NVEAIS Data Reporting Instrument

Form Approved

Attachment 4- NVEAIS Data Reporting Instrument OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 1 hour 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, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-xxxx)

Part I – general characterization of outbreak response

1. Did the exposure(s) take place in a single or multiple locations, for example a single restaurant or two or more restaurants, a single school or two or more schools or a combination of establishments, etc.?

• Single Location If a single location, skip to #5

• Multiple Locations

2. Did the exposure(s) happen in a single County/Township / Parish or multiple Counties / Townships / Parishes in your state?

• Single County / Township / Parish

• Multiple Counties / Township / Parish

3. Did the exposure(s) occur in a single state or multiple states?

• Single State

• Multiple states

4. How many food service establishment locations within your jurisdiction were associated with this outbreak? __________________

5. Were any environmental assessments conducted at foodservice establishments in your jurisdiction as a part of this outbreak?

   • Yes

   • No If No, skip to #5c

1. Briefly, describe the reason(s) why environmental assessments were conducted in your jurisdiction as a part of this outbreak. _______________________________________________

_____________________________________________________________________________

2. How many environmental assessments were conducted in foodservice establishments in your jurisdiction as a part of this outbreak?____________________________ Skip to #6

3. Why were no environmental assessments conducted at foodservice establishments in your jurisdiction as a part of this outbreak? ______________________________________

______________________________________________________________________

6. Were any non-food service establishment locations within your jurisdiction associated with this outbreak investigation?

• Yes

• No If No, skip to #7

1. How many non-food service establishments in your jurisdiction were associated with this outbreak? _________

2. How many environmental assessments were conducted at non-food service establishments in your jurisdiction as part of this outbreak? _____________________

7. Was a primary agent identified in this outbreak?

• Yes

• No If No, Skip #8

1. What was the identified agent?

• Hepatitis A

• Bacillus cereus

• Campylobacter

• Clostridium perfringens

• Cryptosporidium

• Cyclospora

• E. coli 0157:H7

• E. coli STEC/VTEC

• Listeria

• nororvirus

• Salmonella

• Shigella

• Staphylococcus aureus

• Vibrio parahaemolyticus

• Yersinia

• Toxic agent (Please describe)

• Other agent (Please describe)

• Chemical hazard (Please describe)

• Physical hazard (Please describe)

2. Was a serotype identified for this outbreak?

• Yes

• No    If No, skip to #8

3. What was the identified serotype?    _________________________________________

8. Was this outbreak reported to a state or local Communicable Disease Surveillance Program?

• Yes

• No If No, skip to #9

1. Select the state or local surveillance system(s) where this outbreak was reported (check all that apply)

• State – outbreak reporting number assigned by the state? ________________________

• Local – outbreak reporting number assigned by the jurisdiction? ____________________

• Other (Please describe):___________________________________________________

9. Was this outbreak reported to a national surveillance system?

• Yes

• No If No, skip to Part II

1. Select the national surveillance system(s) where this outbreak was reported and record the corresponding reporting number. (check all that apply)

• NORS – reporting number assigned by the CDC? _______________________________

• PulseNet – outbreak code assigned by CDC? __________________________________

• FoodNet – reporting number assigned by the CDC? _____________________________

• CalciNet – reporting number assigned by the CDC? _____________________________

• NNDSS – reporting number assigned by the CDC? ______________________________

• Other (Please describe):___________________________________________________

Part II – Establishment DESCRIPTION, Categorization, and menu review

1. Date the establishment was identified for an environmental assessment:____/____/______

2. Date of first contact with establishment management: / /

3. Number of visits to the establishment to complete this environmental assessment: ________

4. Number of contacts with the establishment other than visits, (ex. phone calls, phone interviews with staff, faxes, etc.) to complete this environmental assessment: ____________

5. Facility Type

• Camp

  • Caterer

  • Church

  • Correctional Facility

• Daycare center

• Feeding Site

  • Food Cart

• Grocery Store

• Hospital

• Mobile Food Unit

  • Nursing Home

  • Temporary Food Stand

  • Restaurant

• Restaurant in a Supermarket

• School Foodservice

• Workplace Cafeteria

• Other (Please Describe)

_________________________

6. How many critical violations were noted during the last routine inspection? ______________

7. What is the establishment’s source of potable water?

• Community water system

• Transient, non-community water system

• Non-transient, non-community water system

• Other (Please describe): _________________________________________

8. What is the establishment’s sewage disposal method?

• Public sewage

• On-site sewage disposal system

• Other (Please describe):_______________________________

9. Was a translator needed to communicate with the kitchen manager during the environmental assessment?

• Yes

• No If No, skip to #10

1. Was a translator used to communicate with the kitchen manager?

• Yes

• No

10. Was a translator needed to communicate with the food workers during the environmental assessment?

• Yes

• No If No, skip to #11

1. Was a translator used to communicate with the food workers?

• Yes

• No

11. Establishment Type:

• Prep Serve

• Cook Serve

• Complex

12. Do customers have direct access to unpackaged food such as a buffet line or salad bar in this establishment?

• Yes

• No

13. Does the establishment serve raw or undercooked animal products (example, oysters or shell eggs) in any menu item?

• Yes

• No If No, skip to #14

1. Is a consumer advisory regarding the risk of consuming raw or undercooked animal products provided (for example: on the menu, on a sign)?

• Yes

• No If No, skip to #14

2. Where is the consumer advisory located? (check all that apply)

• On the menu as a footnote

• On the menu in the menu item description

• On a sign

• Other (Please describe):_____________________________________________

14. Which one of the options below best describes the menu for this establishment?

• American (non-ethnic)

• Chinese

• Thai

• Japanese

• French

• Italian

• Mexican

• Other (Please describe): ____________________________________

Part IV – establishment Observation

This series of questions is based on the initial observation of the physical facility and the food handling practices at the time of the initial environmental assessment and NOT the physical facility condition or food handling practices thought to have been in place at the time of the exposure. Data collection should occur during the hours of operation if at all possible. Please answer the following questions by observation of the item in question. It should be a rare occurrence, but if any question cannot be answered, please skip that question.

1. Date observations were made:_________/_______/_____________

2. Are hand sinks available in the employee restroom(s)?

• Yes

• No If No, skip to # 3

• Could Not Observe If Could Not Observe, skip to #3

1. How many hand sinks are in the employee restrooms? ___________

2. Is warm water (minimum 100°F) available at all employee restroom hand sinks?

• Yes

• No (Please specify number without _____ )

• Could Not Observe

3. Is soap available at (or near) all employee restroom hand sinks?

• Yes

• No (Please specify number without _____ )

• Could Not Observe

4. Are paper or cloth drying towels available at (or near) all employee restroom hand sinks?

• Yes

• No (Please specify number without _____ )

• Could Not Observe

3. Is a hand sink available in the work area(s)?

• Yes

• No If No, skip to # 4

• Could Not Observe If Could Not Observe, skip to # 4

1. How many hand sinks are located in the work area(s)? ______________

2. Is warm water (minimum100°F) available at all hand sinks in the work area?

• Yes

• No (Please specify number without _____ )

• Could Not Observe

3. Is soap available at (or near) all hand sinks in the work area?

• Yes

• No (Please specify number without _____ )

• Could Not Observe

4. Are paper or cloth drying towels available at (or near) all hand sinks in the work area?

• Yes

• No (Please specify number without _____ )

• Could Not Observe

4. Are there cold storage units in the establishment?

• Yes

• No If No, skip to # 6

• Could Not Observe If Could Not Observe, skip to #6

1. How many cold storage units are in the establishment? ­­­­­­­­­­­­­­­­____________

2. Which types of units did you observe? (check all that apply)

• Reach in

• Walk-in

• Self-Serve / Salad Bar

• Open top units

5. Are all cold storage areas maintained at a temperature of 41°F or below?

• Yes If Yes, skip to # 6

• No

• Could Not Observe

1. How many cold storage units are above 41°F? ­____________

2. Which types of units did you observe to be above 41°F? (check all that apply)

• Reach in

• Walk-in

• Self-Serve / Salad Bar

• Open top units

6. Are any food workers using gloves while handling food?

• Yes

• No

• Could Not Observe

7. Is there a supply of disposable gloves available in the establishment?

• Yes

• No

• Could Not Observe

8. Are any food workers handling RTE foods with bare hands?

• Yes

• No

• Could Not Observe

9. Are there records to indicate that the temperatures of incoming ingredients are being taken and recorded?

• Yes

• No

• Could Not Observe

10. Are there records to indicate that the temperatures of foods, excluding incoming ingredients, are being taken and recorded?

• Yes

• No

• Could Not Observe

11. Is there any evidence of direct cross contamination of raw animal products with ready to eat foods?

• Yes

• No

• No raw animal products used

• Could Not Observe

12. Is there cooling of hot foods in this establishment?

• Yes

• No If No, skip to # 13

• Could Not Observe If Could Not Observe, skip to # 13
  
  

1. What cooling method(s) are used? (Check all that apply)

• Portioning into smaller pans and cooled in regular cooler

• Portioning into smaller pans and cooled in blast chiller

• Used ice as an ingredient

• Used ice bath for food container prior to cooling in regular cooler

• Used ice bath for food container prior to cooling in blast chiller

• Used Ice wands prior to cooling in regular cooler

• Used ice wands prior to cooling in blast chiller

• Combination methods (ice, ice wand, portioning, etc.) with cooling in regular cooler

• Combination of methods (ice, ice wand, portioning, etc.) and cooling in blast chiller

• Other (Please describe)________________________________

13. Were any foods observed in hot holding?

• Yes

• No If No, skip to # 14

• Could Not Observe If Could Not Observe, skip to # 14

1. Were the temperatures of any foods in hot holding measured?

• Yes

• No If No, skip to # 14

2. Were the temperatures of all foods measured in hot holding at 130°F or above?

• Yes

• No

14. Were any foods observed in cold holding?

• Yes

• No If No, skip to # 15

• Could Not Observe If Could Not Observe, skip to # 15

1. Were the temperatures of any foods in cold holding measured?

• Yes

• No If No, skip to # 15

2. Were the temperatures of all foods measured in cold holding at 41°F or below?

• Yes

• No

15. Were any foods observed during cooking?

• Yes

• No If No, skip to # 16

• Could Not Observe If Could Not Observe, skip to #16

1. Were the temperatures of any foods being cooked measured?

• Yes

• No If No, skip to # 16

2. Were the temperatures of all foods measured during cooking at the recommended temperatures?

• Yes

• No

16. Are wiping cloths used in the establishment?

• Yes

• No If No, skip to # 17

• Could Not Observe If Could Not Observe, skip to #17

1. Are all wiping cloths stored in a sanitizer solution between uses?

• Yes

• No

• Could Not Observe

17. Are there mechanical washing machines for dishes, utensils, or other equipment?

• Yes

• No If No, skip to # 18

• Could Not Observe If Could Not Observe, skip to #18

1. Does the wash cycle reach the temperatures recommended for that washing machine?

• Yes

• No

• Could Not Observe

2. Does the sanitizing cycle reach the temperatures recommended for sanitization?

• Yes

• No

• Could Not Observe

3. Is chemical sanitizing used?

• Yes

• No If No, skip to #18

• Could Not Observe If Could Not Observe, skip to #18

4. Did the chemical sanitizing cycle have the required levels of chemical sanitizer recommended for the machine?

• Yes

• No

• Could Not Observe

18. Are there any hand washed dishes, utensils or other equipment?

• Yes

• No If No, skip to #19

• Could Not Observe If Could Not Observe, skip to #19

1. Are hand washed dishes, utensils or other equipment washed, rinsed and sanitized (either with heat or chemical)?

• Yes

• No If No, skip to #19

• Could Not Observe If Could Not Observe, skip to #19

2. Is the sanitizing method (heat or chemical) properly implemented?

• Yes

• No

• Could Not Observe

19. Did you observe signs and instructions posted in the establishment?

• Yes

• No If No, skip to #20

1. Did any signs or posted instructions use pictures or symbols to communicate a message?

• Yes

• No If No, skip to #20

2. What languages did you observe on signs or instructions posted for food workers?

• English

• Spanish

• French

• Chinese (any dialect)

• Japanese

• No written words

• Other

20. Were there any differences to the physical facility, food handling practices you observed on your initial visit or other circumstances that were different at the time of exposure?

• Yes If yes, briefly explain

• No If No, skip to #21 Comments

1. Briefly explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21. Comments: Use this space to record additional comments. This section provides the evaluator the opportunity to briefly describe specific circumstances during or right before the time of the exposures that is believed to have played a significant exposure role. For example, over the course of the environmental assessment it may have been determined that the establishment operated with no hot water or walk-in cooler units failed, or the kitchen manager was on vacation and normal polices or procedures were not followed in that absence, or the establishment was out of single use gloves during the time in question or a large number of food workers did not show up for work, hindering implementation of normal policies and procedures.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part V – Suspected / Confirmed Food

1. Was a specific ingredient or multi-ingredient food suspected or confirmed in this outbreak?

• Yes If Yes, Skip to # 2

• No

1. If No, explain why food was not the suspected vehicle in this outbreak and skip to Part VI - Sampling. __________________________________________________________________________________________________________________________________________________________

2. Is this food a single specific ingredient (example, ground beef or lettuce) or multi-ingredient (example, hamburger sandwich, garden salad)?

• Single specific ingredient food

• Multi-ingredient food

Please answer the following questions about the identified ingredient/food:

3. What is the name of the suspected or confirmed ingredient / food vehicle? (ex., lettuce or garden salad) __________________________________________________________

4. Select the reason that best describes how this single specific ingredient or multi ingredient food was implicated in the outbreak (select only one):

• Suspected 1 - the outbreak agent was not identified but the ingredient / food is commonly associated with the type of agent suspected based on symptoms of the ill (For example: the symptoms of those ill suggested a bacterial, viral, or chemical agent and the ingredient is commonly associated with the agent type, such as Salmonella enteritis and eggs).

• Suspected 2 - a statistical significance was found for this ingredient / food that was consumed by those ill.

• Suspected 3 - the agent was laboratory confirmed based on clinical samples and the ingredient / food is commonly associated with agent.

• Suspected 4 – the agent was laboratory confirmed based on clinical samples and a statistical significance was found for this ingredient / food that was consumed by those ill.

• Confirmed 1 - the agent was laboratory confirmed in samples of an epidemiologically linked food samples. (See instructions regarding the exception to this definition)

• Confirmed 2 - the agent was laboratory confirmed based on clinical samples and a matching agent was found in food samples.

5. Which of the following best describes the food preparation process used for this specific ingredient or multi-ingredient food prior to consumption?

• Prep Serve: Did NOT involve a kill step. It may include heating commercially prepared foods for service.

• Cook Serve: Involved a kill step and may be followed by hot holding but is prepared for same-day service.

• Complex 1: Involved a kill step, followed by holding beyond same-day service.

• Complex 2: Involved a kill step, followed by holding and cooling.

• Complex 3: Involved a kill step, followed by holding, cooling, and re-heating

• Complex 4: Involved a kill step, followed by holding, cooling, re-heating, and freezing.

6. During the likely time the ingredient / food was prepared, were any events noted that appeared to be different from the ordinary operating circumstances or procedures as described by managers and / or workers?

• Yes

• No If No, skip to # 7

1. If yes, how would they be best characterized: (check all that apply)

• Differences with the ingredient(s) used, such as a different source for the ingredients, a different form (fresh instead of canned), or a substitution (red round tomatoes instead of cherry)

• Differences with how ingredient(s) were handled

• Differences with the method of preparation, cooking, holding, serving the food

• Differences with equipment used to handle the food

• Differences with equipment used to cook the food

• Differences with equipment used to store or hold the food

• Differences with cleaning and sanitizing food contact equipment

• Different employee involved in preparing, cooking, holding, and /or serving food

• Ill employees

• Ill family members

• Other (Please describe)

Ingredient Description:

Please answer the following questions separately for each ingredient identified as a suspected/confirmed vehicle in this outbreak. If a single specific ingredient, such as lettuce, is identified as the vehicle this form will be filled out once. For a multi-ingredient vehicle, such as garden salad, please fill out a separate sheet for EACH ingredient of the multi-ingredient food. If a single specific ingredient is identified as the vehicle the answer to #7 will be the same as #3. For a multi-ingredient food please put the name of the ingredient for which questions 8-10 will correspond.

7. Name of the single specific ingredient:___________________________________

8. Is the ingredient an animal product?

• Yes

• No If No, skip to # 9

1. Select the type of animal product (select only one):

• Beef Skip to #8d

• Poultry Go to #8b

• Pork Skip to #8d

• Lamb Skip to # 8d

• Miscellaneous meat (goat, rabbit) Skip to #8d

• Seafood Skip to # 8c

• Dairy Skip to # 8e

• Eggs Skip to # 8f

2. If Poultry, select the type (select only one) and skip to #8d:

• Chicken

• Turkey

• Duck

• Goose

• Other (Please describe) (ex: Ostrich, Emu, etc.) _______________________

3. If Seafood, select the type (select only one):

• Fin Fish (Please describe) _______________________­­­________(Ex: trout, bass, cod, mackerel)

• Shellfish (Please describe) _______________________­­­________(Ex: oysters)

• Crustaceans (Please describe) ____________________________(Ex: shrimp)

• Marine Mammals (Please describe) ________________________(Ex: Dolphin)

• Other seafood (Please describe)_____________________________________

4. For beef, poultry, pork, lamb, and seafood products select the best description of the product upon arrival at the foodservice establishment. (select only one):

• Raw, non-frozen

• Raw, frozen

• Raw, intended for raw service (ex; oysters, steak tartar)

• Commercially processed precooked: may require heating for palatability (examples include deli meat, hot dogs, ready to heat and eat chicken nuggets, canned ham, etc.)

• Commercially processed further cooking required (examples include chicken nuggets that require full cooking, pre-formed hamburger patties, etc.)

• Dried / Smoked

• Other (Please describe) _______________________________________________________

5. For dairy, select the best description of the product upon arrival at the foodservice establishment (select only one) and skip to question 9.

• Pasteurized fluid milk

• Non-pasteurized fluid milk

• Pasteurized dairy product (Please describe) __________________________________________

• Non-pasteurized dairy product (Please describe) ________________________________________

• Cheese (Please describe) ______________________________________________________________

6. For eggs, select the best description of the product upon arrival at the foodservice establishment (select only one):

• Non-pasteurized in-shell eggs

• Pasteurized in-shell eggs

• Pasteurized egg product (Please describe) _____________________________________________

• Non-pasteurized egg product (Please describe) _____________________________________

9. Is this ingredient a plant or plant product?

• Yes

• No If No, skip to #10

1. Select the type of plant product (select only one)

• Produce(Please describe) _____________________(Ex: Lettuce, Tomatoes, Potatoes, Sprouts, etc.) go to #9b

• Fruit (Please describe) _____________________________ (Ex: Apples, Bananas, Berries, Citrus, etc.) skip to #9c

• Fungi (Please describe) __________________________(Ex: Mushrooms) skip to #9c

• Nuts / Seeds(Please describe) ___________________________(Ex: Pecans, Peanuts, Sesame seeds) skip to #9c

• Grains / Cereals(Please describe) __________________(Ex: Rice, Wheat, Barley, Rye, Oats) skip to #9c

• Grain / Cereal Products(Please describe) _____________________( Ex: Bread, Pasta, etc.) skip to #9c

2. If Produce, select type (select only one):

   • Leafy Greens (Please describe) _____________________ (Ex: Iceberg, Romaine, Spinach)

   • Sprouts (Please describe) ___________________________ (Ex: alfalfa)

   • Root Vegetable (Please describe) ___________________ (Ex: Potatoes, Carrots, Garlic)

   • Vine or Above Ground Vegetable (Please describe fully) _________________________ (Ex: Asparagus, Beans/Red, Beans/Black, Corn, Cucumbers, Peppers/Jalapeno, Peppers/Red, Peppers/Green, Squash/Yellow, Squash/Spaghetti, Tomatoes/Red Round, Tomatoes/Cherry, Tomatoes/Grape etc.)

3. Provide the best description of the plant product upon arrival of the product to the foodservice establishment (select only one).

• Raw, whole, non-frozen, fresh (Ex: heads of lettuce, green beans, unshelled peas)

• Commercially processed fresh product (Ex: bagged lettuce, fresh chopped peppers, shelled nuts)

• Raw, frozen (Ex: Frozen corn, peas, strawberries, etc.)

• Commercially processed – canned, dried, other:

10. Was the ingredient described in question 8 or 9?

• Yes If Yes, skip #11

• No

1. Please describe the ingredient class/category? _________________________________________

11. Is any information present (product manifests, records, tags, etc.) that this ingredient is an imported food item?

• Yes

• No If No, skip to #12

1. Please describe the information used to indicate this is an imported food item (receipt information such as company, location of origin, lot number; tag numbers, etc.):

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. Comments: Provide any comments that would help describe the foods involved in this outbreak. Please make concise comments about the food flow when important information from your environmental assessment needs to be added.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part VI – sampling

1. Were any samples taken?

• Yes

• No If No, skip to Part VII, Contributing Factors

2. How many samples were taken? ________________________________

Sample Description:

Please answer the following questions separately for each sample taken in this outbreak. If only one sample was taken answer questions 3-6 once. For a multiple samples, please fill out questions 3-6 for EACH sample.

3. What type of sample was taken (check all that apply)?

• Environmental

• Specific Food Ingredient If specific food ingredient, skip to #5

• Multi-Ingredient Food If multi-ingredient food, skip to #5

4. If environmental, where was the sample taken from? _______________________________

5. What was the specific food or multi-ingredient food sampled? _________________________

6. Was an agent identified in the sample?

• Yes

• No If No, skip to #7

1. What was the identified agent?

• Hepatitis A

• Bacillus Cereus

• Campylobacter

• Clostridium Perfringens

• Cryptosporidium

• Cyclospora

• E. Coli 0157:H7

• Listeria

• Norovirus

• Salmonella

• Shigella

• Staphylococcus Aureus

• Vibrio Parahaemolyticus

• Yersinia

• Toxic Agent (Please describe) _ ____________________________________

• Other agent (Please describe) ____________________________________

• Chemical hazard (Please describe) __________________________________

• Physical hazard (Please describe) ____________________________________

2. Was a serotype of the agent identified?

• Yes (Please describe) _____________________________________

• No

3. Was a PFGE pattern identified for the agent identified?

• Yes (Please describe) _____________________________________

• No

7. Comments:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Part VII - contributing Factors (CF)

Article I.Were any contributing factors identified in this outbreak?

• Yes

• No (Answer #2 and #3 and end survey)

Article II.During the outbreak investigation, what activities were used to try to identify the contributing factors? (check all that apply)

• Routine environmental inspection

• Environmental Assessments

• Other environmental investigation (please describe:____________________________)

• Assumed based on etiology

• Interview of operator and/or food worker

• Environment/food sample culture

• Clinical samples / Syndrome

• Epidemiologic investigation (case-control or cohort study)

• Other (please describe:____________________________________________)

2. Please rate the quality of communication between the food regulatory program and the communicable disease control program during this outbreak investigation.

     

Very poor Poor Fair Good Very good There was no

Communication

Contamination Factors

Factors that introduce or otherwise permit contamination; contamination factors relate to how the etiologic agent got onto or into the food vehicle

3. Were any Contamination Factors identified in this foodborne illness outbreak?

• Yes

• No If No, skip to #5 (Proliferation/Amplification Factors)

1. How many Contamination Factors identified were in this foodborne illness outbreak? _________

Proliferation/Amplification Factors (bacterial outbreaks only)

Factors that allow proliferation of the etiologic agents; proliferation factors relate to how bacterial agents were able to increase in numbers and/or produce toxic products prior to the vehicle being ingested.

5. Were Proliferation/Amplification Factors identified in this foodborne illness outbreak?

• Yes

• No If No, skip to # 6 (Survival Factors)

1. How many Proliferation/Amplification Factors were identified in this foodborne illness outbreak? _______

Survival Factors (primarily microbial outbreaks)

Factors that allow survival or fail to inactivate the contaminant; survival factors refer to processes or steps that should have eliminated or reduced the microbial agent but did not because of one of these factors.

5. Were any Survival Factors identified in this foodborne illness outbreak?

• Yes

• No If No, skip to end

1. How many Survival Factors were identified in this foodborne illness outbreak? _____________

Contributing Factor Description:

Please answer the following questions separately for each contributing factor identified in this outbreak. If one contributing factor is identified, questions7-9 will be answered just once. If multiple contributing factors are identified, questions 7-9 will be answered for EACH contributing factor.

7. Which Contributing Factor was identified?

• C1

• C2

• C3

• C4

• C5

• C6

• C7

• C8

• C9

• C10

• C11

• C12

• C13

• C14

• C15 (Define)

• P1

• P2

• P3

• P4

• P5

• P6

• P7

• P8

• P9

• P10

• P11

• P12 (Define)

• S1

• S1

• S2

• S3

• S4

• S5

8. In your judgment, was this the primary Contributing Factor for this outbreak?

• Yes

• No

1. Briefly explain why this is a contributing factor in this outbreak.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. When did this factor most likely occur?

• Prior to vehicle entry into the foodservice establishment

• While the vehicle was at the foodservice establishment

• After the vehicle left the foodservice establishment

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