Control 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

(3) Control Questionnaire_02-18-2011

Control 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

Control 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:_______________




Matched-Case Person ID Number (FoodNet site-specific)_________________


Matched-Case Study ID Number____________________


Matched-Case State Lab ID Number__________________


Control: 1 2 3



-- Date Matched CASE’S SYMPTOMS Began: ____mm/_____dd/20____

--Date 7 days before Matched CASE’S SYMPTOMS began: __mm/_____dd/20____


--Date one month before Matched CASE’S SYMPTOMS began: ____mm/_____dd/20____


These dates will be used to ascertain the control’s exposure history so it can be matched with the history of the case.

___________________________________________________________________________________________



START HERE AFTER OBTAINING CONSENT



Age Strata of matched case-patient:

0 to <2 years

2 to <6 years

6 to <18 years

18 to <40 years

40 to <60 years

60 or older years

Initial Demographic Questions:



1. What is your/your child’s age? _______Years______months


2. What is your/your child’s gender?

Gender: F M Refused


3. In what county do you/your child live? ___________________


Section 1: Health Questions


I will be asking you some questions about specific dates so it may be helpful to have a calendar in front of you. Do you need a few minutes to get one?


First, I would like to ask you some health related questions. The following questions refer to the four week time period from___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) to ___/___/___ (Date one day before CASE’S SYMPTOMS began).


4. During this four week time frame, did you/your child have any diarrhea?

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

No................…………….......Go to Q5.…. …………….................................... 2

Don't know/Not sure………...Go to Q5..… …......................................…… 7

Refused................. ………….Go to Q5...........…...............................……………...9


4a. When you/your child had this diarrhea, what was the maximum number of stools you/your child had in a 24 hour period? _______ Don’t know/not sure Refused


5. Were you/ Was your child diagnosed with an E. coli infection any time between ___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) and ___/___/___ (Date one day before CASE’S SYMPTOMS began)?

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

No................…………….....Go to Q6....…. …………….................................... 2

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

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


IF YES/DON’T KNOW/NOT SURE/REFUSED,

Sorry, but we need to do this interview with someone who definitely did not have an E. coli infection within the past month. Thank you for your time. END.



6. Did you/your child take an antibiotic for any reason between ___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) and ___/___/___ (Date one day before CASE’S SYMPTOMS began)?

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

No................…………….... Go to Q7....…. …………….................................... 2

Don't know/Not sure..….… Go to Q7...........… …......................................…… 7

Refused................. ……….. Go to Q7..……...........….............................……… 9


6a. What was the name of the antibiotic? Interviewer: refer to appendix 1, list all.

Specify:____________________________________

6b. When did you/your child start taking that antibiotic?

Start __/__/__

Don't know/Not sure..….… Go to Q6d...........… …......................................…… 7

Refused................. ……….. Go to Q6d..……...........….............................……… 9


6c. When did you/your child stop taking that antibiotic?

End__/__/__

Don't know/Not sure..….… Go to Q6d...........… …......................................…… 7

Refused................. ……….. Go to Q6d..……...........….............................………9


6d. if unsure of dates, for how many days? ____

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

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


7. Were you/Was your child taking any stomach acid-reducing medications between ___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) and ___/___/___ (Date one day before CASE’S SYMPTOMS began)? Such medications might include Tums, Rolaids, Maalox, Zantac, or Prilosec and many others.

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 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)


8. During those 7 days, 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

8a

Municipal water, that is, water that is provided by the city or town?

Y

N U R

Y N U R

8b

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 Q8f

8c

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


8d

Was it treated by some

other method, for

example, boiled, filtered,

UV light, distilled? do not

include water softeners.

Y

N U R


8e

Do cattle sometimes go

near the well? For

example, within 50 feet

Y

N U R


8f

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 Q8j

8g

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


8h

Was it treated by some

other method, for

example, boiled, filtered,

UV light, distilled? do not

include water softeners.

Y

N U R


8i

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

8j

Bottled water?

Specify brand_____________

Y N U R


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

already mentioned during those 7 days? Specify_________________

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

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

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

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


10. Did you/your child go swimming or play in water during those 7 days?

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?

10a

The ocean?

Y

N U R


Y N U R

10b

A swimming pool?

Y

N U R


Y N U R

10c

A wading pool?

Y

N U R


Y N U R

10d

A splash pad or fountain?

Y

N U R


Y N U R

10e

A water park?

Y

N U R


Y N U R

10f

An irrigation ditch?

Y

N U R


Y N U R


Go to Q10h

10g

Were there

cattle nearby?

For example,

within 50 feet

Y

N U R



10h

In a lake, river, or stream (body of fresh water)?

Y

N U R


Y N U R


Go to Part 2

10i

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. These may be animals you own, animals your neighbors own, or any other animals.


Again, these question will refer to the 1 week time period from __/___/___ (Date seven days before CASE’S SYMPTOMS began) to ___/___/___ (Date one day before CASE’S SYMPTOMS began)


11. During those 7 days, did you/your child have contact with any pets or backyard animals, including fish or reptiles?

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

No.......................................... Go to Q13......................................... 2

Don't know/Not sure.............. Go to Q13......................................... 7

Refused.................................. Go to Q13....................................... 9


12. 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?

12a

A dog

Y

N U R


Y N U R

Go to Q12c

12b

Did you/your child

feed the dog(s) animal-

based products such as

rawhides, pig’s ears or

cow hooves?


Y

N U R




12c

A cat

Y

N U R


Y N U R

12d

A bird

Y

N U R


Y N U R

12e

Reptiles or amphibians like a turtle, snake, iguana or frog

Y

N U R


Y N U R

Go to Q12g

12f

What type of reptile or

amphibian?

Specify:_______



12g

Fish

Y

N U R


Y N U R

12h

Chickens

Y

N U R


Y N U R

12i

A goat

Y

N U R


Y N U R

12j

Another pet or backyard animal

Y

N U R


Y N U R

Go to Q12k

12k

What type of animal?

Specify_______





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

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

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

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

Refused.................................. Go to Q14....................................... 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?

13a

Cattle/Cows

Y N U R


Y N U R

Y N U R

Y N U R

13b

Calves

Y N U R


Y N U R

Y N U R

Y N U R

13c

Chickens

Y N U R


Y N U R

Y N U R

Y N U R

13d

Turkeys

Y N U R


Y N U R

Y N U R

Y N U R

13e

Pigs

Y N U R


Y N U R

Y N U R

Y N U R

13f

Goats

Y N U R


Y N U R

Y N U R

Y N U R

13g

Sheep/lambs

Y N U R


Y N U R

Y N U R

Y N U R

13h

Horse

Y N U R


Y N U R

Y N U R

Y N U R

13i

Deer or elk

Y N U R


Y N U R

Y N U R

Y N U R

13j

Other?________

Y N U R


Y N U R

Y N U R

Y N U R

13k

Other?________

Y N U R


Y N U R

Y N U R

Y N U R


14. Did you/your child work 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 visit 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 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?

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. During those 7 days, 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 Q17........................................ 2

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

Refused.................................. Go to Q17…..................................... 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?

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


16l. Was that place a

Petting zoo?……………………………………………………….. 1

Camp?……………………………………………………………... 2

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

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


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

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 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?

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


18. 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 Q19........................................ 2

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

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

18a. What type of work do you do? __________________________

18b. What type of animal?_________________________________


19. 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 Q21........................................ 2

Don't know/Not sure.............. Go to Q21........................................ 7

Refused.................................. Go to Q21....................................... 9


19a. What type of activity, setting or work? __________________________


20. Were any of the following animals present?

20a

Cattle, cows or calves

Y N U R

20b

Goats

Y N U R

20c

Sheep or lambs

Y N U R

20d

Other,

specify____________________________

Y N U R



21. 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 Q22........................................ 2

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

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


21a. 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


21b. During those 7 days, did you/your child have contact with any other wild animal or wild animal droppings or feces?

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

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

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

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


21c.what type of wild animal or wild animal droppings or feces?

Specify: ________________________________

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

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


22. For adult cases: Did you garden during those 7 days?

For pediatric cases: Did your child play or help in the garden during those 7 days?

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

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

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

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


23. 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

23a. Compost

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

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

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

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

23b. Manure

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

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

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

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


23c. Type of manure (cow, sheep, etc.)__________________________

23d. When did you apply the compost or manure?_____________________________

23e. 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. Again, I will be asking you about a specific time period.


The following questions refer to the 1 week time period from: ___/___/___ (Date seven days before CASE’S SYMPTOMS began) to ___/___/___ (Date one day before CASE’S SYMPTOMS began).


24 Did you/your child travel out-of-state, but within the United States during those 7 days?

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

No.......................................... Go to Q25........................................ 2

Don't know/Not sure.............. Go to Q25........................................ 7

Refused.................................. Go to Q25....................................... 9


24a. What cities and states did you/your child visit? ______________________ ________________________________________________________________

24b.When did you/your child leave? _____/_____/_____


24c.When did you/your child return from your/his/her trip? _____/_____/______


25. Did you/your child travel to another country during those 7days?

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

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

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

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


25a. What country(s) did you/your child visit? _________________________ ______________________________________________________________


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


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







26. For adult control: During those 7 days, 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 control: During those 7 days, 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


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

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

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

No.......................................... Go to Q28........................................ 2

Don't know/Not sure.............. Go to Q28........................................ 7

Refused.................................. Go to Q28....................................... 9


27a. Did the child/children attend a childcare setting or center?

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

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

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

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


28 During those 7 days, 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 Q29........................................ 2

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

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


28a. What type of facility or setting was it?

Specify______________________________________


29. During those 7 days, 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


29a. 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. 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 control is younger than 12 months, go to Q30; otherwise, go to Q31:

30. 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


31. 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:

32. 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 *

32a

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 __________

32b

Pre-made, frozen hamburger patties?

Y N U R


Y N U R

1 2 3 4 5 6 7 8 U R __________

32c

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 __________

32d

Any steak?

Y N U R


Y N U R

1 2 3 4 5 6 7 8 U R __________

32e

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 __________

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

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

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

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

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


34. 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



35. 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


36. Did you/your child eat at a fast food restaurant during those 7 days? 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 Q38........................................ 2

Don't know/Not sure.............. Go to Q38........................................ 7

Refused.................................. Go to Q38....................................... 9



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




If YES

Was any of it pink when you ate it?

37a

Hamburgers made from ground beef?

Y N U R


Y N U R

37b

Any other forms of ground beef (tacos)?

Y N U R


Y N U R


38. Did you/your child eat at a sit down or table service restaurant during those 7 days?

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

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

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

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




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




If YES

Was any of it pink when you ate it?

39a

Hamburgers made from ground beef?

Y N U R


Y N U R

39b

Any other foods that contained ground beef as an ingredient like tacos, or lasagna?

Y N U R


Y N U R

39c

Any steaks?

Y N U R


Y N U R

39d

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.


All food questions are in regards to the specific one week time period between ___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began)



40. I’m going start with questions about other meat poultry or fish. During those 7 days, 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

40a

Chicken?

Y N U R


H O B U R

40b

Turkey?

Y N U R


H O B U R

40c

Pork?

Y N U R


H O B U R

40d

Lamb?

Y N U R


H O B U R

40e

Veal?

Y N U R


H O B U R

40f

Jerky?

What type of jerky? Specify:_______________

Y N U R


H O B U R

40g

Venison (deer meat)?

Y N U R


H O B U R

40h

Elk?

Y N U R


H O B U R

40i

Goat?

Y N U R


H O B U R

40j

Bison?

Y N U R


H O B U R

40k

Salami?

Y N U R


H O B U R

40l

Pepperoni?

Y N U R


H O B U R

40m

Summer sausage?

Y N U R


H O B U R

40n

Other Sausage?

What type of sausage? Specify:_______________

Y N U R


H O B U R

40o

Shrimp?

Y N U R


H O B U R

40p

Other Shellfish?

Y N U R


H O B U R

40q

Raw Fish/sushi?

Y N U R


H O B U R

40r

Other meat, poultry, or fish?

Specify______________

Y N U R


H O B U R


41. 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

41a. 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 eaten between ___/___/___ and ___/___/___ (7-day period before the matched CASE’S SYMPTOMS began). Please include any vegetables that you consumed as a smoothie or blended or puréed.


42. Did you/your child eat any lettuce?

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

No.......................................... Go to Q44........................................ 2

Don't know/Not sure.............. Go to Q44........................................ 7

Refused.................................. Go to Q44....................................... 9


43. 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.

43a

Iceberg?

Y N U R


H O B U R


Y N U R

43b

Romaine?

Y N U R


H O B U R


Y N U R

43c

Other lettuce? specify_______

Y N U R


H O B U R


Y N U R


44. 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?

44a

Raw Spinach?

Y N U R


H O B U R


Y N U R

44b

Mixed Greens, such as spring mix or swiss chard?

Y N U R


H O B U R


Y N U R

45. The following questions refer to RAW vegetables that you/your child were prepared at your/your child’s home, someone else’s home, or outside the home during the one week time period between ___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began)


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

45a

Did you eat

raw cabbage (including cole slaw)?

Y N U R


H O B U R

45b

Tomatoes?

Y N U R


H O B U R

45c

Cucumbers?

Y N U R


H O B U R

45d

Peppers?

Specify____________

Y N U R


H O B U R

45e

Celery?

Y N U R


H O B U R

45f

Carrots?

Y N U R


H O B U R

45g

Radishes?

Y N U R


H O B U R

45h

Pea pods?

Y N U R


H O B U R

45i

Green onions/ scallions?

Y N U R


H O B U R

45j

Other onions (white, red)?

Specify:____________

Y N U R


H O B U R

45k

Broccoli?

Y N U R


H O B U R

45l

Alfalfa sprouts?

Y N U R


H O B U R

45m

Bean sprouts?

Y N U R


H O B U R

45n

Other sprouts? Specify:___________

Y N U R


H O B U R

45o

Parsley?

Y N U R


H O B U R

45p

Cilantro?

Y N U R


H O B U R

45q

Any other fresh herbs?

Specify:____________

Y N U R


H O B U R

45r

Fresh salsa?

Y N U R


H O B U R




FRUITS:

46. The following questions refer to RAW fruits. Please remember to include any fruits that you ate from a salad bar, as a smoothie, blended, puréed or in home-squeezed juice during the time period between___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began)





If YES

Where was it prepared?

Home,

Outside, or Both

46a

Oranges?

Y N U R


H O B U R

46b

Other citrus? Specify:_________

Y N U R


H O B U R

46c

Pears?

Y N U R


H O B U R

46d

Apples?

Y N U R


H O B U R

46e

Other tree fruit, for example: apricot, nectarine, peach, plum?

Y N U R


H O B U R

46f

Strawberries?

Y N U R


H O B U R

46g

Raspberries?

Y N U R


H O B U R

46h

Blueberries?

Y N U R


H O B U R

46i

Grapes?

Y N U R


H O B U R

46j

Bananas?

Y N U R


H O B U R

46k

Cantaloupe?

Y N U R


H O B U R

46l

Watermelon?

Y N U R


H O B U R

46m

Honeydew?

Y N U R


H O B U R

46n

Pineapple?

Y N U R


H O B U R

46o

Exotic fruits like kiwi, avocado, mango? Specify:____________


Y N U R


H O B U R

46p

Other fruit?

Specify:____________

Y N U R


H O B U R


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

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

No.......................................... Go to Q48........................................ 2

Don't know/Not sure.............. Go to Q48........................................ 7

Refused.................................. Go to Q48....................................... 9

47a. Which ones were organic?

_____________________________________________________________________

_____________________________________________________________________


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

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 home grown?

_____________________________________________________________________

_____________________________________________________________________


49. During those 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


50. During those 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


50a. What type of juice? ________________________________________












DAIRY:

51. The following questions refer to dairy products that you may have eaten within the 7-day time period between___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began).


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

51a

Unpasteurized or raw milk?

Y N U R


H O B U R

51b

Pasteurized milk?

Y N U R


H O B U R

51c

Hard cheese, for example, Gouda, Cheddar?

Specify: ______________

Y N U R


H O B U R

51d

Soft cheese, for example, Feta, Brie or Camembert?

Specify: ______________

Y N U R


H O B U R

51e

Queso fresco or Mexican style cheese?

Y N U R


H O B U R

51f

Cheese curds?

Y N U R


H O B U R

51g

Any other cheese?

Specify___________________

Y N U R


H O B U R

51h

Were any of the cheeses you/your child ate unpasteurized?

Specify: __________________

Y N U R


H O B U R

51i

Ice cream?

Y N U R


H O B U R

51j

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.

52. What is your occupation? Specify_________________________________


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


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 _________________________

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

Yes……………………………………………………………………….1

No…………………………………………………………………..……2

Unknown…………………………………….…………………………..7

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




55. 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____________________________.


56. 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


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

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

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

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

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


58. 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

___________________________________________________________________________________

12/30/08**


Section 4: Control/Interviewer Information



59. Who completed the interview?

Control…………………………………………… 1

Spouse/Partner………………………………… 2

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

Guardian…….………………………………… 4

Other Relative………………………………… 5

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

Don’t Know/Not Sure………………………… 9












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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