Shiga toxin producing E. coli

Form Approved
OMB No. 0920-XXXX (for CDC)
Exp. Date xx/xx/20xx

Foodborne Diseases Active Surveillance Network (FoodNet)
Data Analysis Request and Use Form
(Active Surveillance and Census Data)
Data Use Policy:

All data request fields must be completed and this agreement signed before foodborne disease data as collected and compiled by
the Foodborne Diseases Active Surveillance Network, Division of Foodborne, Waterborne, and Environmental Diseases, National
Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Centers for Disease Control and Prevention (CDC) can be
released.
By signing this agreement, I give the following assurances with respect to the use of the data provided.
I will refer third party requests for these data to the CDC Foodborne Diseases Active Surveillance Network
(FoodNet) staff.
I will not release the dataset or any part of it to any person other than those listed as collaborators in the attached
request or in future communications with CDC FoodNet staff.
I recognize that the data are not guaranteed to be without error. I also recognize that because of the dynamic
nature of the reporting surveillance system, reporting agencies can modify or delete past reports at any time,
even months or years after they are initially reported. Therefore, I acknowledge that the dataset accurately
represents the data present in the system on the date of download and is subject to change.
I recognize that requests for state-specific data may require additional review by the state(s). If requested, I
agree to obtain permission and maintain contact with at least one state health department representative for the
duration of my use of the data. The state health department representative must indicate that they approve this
data request by signing a copy of this data use agreement or through electronic communication.
I will not use these data except for statistical analysis and reporting as described in the attached request.
Any effort to determine the identity of any reported case is prohibited. I will not link these data files with
individually identifiable data from other sources.
All written and oral presentations of results of analyses will include an acknowledgement of the Foodborne
Diseases Active Surveillance Network, CDC as the source of data. [Suggested citation: CDC. Foodborne
Diseases Active Surveillance Network. Atlanta, GA: US Department of Health and Human Services, CDC. Data
received on mmddyy.]
All written and oral presentations will include the following disclaimer: "The findings and conclusions in this
report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease
Control and Prevention."
In the spirit of collaboration, I agree to keep the Foodborne Diseases Active Surveillance Network (FoodNet)
informed of the results of analyses. I understand that FoodNet staff may request periodic updates on the status of
this analysis, and I agree to provide these updates when requested.
I have carefully read and understand the above statements and I agree to comply with the above-stated requirements.

I agree to these terms and conditions

Name

Date

Public reporting burden of this collection of information is estimated to average 15 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).

Foodborne Diseases Active Surveillance Network (FoodNet)
Data Analysis Request and Use Form
(Active Surveillance and Census Data)
Date Requested:

Requester's Name:
Phone Number:
Affiliation:

E-mail:
CDC

USDA

FDA

FoodNet Site

Other (specify)

Research Question/Interest:

Intended use:

Conference abstract/presentation
Data for regulatory action
Student project/thesis/dissertation

Select pathogen(s):
All
Campylobacter
Cryptosporidium
Cyclospora
Listeria
Salmonella
Shigella
STEC O157
STEC non-O157
Vibrio
Yersinia
Select site (s):
All
California
Colorado
Connecticut
Georgia
Maryland
Minnesota
New Mexico
New York
Oregon
Tennessee

Publication
Other (describe)

Select variables:

Pregnant (Listeria)
International travel (2004-current)
Fetal outcome (Listeria)
Travel destination (2004-current)
Age
Underlying conditions (Listeria)
Dates of international travel
Sex
Mom-baby pair (Listeria)
(2004-current)
Race
Sterile site (Listeria)
Immigrate (2004-current)
Ethnicity
Where pathogen cultured
Specimen source
County
(Campy; 2009-current)
Specimen collection date
Hospitalization
Where pathogen speciated
Specimen collection month
(Campy; 2009-current)
Hospital dates
State lab received
CSTE case definition (Listeria and Crypto)
Length of hospital stay
State lab ID
Interview (2009-current)
Hospital transfer
Sent to CDC (2009-current)
Death
Culture-independent variables (2009-current)
Bloody diarrhea (2012-current)
Serogroup (Salmonella)
Diarrhea (2012-current)
Serotype/Species (specify below)
Fever (2012-current)
HUS (E.coli; 2010-current)
Date of illness onset (2009-current)
Outbreak-related (2004-current)
CDC outbreak ID (2004-current)
Specify year(s):
Outbreak type (2004-current)
Specify data detail: Individual records
Summary data (describe in comments)

Are you requesting census data?

Specify data format:
SAS
No

Excel

Other (specify):

Yes (specify years, age/sex/race groups):

Comments:

Modified 04/19/2012

Steering Committee Proposal
Centers for Disease Control and Prevention
Emerging Infections Program
Foodborne Diseases Active Surveillance Network (FoodNet)

Proposed by:

Title:
Date Submitted:
Purpose:

Proposal:

Data Sources:

Timeline:

Publication:

Please e-mail your completed form and direct any questions to: [email protected]
Submit by Email

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