Case questionnaire

FoodNet Non-0157 Shiga Toxin-Producing E.coli Study: Assessment of Risk Factors for Laboratory-Confirmed Infections and Characterization of Illnesses by Microbiological Characteristics

(2) Case Questionnaire_02-18-2011

Case Questionnaire

OMB: 0920-0905

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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 CampylobacterShigella

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




















































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