Case questionnaire

Form Approved

OMB No. 0920-xxxx

Exp xx/xx/xx

FoodNet Non-O157 STEC Case-Control Study

Case Questionnaire

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Date of interview:___mm/___dd/20___ Day of week:______________

Time of interview:__________

Interviewer:_______________

CASE IDENTIFIERS AND ISOLATE INFORMATION

PLEASE COMPLETE BEFORE CALLING THE CASE

Person ID Number (FoodNet site-specific)_________________

Study ID Number ___________________________

State Lab ID Number ___________________________

County __________________

State __________________

Specimen Collection Date ___mm/___dd/20___

Identified as E. coli (isolated)? Y N Pending

Another serotype isolated? Y N if yes,

Serotype O____ H___ Pending Serotype O____ H___ Pending

Shiga toxin 1 Y N Pending Shiga toxin 1 Y N Pending

Shiga toxin 2 Y N Pending Shiga toxin 2 Y N Pending

Undifferentiated Y N Pending Undifferentiated Y N Pending

E coli serology testing done? Y N U if yes, results:__________________

Other pathogen(s) isolated? Y N

If yes, what pathogen(s)? (check all that apply)

 Salmonella  Campylobacter  Shigella

 Cryptosporidium  Norovirus  Other (specify) ________________________

Gender of case

Male……………………………………………………1

Age Strata:

 0 to <2 years

 2 to <6 years

 6 to <18 years

 18 to <40 years

 40 to <60 years

 60 or older years

Female………………………………………….……....2

HUS? Y N U

IF YES, HUS CASEID NUMBER:______________________

Outbreak-associated? Y N

Age of case at time of illness onset_______Years______months

(IF UNKNOWN, ASK DURING INTERVIEW)

START HERE AFTER OBTAINING CONSENT

Section 1: Health Questions

PART 1. SCREENING QUESTIONS

I would like to begin with several questions about your/your child’s recent illness with Shiga toxin-producing E. coli. I will be asking about specific dates around the time of your/your child’s illness, so it may be helpful for you to have a calendar or day planner in front of you. Do you need a few minutes to get one?

1. First, have you or another family member already spoken with someone else from the health department about this infection?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

IF YES The _____ state health department is conducting this survey as part of a national study of E. coli infections, in cooperation with the Centers for Disease Control and Prevention (CDC). Even though some of the questions will be similar to ones you have been asked before, we need to ask them in the same way to each person who had this infection.

IF NO, UNKNOWN, OR REFUSED Someone else from the health department may contact you at a later time.

2. Were you/Was your child ill with any symptoms because of this E. coli infection?

Yes................…………….. Go to Q4……………............................................. 1

No................…………….... Go to Q3....…. …………….................................... 2

Don't know/Not sure..….… Go to Q3...........… …......................................…… 7

Refused................. ……….. Go to Q3..……...........….............................……… 9

3. Why did you/your child have a stool or other specimen tested? Interviewer: This question is

intended to help you assess if the case was ill.

Specify:_______________________________________________________________

 IF ILL Interviewer: mark yes on Q2 and continue on to Q4.

 IF NO ILLNESS/DK/REFUSED,

Sorry. We can only interview persons who became ill. Thank you for your time. STOP.

4. On what date did your/your child notice your/her/his first symptom? It might help to look at a calendar to help you remember this date. Interviewer: If respondent is unsure of date, prompt with date specimen was collected and ask them to provide their best estimate when illness began.

_____/_____/_____

mo day yr (= ONSET DATE - write this date on calendar)

 IF ONSET WITHIN 45 DAYS OF SPECIMEN COLLECTION, GO TO Q5

 IF ONSET MORE THAN 45 DAYS PRIOR TO SPECIMEN COLLECTION,

Sorry. Your illness started more than 45 days before your stool specimen was collected. Since you became ill so long ago, we will not be asking you any additional questions at this time. Thank you for your time. STOP.

Don't know/Not sure................................……......................................................... 7

Refused......................................................…............................................................ 9

 IF NO ONSET DATE/DK/REFUSED, Sorry. We can only interview persons who know when their illness started. Thank you for your time. STOP.

PART 2. HISTORY OF ILLNESS AND MEDICAL CARE

5. During your/your child’s illness, did you/your child have any of the following symptoms?

Interviewer: Please read each symptom

		Yes	No	DK/ not sure	Refused
5a	Fever	Y	N	U	R
			Go to Q5c
5b	What was your/your child’s highest temperature?	__________°	Circle one F C
5c	Chills	Y	N	U	R
5d	Nausea	Y	N	U	R
5e	Vomiting	Y	N	U	R
5f	Abdominal pain	Y	N	U	R
5g	Achy joints or muscles	Y	N	U	R
5h	Fatigue	Y	N	U	R
5i	Diarrhea	Y	N	U	R
			Go to Q5n
5j	On what date did your/your child’s diarrhea start?	__/__/20__ mm/dd/yyyy		U	R
5k	What was the maximum number of stools in a 24-hour period?	___ # stools		U	R
5l	Are you/your child still having diarrhea?	Y	N	U	R
		Go to Q5n		Go to Q5n
5m	How many days did the diarrhea last?	____ # days		U	R
5n	Blood in stools or bloody diarrhea	Y	N	U	R
5o	Other	Y	N	U	R
			Go to Q6
5p	What other symptoms did you/your child have?	Specify:

6. What was the first symptom that you/your child had? Interviewer: Read list of symptoms if person

being interviewed doesn’t initially choose one. CHOOSE ONLY ONE.

Fever……………………………………………..……………………………….. 1

Chills…………………………………………………………….……………….. 2

Nausea ………………………………………………………………..…… …..... 3

Vomiting…………………………………………………..………………………. 4

Abdominal pain…… …………………...………………….……………………… 5

Achy joints or muscles……...……………………………………………… …….. 6

Fatigue ……………………...……………………………………………….……... 7

Diarrhea…………………………………………………………………….. ……. 8

Other………………………...……………………………………………………. 9

Specify ______________________________________

7. Did you/your child take an antibiotic for any reason in the four weeks before your illness?

Yes................…………….. ………….……………............................................. 1

No................…………….... Go to Q8....…. …………….................................... 2

Don't know/Not sure..….… Go to Q8...........… …......................................…… 7

Refused................. ……….. Go to Q8..……...........….............................……… 9

7a. What was the name of the antibiotic? Interviewer: refer to appendix 1, list all

Specify:_____________________________________________________

7b. When did you/your child start taking that antibiotic?

Start __/__/__

Don't know/Not sure..….… Go to Q7d...........… …......................................…… 7

Refused................. ……….. Go to Q7d..……...........….............................……… 9

7c. When did you/your child stop taking that antibiotic?

End__/__/__ …………………. Go to Q8

Don't know/Not sure..….… Go to Q7d...........… …......................................…… 7

Refused................. ……….. Go to Q7d..……...........….............................……… 9

7d. If unsure of dates, for how many days? ____

Don't know/Not sure..……………...........… …......................................…… 7

Refused................. ………………..……...........….............................……… 9

8. Were you/your child taking any stomach acid-reducing medications in the four weeks before

your/your child’s illness? Such medications might include Tums, Rolaids, Maalox, Zantac, or Prilosec

and many others.

Yes................…………….. …… ……..……………............................................. 1

No................…………….... Go to Q9....…. …………….................................... 2

Don't know/Not sure..….… Go to Q9...........… …......................................…… 7

Refused................. ……….. Go to Q9..……...........….............................……… 9

8a. What was the brand or name of that medication? Interviewer: refer to appendix 2, list all

Specify:____________________________________________________________

Section 2: Exposures

I will now ask you about some things you/your child may have done or foods you may have eaten during a specific time period. We’ll start with questions about water.

PART 1. WATER

The following questions refer to the 7-day time period from:

___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___(day before case’s onset)

9. In the 7 days before your/your child’s illness, what were the sources of your/your child’s drinking water? For each source I will be asking whether you/your child drank the water at home or outside the home. This includes water used to wash vegetables, and to mix drinks and baby formula.

Did you drink any			At home	At places other than home
9a	Municipal water, that is, water that is provided by the city or town?	Y	N U R	Y N U R
9b	Tap water from a private well (a well on the premises)?	Y	N U R	Y N U R
			If N/U/R to well water at home Go to Q9f
9c	Was it treated with a whole-house point-of- entry device: a device installed by some homeowners to treat all water when it first enters the house; for example, a reverse osmosis unit? do not include water softeners.	Y	N U R
9d	Was it treated by some other method, for example, boiled, filtered, UV light, distilled? do not include water softeners.	Y	N U R
9e	Do cattle sometimes go near the well? For example, within 50 feet	Y	N U R
9f	Tap water that came from a spring?	Y	N U R	Y N U R
			If N/U/R to spring water at home Go to Q9j
9g	Was it treated with a whole-house point-of- entry device: a device installed by some homeowners to treat all water is treated when it first enters the house; for example, a reverse osmosis unit? do not include water softeners.	Y	N U R
9h	Was it treated by some other method, for example, boiled, filtered, UV light, distilled? do not include water softeners.	Y	N U R
9i	Do cattle sometimes go near the spring? For example, within 50 feet	Y	N U R
Did you drink any		At home or outside the home
9j	Bottled water? Specify brand_____________	Y N U R

10. Did you/your child drink any untreated water from a pond, lake, river, stream or another source not

already mentioned during the 7 days before your/your child’s illness? Specify______________

Yes.............................................................................................. 1

No............................................................................................ 2

Don't know/Not sure............................................................... 7

Refused.................................. ................................................ 9

11. Did you/your child go swimming or play in water during the 7 days before your/your child’s illness?

Yes.............................................................................................. 1

No.......................................... Go to Part 2...................................... 2

Don't know/Not sure.............. Go to Part 2...................................... 7

Refused.................................. Go to Part 2..................................... 9

Did you/your child swim or play in:				If YES 	Did you/your child put your/their face in the water or swallow any water?
11a	The ocean?	Y	N U R		Y N U R
11b	A swimming pool?	Y	N U R		Y N U R
11c	A wading pool?	Y	N U R		Y N U R
11d	A splash pad or fountain?	Y	N U R		Y N U R
11e	A water park?	Y	N U R		Y N U R
11f	An irrigation ditch?	Y	N U R		Y N U R
			Go to Q11h
11g	Were there cattle nearby? For example, within 50 feet	Y	N U R
11h	In a lake, river, or stream (body of fresh water)?	Y	N U R		Y N U R
			Go to Part 2
11i	Were there cattle nearby? For example, within 50 feet	Y	N U R

PART 2. ANIMALS

I’d now like to ask you about some animals you/your child may have come into contact with in the 7 days before your/your child’s illness began. These may be animals you own, animals your neighbors own, or any other animals.

Again, the period is

___/___/___(SEVEN DAYS BEFORE case’s onset) to ___/___/___ (day before case’s onset).

12. In the 7 days before your/your child’s illness, did you/your child have contact with any pets or backyard animals, including fish or reptiles?

Yes......................................... ………….......................................... 1

No.......................................... Go to Q14......................................... 2

Don't know/Not sure.............. Go to Q14......................................... 7

Refused.................................. Go to Q14....................................... 9

13. Which of these pets or backyard animals did you/your child have contact with?

					If YES 	Did you/your child have contact with the animal’s treats, food or feed?
13a	A dog	Y		N U R		Y N U R
				Go to Q13c
13b	Did you/your child feed the dog(s) animal- based products such as rawhides, pig’s ears or cow hooves?	Y		N U R
13c	A cat	Y		N U R		Y N U R
13d	A bird	Y		N U R		Y N U R
13e	Reptiles or amphibians like a turtle, snake, iguana or frog	Y		N U R		Y N U R
				Go to Q13g
13f	What type of reptile or amphibian?	Specify:_______
13g	Fish	Y	N U R			Y N U R
13h	Chickens	Y	N U R			Y N U R
13i	A goat	Y	N U R			Y N U R
13j	Another pet or backyard animal	Y	N U R			Y N U R
			Go to Q14
13k	What type of animal?	Specify________

14. During this 7-day time period, did you/your child live on a farm?

Yes.................................................................................................. 1

No.......................................... Go to Q15........................................ 2

Don't know/Not sure.............. Go to Q15........................................ 7

Refused.................................. Go to Q15....................................... 9

Were any of the following animals present on the farm?			If YES	Did you/your child have contact with the animal?	Did you/your child have contact with the animal’s manure or go into the animal’s living area?	Did you/your child have contact with animal’s food or feed?
14a	Cattle/Cows	Y N U R		Y N U R	Y N U R	Y N U R
14b	Calves	Y N U R		Y N U R	Y N U R	Y N U R
14c	Chickens	Y N U R		Y N U R	Y N U R	Y N U R
14d	Turkeys	Y N U R		Y N U R	Y N U R	Y N U R
14e	Pigs	Y N U R		Y N U R	Y N U R	Y N U R
14f	Goats	Y N U R		Y N U R	Y N U R	Y N U R
14g	Sheep/lambs	Y N U R		Y N U R	Y N U R	Y N U R
14h	Horse	Y N U R		Y N U R	Y N U R	Y N U R
14i	Deer or elk	Y N U R		Y N U R	Y N U R	Y N U R
14j	Other?________	Y N U R		Y N U R	Y N U R	Y N U R
14k	Other?________	Y N U R		Y N U R	Y N U R	Y N U R

15. Did you/your child work on a farm?

Yes..................................................................................................... 1

No.......................................... Go to Q16........................................ 2

Don't know/Not sure.............. Go to Q16........................................ 7

Refused.................................. Go to Q16....................................... 9

Were any of the following animals present on the farm?			If YES 	Did you/your child have contact with the animal?	Did you/your child have contact with the animal’s manure or go into the animal’s living area?	Did you/your child have contact with animal’s food or feed?
15a	Cattle/Cows	Y N U R		Y N U R	Y N U R	Y N U R
15b	Calves	Y N U R		Y N U R	Y N U R	Y N U R
15c	Chickens	Y N U R		Y N U R	Y N U R	Y N U R
15d	Turkeys	Y N U R		Y N U R	Y N U R	Y N U R
15e	Pigs	Y N U R		Y N U R	Y N U R	Y N U R
15f	Goats	Y N U R		Y N U R	Y N U R	Y N U R
15g	Sheep/lambs	Y N U R		Y N U R	Y N U R	Y N U R
15h	Horse	Y N U R		Y N U R	Y N U R	Y N U R
15i	Deer or elk	Y N U R		Y N U R	Y N U R	Y N U R
15j	Other?______	Y N U R		Y N U R	Y N U R	Y N U R
15k	Other?______	Y N U R		Y N U R	Y N U R	Y N U R

16. Did you/your child visit a farm?

Yes..................................................................................................... 1

No.......................................... Go to Q17........................................ 2

Don't know/Not sure.............. Go to Q17........................................ 7

Refused.................................. Go to Q17....................................... 9

Were any of the following animals present on the farm?			If YES	Did you/your child have direct contact with the animal?	Did you/your child have contact with the animal’s manure or go into the animal’s living area?	Did you/your child have contact with animal’s food or feed?
16a	Cattle/Cows	Y N U R		Y N U R	Y N U R	Y N U R
16b	Calves	Y N U R		Y N U R	Y N U R	Y N U R
16c	Chickens	Y N U R		Y N U R	Y N U R	Y N U R
16d	Turkeys	Y N U R		Y N U R	Y N U R	Y N U R
16e	Pigs	Y N U R		Y N U R	Y N U R	Y N U R
16f	Goats	Y N U R		Y N U R	Y N U R	Y N U R
16g	Sheep/lambs	Y N U R		Y N U R	Y N U R	Y N U R
16h	Horse	Y N U R		Y N U R	Y N U R	Y N U R
16i	Deer or elk	Y N U R		Y N U R	Y N U R	Y N U R
16j	Other?______	Y N U R		Y N U R	Y N U R	Y N U R
16k	Other?______	Y N U R		Y N U R	Y N U R	Y N U R

17. Did you/your child visit a petting zoo or petting zoo-like setting, like a birthday party, camp, or

any other venue or setting where farm animals were present?

Yes..................................................................................................... 1

No.......................................... Go to Q18........................................ 2

Don't know/Not sure.............. Go to Q18......................................... 7

Refused.................................. Go to Q18…..................................... 9

Were any of the following animals present?			If YES 	Did you/your child have direct contact with the animal?	Did you/your child have contact with the animal’s manure or go into the animal’s living area?	Did you/your child have contact with animal’s food or feed?
17a	Cattle/Cows	Y N U R		Y N U R	Y N U R	Y N U R
17b	Calves	Y N U R		Y N U R	Y N U R	Y N U R
17c	Chickens	Y N U R		Y N U R	Y N U R	Y N U R
17d	Turkeys	Y N U R		Y N U R	Y N U R	Y N U R
17e	Pigs	Y N U R		Y N U R	Y N U R	Y N U R
17f	Goats	Y N U R		Y N U R	Y N U R	Y N U R
17g	Sheep/lambs	Y N U R		Y N U R	Y N U R	Y N U R
17h	Horse	Y N U R		Y N U R	Y N U R	Y N U R
17i	Deer or elk	Y N U R		Y N U R	Y N U R	Y N U R
17j	Other?______	Y N U R		Y N U R	Y N U R	Y N U R
17k	Other?______	Y N U R		Y N U R	Y N U R	Y N U R

17l. Was that place a

Petting zoo?……………………………………………………….. 1

Camp?……………………………………………………………... 2

Birthday party with animals?……………………………………… 3

Other, specify____________________________________............ 4

18. Did you/your child visit a state or county fair?

Yes..................................................................................................... 1

No.......................................... Go to Q19........................................ 2

Don't know/Not sure.............. Go to Q19........................................ 7

Refused.................................. Go to Q19....................................... 9

Were any of the following animals present at the fair?			If YES 	Did you/your child have direct contact with the animal?	Did you/your child have contact with the animal’s manure or go into the animal’s living area?	Did you/your child have contact with animal’s food or feed?
18a	Cattle/Cows	Y N U R		Y N U R	Y N U R	Y N U R
18b	Calves	Y N U R		Y N U R	Y N U R	Y N U R
18c	Chickens	Y N U R		Y N U R	Y N U R	Y N U R
18d	Turkeys	Y N U R		Y N U R	Y N U R	Y N U R
18e	Pigs	Y N U R		Y N U R	Y N U R	Y N U R
18f	Goats	Y N U R		Y N U R	Y N U R	Y N U R
18g	Sheep/ lambs	Y N U R		Y N U R	Y N U R	Y N U R
18h	Horse	Y N U R		Y N U R	Y N U R	Y N U R
18i	Deer or elk	Y N U R		Y N U R	Y N U R	Y N U R
18j	Other?______	Y N U R		Y N U R	Y N U R	Y N U R
18k	Other?______	Y N U R		Y N U R	Y N U R	Y N U R

19. Aside from anything you already may have mentioned, does your/your child’s work result in contact with live animals or animal carcasses (e.g., veterinarian, food production, slaughter, rendering, or other work)?

Yes..................................................................................................... 1

No.......................................... Go to Q20........................................ 2

Don't know/Not sure.............. Go to Q20........................................ 7

Refused.................................. Go to Q20....................................... 9

19a. What type of work do you do? __________________________

19b. What type of animal?_________________________________

20. In those 7 days did anyone else in your/your child’s household work on or visit a farm, petting zoo, or state or county fair, or engage in any work that resulted in contact with live animals or animal carcasses?

Yes..................................................................................................... 1

No.......................................... Go to Q22........................................ 2

Don't know/Not sure.............. Go to Q22........................................ 7

Refused.................................. Go to Q22....................................... 9

20a. What type of activity, setting or work? __________________________

21. Were any of the following animals present?

21a	Cattle, cows or calves	Y N U R
21b	Goats	Y N U R
21c	Sheep or lambs	Y N U R
21d	Other, specify____________________________	Y N U R

22. Did you/your child have contact with any wild animals or their droppings or feces during outdoor activities such as spending time in your back yard, hunting, hiking or other activities?

Yes..................................................................................................... 1

No.......................................... Go to Q23........................................ 2

Don't know/Not sure.............. Go to Q23........................................ 7

Refused.................................. Go to Q23....................................... 9

22a. Did you/your child have contact with deer, elk or their droppings or feces?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

22b. Did you/your child have contact with any other wild animal or wild animal droppings or feces?

Yes..................................................................................................... 1

No.......................................... Go to Q23........................................ 2

Don't know/Not sure.............. Go to Q23........................................ 7

Refused.................................. Go to Q23....................................... 9

22c.what type of wild animal or wild animal droppings or feces?

Specify: ________________________________

Don't know/Not sure.................................................. 7

Refused.......................................................................9

23. For adult cases: Did you garden in the 7 days before your illness?

For pediatric cases: Did your child play or help in the garden in the 7 days before his/her illness?

Yes.................................................................................................... 1

No.......................................... Go to Part 3.......................................2

Don't know/Not sure.............. Go to Part 3....................................... 7

Refused.................................. Go to Part 3....................................... 9

24. Was animal manure or compost applied to your garden anytime in the past year?

Yes..................................................................................................... 1

No.......................................... Go to Part 3....................................... 2

Don't know/Not sure.............. Go to Part 3....................................... 7

Refused.................................. Go to Part 3....................................... 9

24a. Compost

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

24b. Manure

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

24c. Type of manure (cow, sheep, etc.)__________________________

24d. When did you apply the compost or manure?_____________________________

24e. Was the compost or manure pre-packaged?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

PART 3. TRAVEL AND SOCIAL CONTACTS

I’d now like to ask you about travel and settings where you/your child may have come in contact with other people in the 7 days before your/your child’s illness began. Just a reminder that those 7 days refer to

___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___ (DAY BEFORE case’s onset).

25. Did you/your child travel out-of-state, but within the United States during the seven days before your/your child’s illness began?

Yes..................................................................................................... 1

No.......................................... Go to Q26........................................ 2

Don't know/Not sure.............. Go to Q26........................................ 7

Refused.................................. Go to Q26....................................... 9

25a. What cities and states did you/your child visit? ______________________ ________________________________________________________________

25b.When did you/your child leave? _____/_____/_____

25c.When did you/your child return from your/his/her trip? _____/_____/______

26. Did you/your child travel to another country during the seven days before your/his/her illness began?

Yes..................................................................................................... 1

No.......................................... Go to Q27........................................ 2

Don't know/Not sure.............. Go to Q27........................................ 7

Refused.................................. Go to Q27....................................... 9

26a. What country(s) did you/your child visit? _________________________ ______________________________________________________________

26b. When did you/your child leave the U.S.? _____/_____/_____

26c. When did you/your child return from your/his/her trip? _____/_____/______

27. For adult case: In the 7 days before your illness began, did you work or volunteer at a child care center/setting where there were children under 5 years of age? A child care setting is defined as a place where there are 2 or more children from different households under the care of a person or persons.

For child case: In the 7 days before your child’s illness began, did your child attend a child care center/setting where there were children under 5 years of age? A child care setting is defined as a place where there are 2 or more children from different households under the care of a person or persons.

Yes............................................................................................... 1

No................................................................................................ 2

Don't know/Not sure.............. ……............................................. 7

Refused.................................. ..................................................... 9

28. If case’s age is 5 years of age or older: Were there any children under five in your household?

If case is under 5 years of age: Were there any other children under five in your child’s household?

Yes..................................................................................................... 1

No.......................................... Go to Q29........................................ 2

Don't know/Not sure.............. Go to Q29........................................ 7

Refused.................................. Go to Q29....................................... 9

28a. Did the child/children attend a childcare setting or center?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

29. In the 7 days before your illness began, did you/your child live, work, volunteer or spend time in a residential facility like a nursing home, hospital, summer camp, dorm, or jail?

Yes..................................................................................................... 1

No.......................................... Go to Q30........................................ 2

Don't know/Not sure.............. Go to Q30........................................ 7

Refused.................................. Go to Q30....................................... 9

29a. What type of facility or setting was it?

Specify______________________________________

30. In those 7 days before you/your child became ill, did you/your child come in contact with anyone

else with a diarrheal illness?

Yes..................................................................................................... 1

No.......................................... Go to Part 4.......................................2

Don't know/Not sure.............. Go to Part 4.................................. 7

Refused.................................. Go to Part 4................................ 9

30a. Where? Mark all that apply.

Home ……………………………………………………………… 1

Daycare ……………………………………………………………. 2

Other setting, specify_________________________________..... 3

PART 4. FOOD SECTION

I am now going to ask you about foods you/your child may have eaten in the seven days before your/your child’s illness began. As a reminder, I am referring to the 7-day time period from:

___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___ (DAY BEFORE case’s onset).

If case is younger than 12 months, go to Q31; otherwise, go to Q32:

31. Does your child eat any foods or drinks other than formula or breast milk?

Yes.................................................................................................1

No.......................................... Go to Demographics....................2

Don't know/Not sure.............. Go to Demographics....................7

Refused.................................. Go to Demographics................... 9

32. In the past 3 months, did you/your child eat or handle any meats, such as beef, pork, poultry or fish?

Yes...........................................................................................1

No.......................................... Go to Vegetables....................2

Don't know/Not sure................................................................7

Refused.................................. ………………….................... 9

BEEF:

33. Did you/your child eat any of the following foods containing beef in your home or someone else’s home (not including at a restaurant, we will ask you about this later)?

* Location code	6. Private slaughter 7. “Cow share” or community supported agriculture (CSA) program 8. Other, specify
1. Grocery store 2. Warehouse style market like Sam’s Club, Costco 3. Butcher 4. Farmer’s market
5. Small, local or independent market, like a specialty food market; for example, an Asian or a Latino market	U. Unknown R. Refused

			If YES	Was any of it pink when you ate it?	Where was the beef obtained? Interviewer: use location code *
33a	Hamburgers made in a home from fresh or frozen ground beef?	Y N U R		Y N U R	1 2 3 4 5 6 7 8 U R __________
33b	Pre-made, frozen hamburger patties?	Y N U R		Y N U R	1 2 3 4 5 6 7 8 U R __________
33c	Any other foods that contained ground beef as an ingredient like tacos, or lasagna?	Y N U R		Y N U R	1 2 3 4 5 6 7 8 U R __________
33d	Any steak?	Y N U R		Y N U R	1 2 3 4 5 6 7 8 U R __________
33e	Other intact, not ground, cuts of beef. For example stew meat, roast beef, pot roast? What type or cut?_____________	Y N U R		Y N U R	1 2 3 4 5 6 7 8 U R __________

34. Did you/your child handle any raw ground beef in your home?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

35. Did you/your child handle any raw steaks or intact cuts of beef in your home?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

36. Did anyone else in your household handle any raw beef (ground or intact cuts)?

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

37. Did you/your child eat at a fast food restaurant during 7 days before the illness? We define a fast

food restaurant as any place where you order and pay for your food at the counter or a drive through; for example, McDonald’s, a cafeteria, or a burger stand at a fair?

Yes..................................................................................................... 1

No.......................................... Go to Q39........................................ 2

Don't know/Not sure.............. Go to Q39........................................ 7

Refused.................................. Go to Q39....................................... 9

38. Did you/your child eat any of the following:

			If YES	Was any of it pink when you ate it?
38a	Hamburgers made from ground beef?	Y N U R		Y N U R
38b	Any other forms of ground beef (tacos)?	Y N U R		Y N U R

39. Did you/your child eat at a sit down or table service restaurant during the 7 days before your/his/her illness?

Yes..................................................................................................... 1

No.......................................... Go to OTHER MEAT.................... 2

Don't know/Not sure.............. Go to OTHER MEAT..................... 7

Refused.................................. Go to OTHER MEAT..................... 9

40. Did you/he/she eat any of the following at a restaurant:

			If YES 	Was any of it pink when you ate it?
40a	Hamburgers made from ground beef?	Y N U R		Y N U R
40b	Any other foods that contained ground beef as an ingredient like tacos, or lasagna?	Y N U R		Y N U R
40c	Any steaks?	Y N U R		Y N U R
40d	Other intact (not ground) cuts of beef (for example stew meat, roast beef, pot roast)? What type or cut?___________________	Y N U R		Y N U R

OTHER MEAT / POULTRY / FISH:

From here to the end of the interview, I’m going to ask you questions about other meats, vegetables and fruits. For each food you/your child ate, I’ll be asking you where it was prepared:

-at a private home, such as your own home or someone else’s home,

-outside the home, meaning a restaurant or commercial food establishment,

-or both.

For example, if you ate something at home that you bought pre-made at a deli or take out from a restaurant, I’d record it as prepared outside the home.

41. I’m going start with questions about other meat poultry or fish. During the seven days before

your/your child’s illness did you/your child eat____

* Interviewer: Take-out is considered as prepared outside the home

			If YES	Where was it prepared*? at Home (any private home), Outside (restaurant or commercial food establishment), or Both
41a	Chicken?	Y N U R		H O B U R
41b	Turkey?	Y N U R		H O B U R
41c	Pork?	Y N U R		H O B U R
41d	Lamb?	Y N U R		H O B U R
41e	Veal?	Y N U R		H O B U R
41f	Jerky? What type of jerky? Specify:_______________	Y N U R		H O B U R
41g	Venison (deer meat)?	Y N U R		H O B U R
41h	Elk?	Y N U R		H O B U R
41i	Goat?	Y N U R		H O B U R
41j	Bison?	Y N U R		H O B U R
41k	Salami?	Y N U R		H O B U R
41l	Pepperoni?	Y N U R		H O B U R
41m	Summer sausage?	Y N U R		H O B U R
41n	Other Sausage? What type of sausage? Specify:_______________	Y N U R		H O B U R
41o	Shrimp?	Y N U R		H O B U R
41p	Other Shellfish?	Y N U R		H O B U R
41q	Raw Fish/sushi?	Y N U R		H O B U R
41r	Other meat, poultry, or fish? Specify______________	Y N U R		H O B U R

42. Were any of the any meats, such as beef, pork, poultry or fish, organic?

Yes..................................................................................................... 1

No.......................................... Go to Vegetables............................... 2

Don't know/Not sure.............. Go to Vegetables............................ 7

Refused.................................. Go to Vegetables........................... 9

42a. Which meats were organic? Mark all that apply

Ground beef……………………………………………………… 1

Other beef………………………………………………………… 2

Pork ……………………………………………………………… 3

Poultry……………………………………………………………. 4

Fish……………………………………………………………….. 5

V EGETABLES:

I’m going to ask you about RAW vegetables that you/your child may have consumed in the 7 days before the illness. Please include any vegetables that you consumed as a smoothie or blended or puréed.

43. Did you/your child eat any lettuce?

Yes..................................................................................................... 1

No.......................................... Go to Q45........................................ 2

Don't know/Not sure.............. Go to Q45........................................ 7

Refused.................................. Go to Q45....................................... 9

44. What type of lettuce?

			If YES	Where was it prepared? Home, Outside, Both	If prepared at HOME 	Was it prepackaged? Interviewer: Read the first time you ask this question: By “prepackaged” I mean in a bag or a clamshell or clear plastic box.
44a	Iceberg?	Y N U R		H O B U R		Y N U R
44b	Romaine?	Y N U R		H O B U R		Y N U R
44c	Other lettuce? specify_______	Y N U R		H O B U R		Y N U R

45. Did you/your child eat any of the following fresh greens?

			If YES	Where was it prepared? Home, Outside, Both	If prepared at HOME 	Was it prepackaged?
45a	Raw Spinach?	Y N U R		H O B U R		Y N U R
45b	Mixed Greens, such as spring mix or swiss chard?	Y N U R		H O B U R		Y N U R

46. The following questions refer to RAW vegetables prepared at your/your child’s home, someone else’s home, or outside the home within the 7-day time period. Please include any vegetables that you/your child ate from a salad bar, as a smoothie, blended, puréed or in home-squeezed juice.

			If YES	Where was it prepared? Home, Outside, or Both
46a	Did you eat raw cabbage (including cole slaw)?	Y N U R		H O B U R
46b	Tomatoes?	Y N U R		H O B U R
46c	Cucumbers?	Y N U R		H O B U R
46d	Peppers? Specify___________	Y N U R		H O B U R
46e	Celery?	Y N U R		H O B U R
46f	Carrots?	Y N U R		H O B U R
46g	Radishes?	Y N U R		H O B U R
46h	Pea pods?	Y N U R		H O B U R
46i	Green onions/ scallions?	Y N U R		H O B U R
46j	Other onions (white, red)? Specify:____________	Y N U R		H O B U R
46k	Broccoli?	Y N U R		H O B U R
46l	Alfalfa sprouts?	Y N U R		H O B U R
46m	Bean sprouts?	Y N U R		H O B U R
46n	Other sprouts? Specify:___________	Y N U R		H O B U R
46o	Parsley?	Y N U R		H O B U R
46p	Cilantro?	Y N U R		H O B U R
46q	Any other fresh herbs? Specify:____________	Y N U R		H O B U R
46r	Fresh salsa?	Y N U R		H O B U R

FRUITS:

47. The following questions refer to RAW fruits. Please remember to include any fruits that you/your

child ate from a salad bar, as a smoothie, blended, puréed or in home-squeezed juice.

			If YES 	Where was it prepared? Home, Outside, or Both
47a	Oranges?	Y N U R		H O B U R
47b	Other citrus? Specify:_________	Y N U R		H O B U R
47c	Pears?	Y N U R		H O B U R
47d	Apples?	Y N U R		H O B U R
47e	Other tree fruit, for example: apricot, nectarine, peach, plum?	Y N U R		H O B U R
47f	Strawberries?	Y N U R		H O B U R
47g	Raspberries?	Y N U R		H O B U R
47h	Blueberries?	Y N U R		H O B U R
47i	Grapes?	Y N U R		H O B U R
47j	Bananas?	Y N U R		H O B U R
47k	Cantaloupe?	Y N U R		H O B U R
47l	Watermelon?	Y N U R		H O B U R
47m	Honeydew?	Y N U R		H O B U R
47n	Pineapple?	Y N U R		H O B U R
47o	Exotic fruits like kiwi, avocado, mango? Specify:____________	Y N U R		H O B U R
47p	Other fruit? Specify:____________	Y N U R		H O B U R

48. Were any of the leafy greens, vegetables or fruits that you/your child ate organic?

Yes..................................................................................................... 1

No.......................................... Go to Q49........................................ 2

Don't know/Not sure.............. Go to Q49........................................ 7

Refused.................................. Go to Q49....................................... 9

48a. Which ones were organic?

_____________________________________________________________________

_____________________________________________________________________

49. Were any of the leafy greens, vegetables or fruits that you/your child ate home grown?

Yes..................................................................................................... 1

No.......................................... Go to Q50........................................ 2

Don't know/Not sure.............. Go to Q50........................................ 7

Refused.................................. Go to Q50....................................... 9

49a. Which ones were home grown?

_____________________________________________________________________

_____________________________________________________________________

50. During these seven days did you consume any unpasteurized apple cider or apple juice?

Unpasteurized juices are usually labeled as such, but might be sold at road side stands without

such labels.

Yes............................................................................. 1

No.............................................................................. 2

Don't know/Not sure.................................................. 7

Refused.......................................................................9

51. During these seven days did you consume any other unpasteurized juice?

Yes..................................................................................................... 1

No.......................................... Go to DAIRY.................................. 2

Don't know/Not sure.............. Go to DAIRY................................... 7

Refused.................................. Go to DAIRY................................... 9

51a. What type of juice? ________________________________________

DAIRY:

52. The following questions refer to dairy products that you/your child may have eaten within the 7-day time

period. In that time, did you/your child eat or drink any of the following?

			If YES	Where was it served or consumed? Home, Outside, or Both
52a	Unpasteurized or raw milk?	Y N U R		H O B U R
52b	Pasteurized milk?	Y N U R		H O B U R
52c	Hard cheese, for example, Gouda, Cheddar? Specify: ______________	Y N U R		H O B U R
52d	Soft cheese, for example, Feta, Brie or Camembert? Specify: ______________	Y N U R		H O B U R
52e	Queso fresco or Mexican style cheese?	Y N U R		H O B U R
52f	Cheese curds?	Y N U R		H O B U R
52g	Any other cheese? Specify___________________	Y N U R		H O B U R
52h	Were any of the cheeses you/your child ate unpasteurized? Specify: __________________	Y N U R		H O B U R
52i	Ice cream?	Y N U R		H O B U R
52j	Yogurt?	Y N U R		H O B U R

Section 3: Demographics

Now I would like to ask you a few questions about your/your child’s community and family. Some of these questions may be personal but they help us figure out how to prevent these infections. You may refuse to answer any of these questions.

53. What is your occupation? Specify_________________________________

54. What type of phone are we speaking to you on now? Choose one, circle answer:

Landline (traditional home or house) phone………………….…………1

Cell or mobile phone …………………………………….……………...2

Other type of phone…………………………………….………………..3

Specify _________________________

55. Is there a working landline (traditional home or house) phone in your home?  

Yes……………………………………………………………………….1

No…………………………………………………………………..……2

Unknown…………………………………….…………………………..7

Refused………………..…………………………………………………9

56. On what type of phone do you make or receive the majority of your personal (non-work) phone calls? Choose one, circle answer:

Landline (traditional home or house) phone………………………….....1

Cell or mobile phone …………………………………………………....2

Equally split between landline & cell……………………………………3

Other……………………………………………………………………..4

Specify____________________________.

57. What is your/your child’s race? Read only if necessary, respondent may choose more than one race

White................................................................................... 1

Black or African American................................................. 2

American Indian or Alaskan Native……...…………......... 3

SPECIFY PRINCIPAL TRIBE _______________

Asian Indian…………………………………………….... 4

Chinese…………………………………………………… 5

Filipino…………………………………………………… 6

Japanese………………………………………………….. 7

Korean …………………………………………………… 8

Vietnamese………………………………………………. 9

Native Hawaiian…………………………………………. 10

Guamanian or Chamarro………………………………… 11

Samoan…………………………………………………… 12

Other Pacific Islander……………………………………. 13

Other Asian………………………………………….…… 14

SPECIFY _________________________________

Some other race………………………………........…......... 15

SPECIFY __________________________________

Do not read Don't know/Not sure.............................................................. 16

Do not read Refused...................................................................................17

58. Are you/Is your child of Hispanic or Latino origin?

Yes.......................................................................................... 1

No........................................................................................... 2

Don't know/Not sure............................................. ................. 7

Refused.................................................................................... 9

59. What is your/your child’s zip code? ___ ___ ___ ___ ___

Don't know/Not sure.................................................... 7 7 7 7 7

Refused......................................................................... 9 9 9 9 9

Closing Statement: That's my last question. Thank you very much for your time and cooperation.

END CALL HERE

___________________________________________________________________________________

Section 4: Case/Interviewer Information

60. Case Status?

Alive……………………………………………… 1

Dead…………………………………………….... 2 DATE (___/___/____ mm/dd/yyyy)

Unknown…………………………………………. 3

61. Who completed the interview?

Case…………………………………………… 1

Spouse/Partner………………………………… 2

Parent………………………………………… 3 CIRCLE: FATHER OR MOTHER

Guardian…….………………………………… 4

Other Relative………………………………… 5

Other…………………………………………… 6 SPECIFY______________________

Don’t Know/Not Sure………………………… 9

12/30/08**

APPENDIX 1: ANTIBIOTICS LIST

Antibiotic Name		Antibiotic Name
Don’t Remember Name	99	Fosfomycin	33
Amoxicillin	1	Keflex	34
Amoxicillin/Clavulanate	2	Keftab	35
Ampicillin	3	Ketek	36
Ancef	4	Levofloxacin	37
Augmentin	5	Levoquin	38
Avelox	6	Linezolid	39
Azithromycin	7	Macrobid	40
Bactrim	8	Metronidazole	41
Biaxin	9	Minocin	42
Ceclor	10	Minocycline	43
Cefaclor	11	Monurol	44
Cefadroxil	12	Moxifloxacin	45
Cefdinir	13	Nitrofurantoin	46
Cefixime	14	Norfloxacin or Norflox	47
Cefprozil	15	Omnicef	48
Ceftin	16	Pediazole	49
Ceftriaxone	17	Penicillin or Pen VK	50
Cefuorixime	18	Rifaximin	51
Cefzil	19	Rocephin	52
Cephalexin	20	Septra	53
Cephradine	21	Suprax	54
Ciprofloxacin or Cipro	22	Telithromycin	55
Clarithromycin	23	Tetracycline	56
Cleocin	24	Trimethoprim/Sulfa	57
Clindamycin	25	Trimox	58
Dicloxacillin	26	Vibramycin	59
Doxycycline	27	Xifaxan	60
Duricef	28	Zithromax or Z-Pak	61
Erythromycin	29	Zyvox	62
Erythromycin/sulfa	30	OTHER – SPECIFY ____________________	77
Flagyl	31	REFUSED	88
Floxin	32	UNKNOWN	99

APPENDIX 2: ANTIACIDS LIST

Medication Name		Medication Name
Don’t Remember Name	99	Novo-Ranidine	35
Aciphex	1	Nu-Cimet	36
Alternagel	2	Nu-Famotidine	37
Alti-Ranitidine	3	Nu-Ranit	38
Aluminum hydroxide	4	Omepral	39
Amphgel	5	Omeprazole	40
Antra	6	Pantoloc	41
Apo-Cimetidine	7	Pantoprazole	42
Apo-Famotidine	8	Pariet	43
Apo-Ranitidine	9	Pepcid (all varieties)	44
Axid	10	Pepto	45
Calcium carbonate	11	Phllips Chewables	46
Carafate	12	PMS-Cimetidine	47
Cimetidine	13	PMS-Ranitidine	48
Cytotec	14	Prevacid (all varieties)	49
Dexlansoprazole	15	Prevpac	50
Esomeprazole	16	Priolsec (all varieties)	51
Fluxid	18	Protonix	53
Famotidine	17	Proton-pump inhibitor (PPI)	52
Gas-X	19	Rabeprazole	54
Gen-Cimetidine	20	Ranitidine	55
Gen-Famotidine	21	ratio-Famotidine	56
Gen-Ranidine	22	Rhoxal-famotidine	57
H2-blocker	23	Rhoxal-ranitidine	58
Kapidex	24	Riva-Famotidine	59
Lansoprazole	25	Rolaids (all varieties)	60
Losec	26	Sodium bicarbonate	61
Maalox (all varieties)	27	Sucralfate	62
Misoprostol	28	Tagamet	63
Mopral	29	Tums (all varieties)	64
Mylanta (all varieties)	30	Zantac	65
Nexium	31	Zegerid	66
Nizatidine	32	OTHER – SPECIFY ____________________	77
Novo-Cimetidine	33	REFUSED	88
Novo-Famotidine	34	UNKNOWN	99