary

Sex: F M F F
State of residence: ___ ___
Age: ______
DOB: ____/____/________

Ethnicity (check one):
F Hispanic/Latino
F Non-Hispanic/Latino
F Unknown

State or local epi case ID: ___________________
CDC outbreak (EFORS) ID: _________________

Race (check all that apply):
F African American/Black
F Asian
F Native Hawaiian or Other Pacific Islander
F Native American/Alaska Native
F White
F Unknown

BOX 2: IS LISTERIA CASE ASSOCIATED WITH PREGNANCY? (Illness in pregnant woman, fetus, or neonate ≤1 month)
F Yes
If yes, skip to Box 4.
F No
If no, continue with Box 3.
F Unknown
If unknown, continue with Box 3.
BOX 3: CASES NOT ASSOCIATED WITH PREGNANCY (Illness in non-pregnant adults and children > 1 month of age)
Type(s) of specimen(s) that grew
Specimen
Submitting Lab
State Public Health Lab Isolate ID Number
Listeria (check all that apply)
collection date
(state, city, county)
(important: must have at least one)
F Blood
____/____/____
F CSF
____/____/____
F Stool
____/____/____
F Other ____________________
____/____/____
F Other ____________________
____/____/____
Type(s) of illness (check all that apply)
F Bacteremia/sepsis
F Meningitis
F Febrile gastroenteritis
F Other _____________________
F Unknown

Was patient hospitalized for listeriosis?
F Yes If yes:
Admit date: ____/____/____
Discharge date: ____/____/____
F Still hospitalized
F No
F Unknown

Patient’s outcome
F Survived
F Died
F Unknown

Public reporting burden of this collection of information is estimated to average 30 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).
Please send completed forms to: Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention,
Mailstop A-38, Atlanta, GA 30338. Fax (404) 639-2206

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LISTERIA CASE FORM

Completed by ______________ Date completed _____________

BOX 4: CASES ASSOCIATED WITH PREGNANCY (Illness in pregnant woman, fetus, or neonate ≤1 month of age)
Type(s) of specimen(s) that grew
Specimen
Submitting Lab
State Public Health Lab Isolate ID Number
collection date
Listeria (check all that apply)
(state, city, county)
(important: must have at least one)
F Blood from mother
____/____/____
F Blood from neonate
____/____/____
F CSF from mother
____/____/____
F CSF from neonate
____/____/____
F Stool from mother
____/____/____
F Placenta
____/____/____
F Amniotic fluid
____/____/____
F Other ______________________
____/____/____
F Other ______________________
____/____/____
BOX 4 (CONTINUED): CASES ASSOCIATED WITH PREGNANCY
Outcome of pregnancy (single
gestation or twin 1) (check one)

Weeks of
gestation

F Still pregnant
F Fetal death (miscarriage or
stillbirth)
F Induced abortion
F Delivery (live birth)
F Other _________________

Date

Outcome of pregnancy (twin 2)
(check one)

Weeks of
gestation

Date

____/____/___
_
____/____/___
_
____/____/___
_
____/____/___
_
____/____/___
_

F Still pregnant as of: __/__/__

____/____/____

F Fetal death (miscarriage or
stillbirth)

____/____/____

F Induced abortion

____/____/____

F Delivery (live birth)

____/____/____

F Other ________________

____/____/____

Type(s) of illness in mother
(check all that apply)
F Bacteremia/sepsis
F Meningitis
F Febrile gastroenteritis
F Amnionitis
F Non-specific “flu-like” illness
F None
F Other _____________________
F Unknown

Type(s) of illness in neonate (twin 1)
(check all that apply)
F Bacteremia/sepsis
F Meningitis
F Pneumonia
F Granulomatosis infantisepticum
F None
F Other _____________________
F Unknown

Type(s) of illness in neonate 2 (twin 2)
(check all that apply)
F Bacteremia/sepsis
F Meningitis
F Pneumonia
F Granulomatosis infantisepticum
F None
F Other _____________________
F Unknown

Was mother hospitalized for listeriosis?
F Yes If yes:
Admit date: ____/____/____
Discharge date: ____/____/____
F Still hospitalized
F No
F Unknown

Was neonate (twin 1) hospitalized for
listeriosis?
F Yes If yes:
Admit date: ____/____/____
Discharge date: ____/____/____
F Still hospitalized
F No
F Unknown

Was neonate 2 (twin 2) hospitalized for
listeriosis?
F Yes If yes:
Admit date: ____/____/____
Discharge date: ____/____/____
F Still hospitalized
F No
F Unknown

Mother’s outcome
F Survived
F Died
F Unknown

Neonate’s (twin 1’s) outcome
F Survived
F Died
F Unknown

Neonate 2’s (twin 2’s) outcome
F Survived
F Died
F Unknown

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Listeria Case Form

Patient State Laboratory ID No.____________

CASE-PATIENT INTERVIEW
Date of interview(mm/dd/yyyy): ___/___/______
Initials of interviewer: ________
Interviewee: F Case-patient F Surrogate F Unknown
If surrogate, relationship to patient: F Parent F Child F Sibling F Spouse F Other, Specify ____________
When did your illness begin? (Onset of illness) (mm/dd/yyyy): ___/___/______ F Not applicable (e.g. pregnant woman without clinical illness)
F Yes
F No F Don’t know
During the 4 weeks before your illness (delivery date), were you admitted to a hospital (>overnight)?
During the 4 weeks before your illness (delivery date), were you a resident in a nursing home
or other long term care facility?
F Yes
F No F Don’t know
If yes, Date of admission (mm/dd/yyyy) ___/___/___
Date of discharge (mm/dd/yyyy) ___/___/___ or F Still hospitalized or residing in facility
During the 4 weeks before your illness (delivery date), did you travel to a state outside your state of residence?
F Yes
F No F Don’t know
If yes, please list states visited: _________________________________
During the 4 weeks before your illness (delivery date), did you travel outside the U.S.?
If yes, name of country visited ___________________________
If yes, Date of departure from U.S. (mm/dd/yyyy) ___/___/___
Date of return to U. S.
(mm/dd/yyyy) ___/___/___
Which of the following symptoms were associated with illness? (read each)
Fever
F Yes
F No F Don’t know
Diarrhea (>3 loose stools/day)
Chills
F Yes
F No F Don’t know
Vomiting
Headache
F Yes
F No F Don’t know
Preterm labor
Muscle Aches
F Yes
F No F Don’t know
Other _________________
Stiff Neck
F Yes
F No F Don’t know
Other _________________

F Yes

F Yes
F Yes
F Yes
F Yes
F Yes

F
F
F
F
F

F No

No
No
No
No
No

F Don’t know

F Don’t know
F Don’t know
F Don’t know
F Don’t know
F Don’t know

FOOD HISTORY
INSTRUCTIONS FOR INTERVIEWER: Ask case-patient about the food he/she consumed during the 4 weeks before his/her Listeria SPECIMEN
COLLECTION DATE. Please list venues and food exposures form U.S. locations only. In the event of a fetal death or neonatal infection (<1 month of age), the
MOTHER is the case-patient, and she should be asked about her food history during the 4 weeks before DELIVERY. Please refer to patient as “you” if
interviewing the case-patient directly; if interviewing a surrogate, please use “he” or “she.”
INSTRUCTIONS TO READ TO CASE-PATIENT (OR SURROGATE):
I am interested in the foods you ate during the 4 weeks before your illness (delivery). I see that you had a positive test for listeriosis (delivered) on ____/____/____.
For most of the interview, I will be asking you questions about the 4 weeks before this date, that is, from ____/____/____ (date 4 weeks before) through
____/____/____ (specimen collection/delivery date). (Have patient get calendar for reference if possible.) First I’d like to ask you about where the foods you ate
were purchased. I am going to read you a list of places where food can be purchased. For each, please tell me if you ate food purchased from that type of place in the
four week time period. I know that it can be difficult to remember that far back, but please do the best you can. If you’re not sure, please tell me whether it’s likely
or unlikely that you ate food purchased from that location.
I. FOOD PURCHASE HISTORY
A. Grocery stores: Did you eat food purchased from any grocery stores during the 4 week time period? (Please read all options.)
F Yes F It’s likely F It’s unlikely
F No
If yes or likely,

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Listeria Case Form
Store Name
1.
2.
3.
4.
5.
6.
7.

Patient State Laboratory ID No.____________
Street Address

City

County

State

B. Delis, small markets, farmers’ markets: Did you eat food purchased from any delicatessens, small local markets, other small shops, or farmers’ markets during
the 4 week period? F Yes F It’s likely F It’s unlikely
F No
If yes or likely,
Store Name
Street Address
City
County
State
1.
2.
3.
4.
5.
6.
7.
C. Restaurants: Did you eat food from any restaurants, including sit-down, fast-food, and take-out restaurants during the 4 week period?
F Yes F It’s likely F It’s unlikely
F No
If yes or likely,
Restaurant Name
Street Address
City
County
State

Dining dates
(mm/dd/yyy)
1.
___/___/___
2.
___/___/___
3.
___/___/___
4.
___/___/___
5.
___/___/___
6.
___/___/___
7.
___/___/___
___/___/___
D. Other venues: cafeterias, concession stands, institutions: Did you eat food purchased or obtained from any other venues, such as school cafeterias, concession
stands, street vendors, institutions (e.g. hospital food), local farms, or private vendors during the 4 week period?
F Yes F It’s likely F It’s unlikely
F No
If yes or likely,
Name
Street Address
City
County
State
Dining dates
(mm/dd/yyy)
1.
___/___/___

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Listeria Case Form

Patient State Laboratory ID No.____________

2.
3.
4.
5.
6.
7.

___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___

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Listeria Case Form

Patient State Laboratory ID No.____________

II. FOOD CONSUMPTION HISTORY
INSTRUCTIONS FOR INTERVIEWER: Please read all options to case-patient in each category. For the names of purchase sites, it is preferable to use codes
from Section I above, e.g. A1 for first grocery store, A3 for third grocery store, C5 for fifth restaurant. A DELI COUNTER serves portions or helpings of salads,
cheeses, and meats sliced ON-SITE at a specified counter within a grocery store, food market, or delicatessen. Foods sliced and packaged AT the FACTORY
and sold as pre-packaged containers in self-serve refrigerated display cases are NOT considered to be from a deli counter
INSTRUCTIONS TO READ TO CASE-PATIENT (OR SURROGATE):
Now I’d like to ask you about the foods that you ate between ____/____/____ (date 4 weeks before) through ____/____/____ (specimen collection/delivery date). For each food item,
please give me your best guess as to whether you ATE the food, you’re not sure but you LIKELY ATE the food, you’re not sure but you LIKELY DID NOT EAT the food, or you
DID NOT EAT the food.
MEATS: In the 4 week period, did you eat any of the following COLD CUT, DELI MEAT, OR LUNCHEON MEAT items?
Likely
Likely
did
Did
If ate or likely ate,
Types or brands:
Ate
Ate
NOT
NOT
If ate or likely ate, Where was it purchased?
Name(s) of store/restaurant/venue:
(choose all types that apply)
(all names that apply)
(all that apply)
eat (=3) eat (=4) How often?
(=1)
(=2)
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Ham
1
2
3
4
F ~ 1x/week
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Bologna
1
2
3
4
F ~ 1x/week
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
Turkey
F Deli/small market ___________________________________________ ___________________
1
2
3
4
F ~ 1x/week
breast
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Other turkey
1
2
3
4
F ~ 1x/week
F Restaurant
___________________________________________ ___________________
deli meat
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
(e.g. turkey
F ~ 5-7x/week
F Don’t know
ham)
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

6

Listeria Case Form

Ate
(=1)
Chicken deli
meat
(NOT fresh
chicken or
rotisserie
chicken)

Pastrami/
Corned
beef

Other deli/
luncheon
meat
(specify)___
__________
___
Patè or meat
spread that
was not
canned

Hot dogs

1

1

1

1

1

Patient State Laboratory ID No.____________

Likely
Ate
(=2)
2

2

2

2

2

Likely
did
NOT
eat (=3)
3

3

3

3

3

Did
NOT
eat (=4)
4

4

4

4

4

If ate or likely ate,
How often?
F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

If ate or likely ate,
Where was it purchased?
(choose all types that apply)
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F

Name(s) of store/restaurant/venue:
(all names that apply)

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

If Yes, were the hot dogs: F Heated before consumption
F Not heated before consumption (eaten directly out of package)

7

Types or brands:

(all that apply)
___________________
___________________
___________________
___________________

___________________
___________________
___________________
___________________

___________________
___________________
___________________
___________________

___________________
___________________
___________________
___________________

___________________
___________________
___________________
___________________

Listeria Case Form

Patient State Laboratory ID No.____________

CHEESES: In the 4 weeks between ____/____/____ (date 4 weeks before) through ____/____/____ (specimen collection/delivery date), did you eat any of the following CHEESES?
Likely
did
If ate or likely ate,
Likely
Did
Types or brands:
Ate
NOT
NOT
Name(s) of store/restaurant/venue:
Ate
If ate or likely ate, Where was it purchased?
(choose all types that apply)
(all names that apply)
(all that apply)
(=1)
(=2)
eat (=3) eat (=4) How often?
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Brie
F ~ 1x/week
1
2
3
4
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Feta

Camembert

Goat

Blue or
gorgonzola

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

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Listeria Case Form

Ate
(=1)
Mexicanstyle cheese
(Queso
fresco,
queso
blanco)

Farmer’s
cheese

Raw
(Unpasteurized
milk) cheese

Other soft
white cheese
(not cream,
cottage, or
ricotta –
specify)____
__________

1

Patient State Laboratory ID No.____________
Likely
Ate
(=2)
2

1

2

1

Did
NOT
eat (=4)

3

4

3

2

1

Likely
did
NOT
eat (=3)

4

3

2

4

3

4

If ate or likely ate,
How often?
F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

If ate or likely ate,
Where was it purchased?
Name(s) of store/restaurant/venue:
(choose all types that apply)
(all names that apply)
F Grocery store
___________________________________________
F Deli/small market ___________________________________________
F Restaurant
___________________________________________
F Other venue
___________________________________________
F Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

Types or brands:

(all that apply)
___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

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Listeria Case Form

Patient State Laboratory ID No.____________

READY-TO-EAT SALADS: In the 4 week period, did you eat any of the following ready-to-eat, deli-style salads (that were NOT PREPARED AT HOME)?
Likely
Did
did
NOT If ate or likely ate, If ate or likely ate,
NOT
eat
How often?
Where was it purchased?
Name(s) of store/restaurant/venue:
Ate
Likely
(choose all types that apply)
(all names that apply)
(=1)
Ate (=2) eat (=3)
(=4)
F Grocery store
___________________________________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________
Potato
F ~ 1x/week
1
2
3
4
F Restaurant
___________________________________________
salad
F ~ 2-4x/week
F Other venue
___________________________________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Pasta salad

Tuna
salad

Bean
salad

Hummus

1

1

1

1

2

2

2

2

3

3

3

3

4

4

4

4

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F ~ 1-2 x/month
F ~ 1x/week
F ~ 2-4x/week
F ~ 5-7x/week
F not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

Types or brands:

(all that apply)
___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

10

Listeria Case Form

Ate
(=1)
Cole slaw

Seafood
salad

Fruit
salad
(including
pre-cut
cubes of a
single
fruit)
Other readyto-eat meat,
vegetable or
fruit salad
not made at
home
(Specify)
__________

1

1

Patient State Laboratory ID No.____________
Likely
Ate
(=2)
2

2

Likely
did
NOT
eat (=3)

Did
NOT
eat (=4)

3

4

3

4

1

2

3

4

1

2

3

4

If ate or likely ate,
How often?
F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

If ate or likely ate,
Where was it purchased?
Name(s) of store/restaurant/venue:
(choose all types that apply)
(all names that apply)
F Grocery store
___________________________________________
F Deli/small market ___________________________________________
F Restaurant
___________________________________________
F Other venue
___________________________________________
F Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

Types or brands:

(all that apply)
___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

11

Listeria Case Form

Patient State Laboratory ID No.____________

SEAFOOD: In the 4 weeks between ____/____/____ (date 4 weeks before) through ____/____/____ (specimen collection/delivery date), did you eat any of the following ready-to-eat
fish or seafood items or fruit items?
Did
NOT
If ate or likely ate,
Likely
Likely
Types or brands:
Ate
did NOT
eat
Name(s) of store/restaurant/venue:
Ate
If ate or likely ate, Where was it purchased?
(choose all types that apply)
(all names that apply)
(all that apply)
(=1)
(=2)
eat (=3)
(=4)
How often?
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Precooked
F ~ 1x/week
1
2
3
4
F Restaurant
___________________________________________ ___________________
shrimp
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Precooked
crab
(including
imitation
crab meat)
Smoked or
cured fish that
was not from a
can (e.g.
smoked
salmon or lox)

1

2

1

3

2

F
F
F
F
F

4

3

4

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F ~ 1-2 x/month
F ~ 1x/week
F ~ 2-4x/week
F ~ 5-7x/week
F not sure

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

12

Listeria Case Form

Patient State Laboratory ID No.____________

Fruit: In the 4 weeks between ____/____/____ (date 4 weeks before) through ____/____/____ (specimen collection/delivery date), did you eat any of the following fruit items?
F Grocery store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Honeydew
1
2
3
4
F ~ 1x/week
F Restaurant
___________________________________________ ___________________
melon
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know
Cantaloupe

Watermelon

1

1

2

2

3

3

4

4

F ~ 1-2 x/month
F ~ 1x/week
F ~ 2-4x/week
F ~ 5-7x/week
F not sure
F ~ 1-2 x/month
F ~ 1x/week
F ~ 2-4x/week
F ~ 5-7x/week
F not sure

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
___________________________________________
Deli/small market ___________________________________________
Restaurant
___________________________________________
Other venue
___________________________________________
Don’t know
Was this item purchased from a deli counter at any of the sites?
F Yes F No F Don’t know

___________________
___________________
___________________
___________________

13

Listeria Case Form

Patient State Laboratory ID No.____________

MILK: In the 4 weeks between ____/____/____ (date 4 weeks before) through ____/____/____ (specimen collection/delivery date), did you drink any of the following types of milk?
Likely
Did
Likely
did NOT
NOT
If ate or likely ate,
Types or brands:
drink
drink If ate or likely ate, Where was it purchased?
Name(s) of store/restaurant/venue:
Drank
drank
(choose all types that apply)
(all names that apply)
(all that apply)
(=2)
(=3)
(=4)
(=1)
How often?
F
Grocery
store
___________________________________________
___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
Whole milk
F ~ 1x/week
1
2
3
4
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F
Other
venue
___________________________________________
___________________
F ~ 5-7x/week
F
Don’t
know
F not sure
Was any of this milk unpasteurized (raw)?
F Yes F No F Don’t know
___________________________________________ ___________________
F ~ 1-2 x/month F Grocery store
F Deli/small market ___________________________________________ ___________________
2% milk
F
~
1x/week
1
2
3
4
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F
Other
venue
___________________________________________
___________________
F ~ 5-7x/week
F
Don’t
know
F not sure
Was any of this milk unpasteurized (raw)?
F Yes F No F Don’t know
F
Grocery
store
___________________________________________ ___________________
F ~ 1-2 x/month
F Deli/small market ___________________________________________ ___________________
1% milk
F
~
1x/week
1
2
3
4
F Restaurant
___________________________________________ ___________________
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was any of this milk unpasteurized (raw)?
F Yes F No F Don’t know
F
Grocery
store
___________________________________________ ___________________
F ~ 1-2 x/month
F
Deli/small
market
___________________________________________
___________________
Skim milk
F ~ 1x/week
1
2
3
4
F
Restaurant
___________________________________________
___________________
F ~ 2-4x/week
F Other venue
___________________________________________ ___________________
F ~ 5-7x/week
F Don’t know
F not sure
Was any of this milk unpasteurized (raw)?
F Yes F No F Don’t know
Other milk –
F
Grocery
store
___________________________________________ ___________________
F ~ 1-2 x/month
chocolate,
F
Deli/small
market
___________________________________________
___________________
F ~ 1x/week
1
2
3
4
buttermilk,
F
Restaurant
___________________________________________
___________________
F ~ 2-4x/week
etc.
F
Other
venue
___________________________________________
___________________
F ~ 5-7x/week
(Specify)___
F
Don’t
know
F not sure
__________
Was any of this milk unpasteurized (raw)?
F Yes F No F Don’t know

14

Listeria Case Form

Patient State Laboratory ID No.____________

OTHER DAIRY: In the 4 week period, did you eat any of the following other dairy items?
Did
Likely
Likely
NOT
If ate or likely ate,
eat
Name(s) of store/restaurant/venue:
Ate
Ate
did NOT
If ate or likely ate, Where was it purchased?
(choose all types that apply)
(all names that apply)
(=2)
eat (=3)
(=4)
(=1)
How often?
F ~ 1-2 x/month
F Grocery store
___________________________________________
Butter (not
F ~ 1x/week
1
2
3
4
F
Deli/small
market
___________________________________________
margarine
F ~ 2-4x/week
F Restaurant
___________________________________________
or other
F ~ 5-7x/week
F Other venue
___________________________________________
butter
F not sure
F Don’t know
substitute)
Cream

Ice cream

Sour cream

Yogurt

1

2

1

1

1

3

2

2

2

4

3

3

3

4

4

4

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

F
F
F
F
F

~ 1-2 x/month
~ 1x/week
~ 2-4x/week
~ 5-7x/week
not sure

Types or brands:

(all that apply)
___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
Deli/small market
Restaurant
Other venue
Don’t know

___________________________________________
___________________________________________
___________________________________________
___________________________________________

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
Deli/small market
Restaurant
Other venue
Don’t know

___________________________________________
___________________________________________
___________________________________________
___________________________________________

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
Deli/small market
Restaurant
Other venue
Don’t know

___________________________________________
___________________________________________
___________________________________________
___________________________________________

___________________
___________________
___________________
___________________

F
F
F
F
F

Grocery store
Deli/small market
Restaurant
Other venue
Don’t know

___________________________________________
___________________________________________
___________________________________________
___________________________________________

___________________
___________________
___________________
___________________

That is all. Thank you very much!

15