Form CDC 52.12 CDC 52.12 National Outbreak Reporting System: Waterborne Disease T

General

National Outbreak Reporting System
Waterborne Disease Transmission

This form is used to report waterborne disease outbreaks. Pages 1-5 ask for the minimum or basic information about the outbreak investigation, epidemiological data, and clinical
specimen and water test results. These are followed by sections specific to the type of water exposure. Only 1 of the 5 water exposure sections should be completed.
Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA, 30333, ATTN: PRA (0920-0004) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESS
CDC USE ONLY

CDC Report ID

State Report ID

General Section
Primary Mode of Transmission

Form Approved
OMB No. 0920-0004

(Check one)

Food (Complete CDC 52.13)

Person-to-person (Complete CDC 52.13)

Water (Complete the tabs for General, Water-General, Water-

Environmental contamination other than food/water

Etiology & Lab, Water Samples and the type of water exposure)

(Complete CDC 52.13)

Animal contact (Complete CDC 52.13)

Other/Unknown (Complete CDC 52.13)

Investigation Methods

(Check all that apply)

Interviews only of ill persons
Case-control study
Cohort study
Food preparation review
Water system assessment: Drinking water
Water system assessment: Nonpotable water

Treated or untreated recreational water venue assessment
Investigation at factory/production/treatment plant
Investigation at original source (e.g., farm, water source, etc.)
Food product or bottled water traceback
Environment/food/water sample testing
Other

Comments

Dates (mm/dd/yyyy)
Date first case became ill (required)

Date last case became ill

Date of initial exposure

Date of last exposure

Date of report to CDC (other than this form)
Date of notification to State/Territory or Local/Tribal Health Authorities

Geographic Location
Reporting state:
Exposure occurred in multiple states
Exposure occurred in a single state but cases resided in multiple states
Other states:
Reporting county:
Exposure occurred in multiple counties in reporting state
Exposure occurred in a single county but cases resided in multiple counties in reporting state
Other counties:
City/Town/Place of exposure:
Do not include proprietary or private facility names

Primary Cases
Sex (Number or percent of the primary cases)

Number of primary cases
Lab-confirmed primary cases

# Male

#

%

Probable primary cases

# Female

#

%

Estimated total primary cases

# Unknown

#

%

Primary Case Outcomes

# Cases

Total # of case
for whom info
is available

Age (Number or percent of the primary cases)

Died

#

# <1 year

#

% 20–49 years

#

%

Hospitalized

#

# 1–4 years

#

% 50–74 years

#

%

Visited Emergency Room

#

# 5–9 years

#

%

#

%

Visited health care provider (excluding ER visits)

#

# 10–19 years

#

% Unknown

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

≥ 75 years

#

%
CS236498

1

General

Incubation Period, Duration of Illness, Signs or Symptoms for Primary Cases only
Incubation Period (Select appropriate units)
Duration of Illness (Among recovered cases-select appropriate units)
Shortest

Min, Hours, Days

Shortest

Min, Hours, Days

Median

Min, Hours, Days

Median

Min, Hours, Days

Longest
Total # of cases for whom info is available

Min, Hours, Days

Longest
Total # of cases for whom info is available

Min, Hours, Days

Unknown incubation period

Unknown duration of illness

Signs or Symptoms
Feature
Vomiting
Diarrhea
Bloody stools
Fever

# Cases with signs or symptoms

Total # cases for whom info available

Abdominal cramps
HUS
Asymptomatic

Secondary Cases
Number of Secondary Cases

Mode of Secondary Transmission (Check all that apply)
Food
Water
Animal contact
Person-to-person
Environmental contamination other than food/water
Other/Unknown

Lab-confirmed secondary cases

#

Probable secondary cases

#

Estimated total secondary cases

#

Estimated total cases (Primary + Secondary)

#

Environmental Health Specialists Network (If applicable)
EHS-Net Evaluation ID: 1.)

2.)

3.)

4.)

Traceback (For food and bottled water only, not public water)
Please check if traceback conducted
Source name

(if publicly available)

Source type

(e.g. poultry farm, tomato
processing plant, bottled
water factory)

Location of source
State

Traceback Comments

Country

Recall
Please check if any food or bottled water product was recalled
Type of item recalled:
Comments:

Reporting Agency
Agency name:

E-mail:

Contact name:

Phone no.:

Contact title:

General Remarks

CDC 52.12 Rev. 2 2013

Fax no.:
Briefly describe important aspects of the outbreak not covered above. Please indicate if any adverse outcomes occurred in special
populations (e.g., pregnant women, immunocompromised persons)

National Outbreak Reporting System

CS236498

2

Water-General

Water - General section

Type of Water Exposure (Check ONE box)
Treated recreational water (e.g., in manufactured venues such as pools, spas/whirlpools, hot tubs, spray pads, at-home kiddie pools)
Untreated recreational water (e.g., water in natural venues such as a freshwater lakes, hot springs, marine beaches/oceans)
Drinking water in public or individual water systems (e.g., municipal system, private well, commercially-bottled water, water kiosk), regardless
of the exposure pathway (i.e., not limited to ingestion).
Other water (e.g., cooling/industrial, water reuse, irrigation, occupational, decorative/display; includes water consumed from sources such as
back-country streams)
Unknown water uses (i.e., the intended purpose or use of the water is unknown or the water exposure category could not be determined)

Epidemiologic Data
1. Estimated total number of persons with primary water exposure:
2. Were data collected from comparison groups to estimate risk?
If No or Unknown, was water the common source
shared by persons who were ill?
Exposure in epidemiologic investigation Total #
(e.g., pool, waterpark,
Exposed
hot spring, well water)
(A)

Yes (specify in table below)

No

Unknown

Yes

No

Unknown

# Ill
Total # Not # Ill Not
Exposed
Exposed Exposed
(B)

Attack rate for residents of reporting state:

%

p-Value

(provide exact
value)

Symptoms/Conditions

Percent of ill persons (primary cases) living in reporting state:

%

Associated Events
Was exposure associated with a specific event or gathering?
No

Relative
Risk

95% Confidence
Interval

Attack rate for non-residents of reporting state:

Geographic Location

Yes

Attack
Odds
Rate (%) Ratio
(B/A)

Unknown

If Yes, what type of event or gathering was involved?

%

Route of Entry

For each category, indicate the
# of ill persons (primary cases)
with:
Gastrointestinal symptoms/
conditions

Ingestion

Respiratory symptoms/
conditions

Contact

Skin symptoms/conditions

Inhalation

Ear symptoms/conditions
Eye symptoms/conditions
Neurologic symptoms/
conditions
If outbreak occurred during a defined event, dates of event:
Start date:

CDC 52.12 Rev. 2 2013

Unknown

Wound infections

End date:
(mm/dd/yyyy)

Other, specify:

Other, specify (e.g.,
hepatitis A, leptospirosis):

(mm/dd/yyyy)

National Outbreak Reporting System

CS236498

3

Water-Etiology & Lab

Outbreak Etiology

(Report the confirmed and/or suspected etiological agent(s) here, even if no clinical specimens were tested)

Confirmed Genus/ Chemical/ Toxin
as Etiology?

Species

Serotype/ Serogroup/
Serovar

Genotype/ Subtype Detected In* Total # People Total # People
(list all
Tested
Positive
that apply)

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
* 1-Clinical Specimens, 2-Water Samples, 3-Clinical Specimens & Water Samples, 4-Other (describe in the general remarks), 5-Unknown, 6-None

Outbreak Isolates (Links data about molecular characterization across multiple systems. For each pathogen, provide a representative for each
distinct molecular designation)
Which CDC system contains this
isolate profile? (e.g., PulseNet,

CaliciNet)

CDC Lab System Outbreak
Number (e.g., PulseNet

State Lab ID

(i.e., Lab tracking number)

Molecular Designation 1

Molecular Designation 2

tracking number)

Clinical Specimens
Yes

1. Were clinical diagnostic specimens taken from persons?

No

Unknown

If Yes, from how many persons were specimens taken?
Specimen Type†

Specimen Subtype§

Tested for ¶ (list all that apply)

†
Specimen Type: 1- Autopsy Specimen (specify subtype), 2-Biopsy (specify subtype), 3-Blood, 4-Bronchial Alveolar Lavage (BAL), 5-Cerebrospinal Fluid (CSF), 6-Conjunctiva/Eye Swab,
7-Ear Swab, 8-Endotracheal Aspirate, 9-Saliva, 10-Serum, 11-Skin Swab, 12-Sputum, 13-Stool, 14-Urine, 15-Vomitus, 16-Wound Swab, 17-Other (describe in the general remarks), 18-Unknown
§

Specimen Subtype: 1-Bladder, 2-Brain, 3-Dura, 4-Hair, 5-Intestine, 6-Kidney, 7-Liver, 8-Lung, 9-Nails, 10-Skin, 11-Stomach, 12-Wound, 13-Other, 14-Unknown

¶

Tested for: 1-Bacteria, 2-Chemicals/Toxins, 3-Fungi, 4-Parasites, 5-Viruses, 6-Other (describe in general remarks), 7-Unknown

Test Types

(Select all test types used for clinical specimens)

Culture

Phage Typing

DNA or RNA Amplication/Detection (e.g., PCR, TR-PCR)

Chemical Testing

Microscopy (e.g., fluorescent, EM)

Tissue Culture Infectivity Assay

Serological/Immunological Test (e.g., EIA, ELISA)

Unknown

Other (describe in the general remarks)
CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

4

Water Samples

Water Samples (Provide representative data about water quality testing, chemical or pathogen testing. Additional sample data can be described in
the remarks or attached)
Was water tested?
Results

Yes (specify in table below)

Sample Number
Source of Sample

No

Unknown

1

2

3

4

5

(e.g., swimming pool, lake)

Additional Description

(e.g., time of day, location of sample collection)

Date (mm/dd/yyyy)
Volume Tested
Temperature
Residual/Free Disinfectant Level

(if total and combined disinfectant
levels given, total - combined = free)

Combined Disinfectant Level

(if total and free disinfectant levels
given, total - free = combined)

Number
Unit
Number
Unit
Number
Unit
Number
Unit

pH
Turbidity (NTU)

Water Samples - Water Quality Indicators (Might not be applicable for treated recreational water samples)
Sample
Number

Type (e.g., fecal coliforms)

Concentration (numerical value)

Water Samples - Microbiology or Chemical/Toxin Analysis

Unit

(Provide both positive and negative test results)

Sample
Number

Genus/ Chemical/ Toxin

Species

Serotype/ Serogroup/ Serovar Genotype/ Subtype

PFGE Pattern

Sample
Number

Test Results Positive?

Concentration

Unit

Test Method (reference: National

(numerical value)

Test Type*

Environmental Methods Index:
http://www.nemi.gov)

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
* Test Type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing,
6-Chemical Testing, 7-Tissue Culture Infectivity Assay, 8-Other (describe in the general remarks), 9-Unknown

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

5

Rec Water-Treated

Recreational Water – Treated Venue
Implicated Water - Recreational Water Venue Description
Venue Number

(use this number to
link the venue with
water treatment or fill
water data below)

Water Venue

Water Venue Subtype

Setting of Exposure

(e.g., spa/whirlpool/hot tub;
pool- swimming pool; pool- waterpark)

(select indoor, outdoor, or
unknown)

USUAL Water Treatment
Provided at Venue

Venue Treatment Subtype

Chlorination Subtype

Fill Water Type

IF PUBLIC WATER WAS USED
TO FILL, USUAL Water Treatment
Provided for Fill Water Before
Coming to the Venue

IF PUBLIC WATER WAS USED TO FILL,
Fill Water Treatment Subtype

(e.g., club, requiring membership;
hotel/motel/lodge/inn; waterpark)

1
2
3
4
5
6

Venue Number

(Reference the
appropriate Venue
Number from above)

Venue Number

(Reference the
appropriate Venue
Number from above)

(e.g., no treatment; coagulation;
disinfection; flocculation; filtration
(pool); unknown)

(e.g., public water supply; sea water;
untreated ground or surface water;
unknown)

(disinfection or pool filtration: e.g., UV;
chlorine dioxide; bag filter; cartridge filter;
unknown)

(chlorine disinfection only: e.g., gaseous;
sodium hypochlorite; cyanurates /stabilized
chlorine)

(disinfection or filtration: e.g., UV; chlorine
dioxide; bag filter; cartridge filter; unknown)

(e.g., no treatment; disinfection;
filtration (treatment plant); unknown)

Recreational Water Quality
Did the venue meet state or local recreational water quality regulations?

Yes

No

Unknown

Yes

No

Unknown

Not applicable

If No, explain:

Was there a pool operator on the payroll with state-approved
training or certification?
CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

6

Rec Water-Treated

Factors Contributing to Recreational Water Contamination and/or Increased Exposure in Treated Venues
Documented/
Observed†

POLICY AND
MANAGEMENT

MAINTENANCE

FACILITY
DESIGN

PEOPLE

Contributing Factors (Check all that apply)*

Suspected†

Exceeded maximum bather load
Primary intended use of water is by diaper/toddler-aged children (e.g., kiddie pool)
Heavy use by child care center groups
Fecal/vomitus accident
Patrons continued to swim when ill with diarrhea
Operator error
Intentional contamination (explain in remarks)
Combined pool filtration/recirculation systems led to cross-contamination
Hygiene facilities (e.g., toilets, diaper changing facilities) inadequate or distant
Some spray feature water bypasses filtration/treatment system and returns to feature unfiltered/untreated
No supplemental disinfection installed that would have inactivated pathogen (e.g., Cryptosporidium)
Water temperature ≥30°C (≥86°F)
Cross-connection with wastewater or non-potable water
Disinfectant control system malfunctioning, inadequate, or lacking (e.g., hand feed chemicals)
Incorrect settings on disinfectant control system
pH control system malfunctioning, inadequate, or lacking (e.g., hand feed chemicals)
Incorrect settings on pH control system
Filtration system malfunctioning or inadequate (e.g., low flow rate)
Supplemental disinfection system malfunctioning or inadequate (e.g., ultraviolet light, ozone)
Insufficient system checks so breakdown detection delayed
No preventive equipment maintenance programs to reduce breakdowns
Ventilation insufficient for indoor aquatic facilities
Chemical handling error (e.g., chemical hookup, improper mixing or application)
Maintenance chemicals not flushed from system before opening to swimmers
Recirculation pump off or restarted with swimmers in water
Low or zero water flow combined with continuous feed of chemicals resulted in excess chemicals in water
Extensive slime/biofilm formation
Recent construction
Cyanurate level excessive
Lack of draining/cleaning
Stagnant water in spa piping was aerosolized
No aquatics operators on payroll who have completed state/local training
Untrained/inadequately trained staff on duty
Remote monitoring system replaces on-site water quality testing
Unclear communication chain for reporting problems
Inadequate water quality monitoring (e.g., inadequate test kit, inadequate testing frequency)
Employee illness policies absent or not enforced
No or inadequate policies on good chemical handling and storage practices
No operator on duty at the time of incident
Facility falls outside aquatic health code
No shock/hyperchlorination policy
Other, specify:
Unknown

* Only check off what was found during investigation.
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.

†

Remarks

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

7

Rec Water-Untreated

Recreational Water – Untreated Venue
Implicated Water - Recreational Water Venue Description
Water Venue
(e.g., canal; lake; river/stream; ocean)

IF SPRING OR HOT SPRING, Water Venue Subtype (select indoor, outdoor or unknown)

Setting of Exposure
(e.g., beach-public; camp/cabin/recreational area)

Recreational Water Quality
Did the venue meet state or local recreational water
quality regulations?
Yes

No

Unknown

Did the venue meet Environmental Protection Agency (EPA)
recreational water quality standards?

Not applicable

If No, explain:

Yes

No

Unknown

Not applicable

If No, explain:

Factors Contributing to Recreational Water Contamination and/or Increased Exposure in Untreated Venues
Documented/
Observed†

POLICY AND
MANAGEMENT

WATER QUALITY

SWIM AREA
DESIGN

PEOPLE

Contributing Factors (Check all that apply)*

Suspected†

Exceeded maximum bather load
Primary intended use of water is by diaper/toddler aged children (e.g., kiddie pool)
Heavy use by child care center groups
Fecal/vomitus accident
Patrons continued to swim when ill with diarrhea
Staff error
Intentional contamination (explain in remarks)
Hygiene facilities (e.g., toilets, diaper changing facilities) inadequate or distant
Malfunctioning or inadequate on-site wastewater treatment system § ¶
Poor siting/design of on-site wastewater treatment system § ¶
Stagnant or poorly circulating water in swim area
Heavy rainfall and runoff
Sanitary sewer overflow (SSO) impact §
Combined sewer overflow (CSO) impact§
Domestic animal contamination (e.g., livestock, pets)
Wildlife contamination - Birds
Wildlife contamination - Mammals
Wildlife contamination - Fish kill
Wastewater treatment plant effluent flows past swim area
Wastewater treatment plant malfunction §
Sewer line break §
Nearby biosolid/land application site (e.g., human or animal waste application)
Contamination from agricultural chemical application (e.g., fertilizer, pesticides)
Contamination from chemical pollution not related to agricultural application
Water temperature ≥30°C (≥86°F)
Seasonal variation in water quality (e.g., lake/reservoir turnover events)
Inappropriate dumping of sewage into water body (e.g., from boat, RV)
Algal bloom
Dumping of ballast water
Tidal wash (i.e., tide exchange or influence by inland water)
No or inadequate monitoring of water quality
No managers have completed state/local required training
Untrained/inadequately trained staff on duty
Unclear communication chain for reporting problems
Employee illness policies absent or not enforced
Other, specify:
Unknown

* Only check off what was found during investigation.
†

“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.

§

The release of sewage does not have to occur at the property/venue/setting where the people were exposed. The sewage may have occurred at a distant site but still affected the
property/venue/setting in question.

¶
“On-site wastewater treatment system” refers to a system designed to treat and dispose of wastewater at the point of generation, generally on the property where the wastewater is generated (e.g.,
septic systems or other advanced on-site systems). However, contamination that originates from these systems can still occur off the property where treatment and disposal takes place due to
migration of contaminants from malfunctioning systems or poor siting and design.

Remarks

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

8

Drinking Water

Drinking Water
Implicated Water - Drinking Water System Description
Water System*

(e.g., commerciallybottled water,
community water
system, individual
water system)

Public Water
System EPA
ID Number†

Water Source

(select ground
water, surface
water or
unknown)

Water Source
Description

(e.g., spring; well;
lake)

Setting of
Exposure

USUAL Water
Treatment Provided
(e.g., no treatment,
disinfection, home
filtration)

(e.g., airport,
mobile home
park)

Water Treatment
Subtype (disinfection or

filtration: e.g., boiling;
chlorine; rapid sand
filter; reverse osmosis)

* Water system definitions: Community and noncommunity water systems are public water systems that have ≥ 15 service connections or serve an average of ≥ 25 residents for ≥ 60 days/year. A community water system serves year-round residents of a community, subdivision, or mobile home park. A noncommunity water system serves an institution, industry, camp, park, hotel, or business and
can be nontransient or transient. Nontransient systems serve ≥ 25 of the same persons for > 6 months of the year but not year-round (e.g., factories and schools), whereas transient systems provide
water to places in which persons do not remain for long periods (e.g., restaurants, highway rest stations, and parks). Individual water systems are small systems not owned or operated by a water utility
that have < 15 connections or serve < 25 persons.
†

Number used for EPA reporting that uniquely identifies the water system within a specific state. The water system ID number can be found at http://www.epa.gov/safewater/dwinfo/index.html by first
selecting a state and then selecting a county.

Drinking Water Quality
Did the drinking water system have any monitoring violations in the 1 month prior to the outbreak?
Yes

No

Unknown

Not applicable

If Yes, explain:

Did the drinking water system have any maximum contaminant level (MCL) violations in the 1 month prior to the outbreak?
Yes

No

Unknown

Not applicable

No

Unknown

Not applicable

If Yes, explain:

Did the drinking water system have any violations in the 12 months prior to the outbreak?§
Yes

If Yes, explain:

§
Sources of information about past violations can be obtained from utility records, consumer confidence reports (water quality reports), or violation
records from state or local health departments
CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

9

Drinking Water

Factors Contributing to Drinking Water Contamination and/or Increased Exposure to Contaminated Drinking Water
1. Did a problem with the source water (i.e., ground water or surface water) contribute to the disease or outbreak?
Yes (specify in table below)

No

Unknown

Documented/
Observed†

Source Water Contributing Factors (Check all that apply)*

Suspected†

Sanitary sewer overflow (SSO) §
Combined sewer overflow (CSO) §
Malfunctioning on-site wastewater treatment system § ¶
Sewage treatment plant malfunction §
Sewer line break §
Poor siting/design of on-site wastewater treatment system § ¶
Nearby biosolid/land application site (e.g., human or animal waste application)
Contamination from agricultural chemical application (e.g., fertilizer, pesticides)
Contamination from chemical pollution not related to agricultural application
Contamination by a chemical that the current treatment methods were not designed to remove
Domestic animal contamination (e.g., livestock, concentrated feeding operations, pets)
Wildlife contamination - Birds
Wildlife contamination - Mammals
Wildlife contamination - Fish kill
Flooding/heavy rains
Algal bloom
Seasonal variation in water quality (e.g., lake/reservoir turnover events, resort community with seasonal loading)
Low water table (e.g., drought, over-pumping)
Ground water under direct influence of surface water (e.g., shallow well)**
Contamination through limestone or fissured rock (e.g., karst)
Contaminated recharge water
Use of an alternate source of water by a water utility
Mixing of raw water from different sources
Improper construction or location of a well or spring
Water system intake failure (e.g., cracked well casing, cracked intake pipe)
Intentional contamination (explain in remarks)
Other, specify:
Unknown

Factors Contributing to Drinking Water Contamination and/or Increased Exposure to Contaminated Drinking Water
2. Did a problem with the water treatment prior to entry into a house or building contribute to the disease or outbreak?
Yes (specify in table below)

No
Documented/
Observed†

Treatment Contributing Factors (Check all that apply)*

Unknown
Suspected†

Change in treatment process (explain in remarks)
No disinfection
Temporary interruption of disinfection
Chronically inadequate disinfection
No filtration
Inadequate filtration
Deficiencies in other treatment processes
Corrosion in or leaching from pipes or storage tanks
Pipe/component failure or break (e.g., pipes, tanks, valves)
Contamination during construction or repair of pipes/components
Construction or repair of pipes/components without evidence of contamination
Operator error
Other, specify:
Unknown
* Only check off what was found during investigation.
†

“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.

§

The release of sewage does not have to occur on the property in which persons have become ill. The sewage release may have occurred at a distant site but still affected the property in question.

¶

“On-site wastewater treatment system” refers to a system designed to treat and dispose of wastewater at the point of generation, generally on the property where the wastewater is generated
(e.g., septic systems or other advanced on-site systems). However, contamination that originates from these systems can still occur off the property where treatment and disposal takes place due to
migration of contaminants from malfunctioning systems or poor siting and design.
** Any water beneath the surface of the ground with substantial occurrence of insects or other macroorganisms, algae, or large-diameter pathogens (e.g., Giardia intestinalis or Cryptosporidium), or
substantial and relatively rapid shifts in water characteristics (e.g., turbidity, temperature, conductivity, or pH) that closely correlate with climatologic or surface water conditions. Direct influence must
be determined for individual sources in accordance with criteria established by the state.

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

10

Drinking Water

3. Did a problem with the distribution system contribute to the disease or outbreak?

Yes (specify in table below)

No

Unknown

(NOTE: For a community water system, the distribution system refers to the pipes and storage infrastructure under the jurisdiction of the water utility
prior to the water meter (or property line if the system is not metered). For noncommunity and nonpublic water systems, the distribution system refers to
the pipes and storage infrastructure prior to entry into a building or house)
Documented/
Observed†

Distribution and Storage Contributing Factors (Check all that apply)*

Suspected†

Cross-connection of potable and nonpotable water pipes resulting in backflow
Low pressure or change in water pressure in the distribution system
Change in water flow direction in the distribution system
Mixing of treated water from different sources
Pipe/component failure or break (e.g., pipes, tanks, valves)
Corrosion in or leaching from pipes or storage tanks
Contamination of mains during construction or repair
Construction or repair of mains without evidence of contamination
Scheduled flushing of the distribution system
Contamination of storage facility
Aging water distribution components (e.g., pipes, tanks, valves)
Water temperature ≥30°C (≥86°F)
Intentional contamination (explain in remarks)
Other, specify:
Unknown

4. Did a problem occur after the water meter or outside the jurisdiction of a water utility that contributed to the disease or outbreak?
(e.g., in a service line leading to a house/building, in the plumbing inside a house/building, during shipping/hauling, during storage
other than in the distribution system, at the point of use, involving commercially-bottled water)
Yes (specify in table below)
Factors Not Under the Jurisdiction of a Water Utility or Contributing Factors at the Point of Use (Check all that apply)*

No
Documented/
Observed†

Unknown
Suspected†

Legionella species in water system
Cross-connection of potable and nonpotable water pipes resulting in backflow
Lack of backflow prevention in plumbing
Low pressure or change in water pressure in the plumbing
Change in water flow direction in the plumbing
Corrosion in or leaching from pipes or storage tanks
Pipe/component failure or break (e.g., pipes, tanks, valves)
Aging plumbing components (e.g., pipes, tanks, valves)
Contamination of plumbing during construction or repair
Construction or repair of plumbing without evidence of contamination
Deficiency in building/home-specific water treatment after the water meter or property line
Deficiency or contamination of equipment/devices using or distributing water
Contamination during commercial bottling
Contamination during shipping, hauling, or storage
Contamination at point of use – Tap
Contamination at point of use – Hose
Contamination at point of use – Commercially-bottled water
Contamination at point of use – Container, bottle, or pitcher
Contamination at point of use – Unknown
Water temperature ≥30°C (≥86°F)
Intentional contamination (explain in remarks)
Other, specify:
Unknown
* Only check off what was found during investigation.
†

“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.

Remarks

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

11

Other or Unknown Water

Other or Unknown Water
Intent for Use
What was the intended use for the implicated water? (check all that apply)
Cooling/Air Conditioning (e.g., cooling tower, swamp cooler)
Industrial/Occupational (e.g., steam cleaner)
Mister (e.g., produce in grocery store, public cooling system)
Agricultural Irrigation
Ornamental (e.g., a decorative non-interactive fountain
Waste water
intended for public display and not designed for swimming
Other (specify):
or recreational use)
Unknown
Implicated Water - Water Description
Water Type

(e.g., cooling tower; drainage ditch;
fountain- ornamental)

Setting of Exposure

USUAL Water Treatment Provided

(e.g., airport; hospital/health care facility,
nursing home; park- state park)

(e.g., no treatment; disinfection;
settling/sedimentation)

Water Treatment Subtype

(disinfection or filtration: e.g., boiling;
chlorine; rapid sand filter; reverse
osmosis)

Factors Contributing to Contamination and/or Increased Exposure to Contaminated Water
Documented/
Observed†

Contributing Factors (Check all that apply)*

Suspected†

Cooling tower/evaporative condenser – shutdown for >3 days without draining to waste
Cooling tower/evaporative condenser – lack of a maintenance program
Cooling tower/evaporative condenser – lack of a qualified water quality specialist
Cooling tower/evaporative condenser – presence of scale or corrosion
Cooling tower/evaporative condenser – presence of dirt, organic matter, or other debris in the cold water basin
Cooling tower/evaporative condenser – absence of drift eliminators
Cooling tower/evaporative condenser – presence of damaged drift eliminators
Cooling tower/evaporative condenser – history of recent repairs to the device
Cooling tower/evaporative condenser – siting of device near building air intakes
Cooling tower/evaporative condenser – siting of device near windows that can be opened
Cooling tower/evaporative condenser – siting of device in immediate area of kitchen exhaust fans, live plants, truck bays,
or other sources of organic matter
Cooling tower/evaporative condenser – construction on the premises of the device within 6 months before the index case
Cooling tower/evaporative condenser – construction within 100 meters of the premises of the device within 6 months
before the index case
Ornamental fountain – presence of submerged lighting
Ornamental fountain – lack of a written cleaning and maintenance program
Ornamental fountain – presence of dirt, organic matter, or other debris in the water basin
Ornamental fountain – intended as an ornamental fountain but utilized as an interactive fountain
Ornamental fountain – inadequate disinfection for recreational use
Ornamental fountain – inadequate filtration for recreational use
Broken/damaged sewer pipe
Recycling of water
Water temperature ≥30°C (≥86°F)
Other, specify:
Unknown
* Only check off what was found during investigation.
†

“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no
documentation (as defined previously) is available.

Remarks

CDC 52.12 Rev. 2 2013

National Outbreak Reporting System

CS236498

12