NEARS Data Recording Instrument

Form Approved

OMB No. 0920-0980

Exp. Date xx/xx/xxxx

Attachment 6 - NEARS Data Recording Instrument

Note: Throughout the data collection instrument, most questions allow for the selection of only one answer choice. However, some questions allow the selection of multiple answer choices and are denoted with the statement (check all that apply) in the question.

Part I – General Characterization of the 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 #3

 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/Townships/Parishes

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? __________________

Public reporting burden for this collection of information is estimated to average 30 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, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-0980)

5. Were any environmental assessments conducted at food service establishments in your jurisdiction as a part of this outbreak?
 Yes

 No If No, skip to #5c

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

__________________________________________________________________________

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

c. Why were no environmental assessments conducted at food service 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

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

b. 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 to #8

a. What was the identified agent?

 Hepatitis A

 Bacillus cereus

 Campylobacter

 Clostridium perfringens

 Cryptosporidium

 Cyclospora

 E. coli 0157:H7

 E. coli STEC/VTEC

 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)

Was the agent identified suspected or confirmed?

 Suspected

 Confirmed

b. Was a serotype identified for this outbreak?

 Yes

 No If No, skip to #8

c. 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

a. 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 (Establishment Description, Categorization, and Menu Review)

a. Select the national surveillance system(s) where this outbreak was reported and record the corresponding reporting number. (check all that apply)
 NORS – reporting number? _______________________________

 PulseNet – outbreak code? __________________________________

 CaliciNet – reporting number? _____________________________

 NNDSS – reporting number? ______________________________

 Other (Please describe):___________________________________________________

Part II – Establishment Description, Categorization, and Menu Review

1. Date the establishment was identified for an environmental assessment (MM/DD/YYYY): __/____/____

2. Date of first contact with establishment management (MM/DD/YYYY): ___/ __/_______

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

4. Number of contacts with the establishment other than visits (for example, 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 Food Service

 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

a. 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

a. 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 (for example, oysters or shell eggs) in any menu item?
 Yes

 No If No, skip to #14

a. 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

b. 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 (nonethnic)

 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 establishment’s hours of operation if at all possible. Please answer the following questions by observation of the item in question. If you are not able to answer a question, skip it.

1. Date observations were made (MM/DD/YYYY): ________/_______/__________

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

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

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

 Yes

 No (Please specify number without _____ )

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

 Yes

 No (Please specify number without _____ )

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

 Yes

 No (Please specify number without _____ )

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

 Yes

 No If No, skip to #4

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

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

 Yes

 No (Please specify number without _____ )

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

 Yes

 No (Please specify number without _____ )

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

 Yes

 No (Please specify number without _____ )

4. Are there cold storage units in the establishment?

 Yes

 No If No, skip to #6

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

b. 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 units maintained at a temperature of 41°F or below?

 Yes If Yes, skip to #6

 No

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

b. 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

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

 No

8. Are any food workers handling ready-to-eat foods with bare hands?
 Yes

 No

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

 No

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

 No

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

a. Please describe the evidence of cross contamination observed. ______________________________________________________________________________________________________________________________________________

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

a. 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

 Using ice as an ingredient

 Using ice bath for food container before cooling in regular cooler

 Using ice bath for food container before cooling in blast chiller

 Using ice wands before cooling in regular cooler

 Using ice wands before cooling in blast chiller

 Combining methods (ice, ice wand, portioning, etc.) with cooling in regular cooler

 Combining 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

a. Were the temperatures of any foods in hot holding measured?
 Yes

 No If No, skip to #14

b. Were the temperatures of all foods measured in hot holding at 135°F or above?
 Yes

 No

14. Were any foods observed in cold holding?

 Yes

 No If No, skip to #15

a. Were the temperatures of any foods in cold holding measured?
 Yes

 No If No, skip to #15

b. 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

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

 Yes

 No If No, skip to #16

b. 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

a. 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

a. Does the wash cycle reach the temperatures recommended for that washing machine?  Yes

 No

b. Does the sanitizing cycle reach the temperatures recommended for sanitization?  Yes

 No

 Could Not Observe

c. Is chemical sanitizing used?  Yes

 No If No, skip to #18

d. 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

a. 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

b. 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

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

 Yes

 No

b. What languages did you observe on signs or instructions posted for food workers? (Check all that apply)

 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 in #20a

 No If No, skip to #21 Comments

a. 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 are 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

a. If No, explain why food was the suspected vehicle in this outbreak and skip to Part VI (Sampling). __________________________________________________________________________________________________________________________________________________________

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

 Single specific ingredient food

 Multi-ingredient food

Please answer questions 3-6 about the identified ingredient/food:

3. What is the name of the suspected or confirmed ingredient/food vehicle? (for example, 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 the Part V of the NVEAIS Instruction Manual about 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 before 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 reheating

 Complex 4: Involved a kill step, followed by holding, cooling, reheating, 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

a. 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 tomatoes)

 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 # 7-11 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, fill this form out once. If a single specific ingredient is identified as the vehicle, the answer to #7 will be the same as the answer to #3.

For a multi-ingredient vehicle, such as garden salad, please fill out a separate sheet for EACH ingredient of the multi-ingredient food. For a multi-ingredient food, the answer to #7 will be the specific name of the ingredient addressed in the answers to #8-10.

7. Name of the single specific ingredient:___________________________________

8. Is the ingredient an animal product?

 Yes

 No If No, skip to #9

a. 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

b. If poultry, select the type (select only one) and skip to #8d:  Chicken

 Turkey

 Duck

 Goose

 Other (Please describe; for example: ostrich, emu, etc.) _______________________

c. If seafood, select the type (select only one):  Fin Fish (Please describe; for example: trout, bass, cod, mackerel) _______________________

 Shellfish (Please describe; for example: oysters) _____________________________________

 Crustaceans (Please describe; for example: shrimp) __________________________________

 Marine Mammals (Please describe; for example: dolphins) _____________________________

 Other Seafood (Please describe)_____________________________________

d. 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, nonfrozen

 Raw, frozen

 Raw, intended for raw service (for example, oysters, steak tartar)

 Commercially processed precooked: may require heating for palatability (examples include various types of deli meat, deli-sliced ham, or canned spam; hot dogs; fully cooked frozen fish sticks that are heated for service, etc.)

 Commercially processed further cooking required (examples include chicken nuggets that require full cooking, preformed hamburger patties, etc.)

 Dried/Smoked

 Other (Please describe) _______________________________________________________

e. For dairy, select the best description of the product upon arrival at the food service establishment (select only one) and skip to #9.  Pasteurized fluid milk

 Unpasteurized fluid milk

 Pasteurized dairy product (Please describe) _________________________________________

 Unpasteurized dairy product (Please describe) _____________________________________

 Cheese (Please describe) _______________________________________________________

f. For eggs, select the best description of the product upon arrival at the food service establishment (select only one):  Unpasteurized in-shell eggs

 Pasteurized in-shell eggs

 Pasteurized egg product (Please describe) _________________________________________

 Unpasteurized egg product (Please describe) _____________________________________

9. Is this ingredient a plant or plant product?  Yes

 No If No, skip to #10

a. Select the type of plant product (select only one):  Produce (Please describe; for example: lettuce, tomatoes, potatoes, sprouts) __________________________________ Skip to #9b

 Fruit (Please describe; for example: apples, bananas, berries, citrus) __________________________________ Skip to #9c

 Fungi (Please describe; for example: mushrooms) __________________________________ Skip to #9c

 Nuts/Seeds (Please describe; for example: pecans, peanuts, sesame seeds) __________________________________ Skip to #9c

 Grains/Cereals (Please describe; for example: rice, wheat, barley, rye, oats) __________________________________ Skip to #9c

 Grain/Cereal Products (Please describe; for example: bread, pasta) __________________________________ Skip to #9c

b. If produce, select type (select only one):  Leafy Greens (Please describe; for example: iceberg, romaine, spinach) ________________________

 Sprouts (Please describe; for example: alfalfa) ___________________________

 Root Vegetable (Please describe; for example: potatoes, carrots, garlic) ________________________

 Vine or Aboveground Vegetable (Please describe fully) _________________________ (For example: asparagus, beans/red, beans/black, corn, cucumbers, peppers/jalapeno, peppers/red, peppers/green, squash/yellow, squash/spaghetti, tomatoes/red round, tomatoes/cherry, tomatoes/grape)

c. Provide the best description of the plant product upon arrival of the product to the food service establishment (select only one).  Raw, Whole, Nonfrozen, Fresh (for example: heads of lettuce, green beans, unshelled peas)

 Commercially Processed Fresh Product (for example: bagged lettuce, fresh chopped peppers, shelled nuts)

 Raw, Frozen (for example: Frozen corn, peas, strawberries, etc.)

 Commercially Processed – Canned, Dried, Other

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

 Yes If Yes, skip #11

 No

a. Please describe the ingredient class/category: _________________________________________

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

 Yes

 No If No, skip to #12

a. 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? _______________

Individual Sample Description

Please answer #3-#5 separately for each sample taken in this outbreak.

If only one sample was taken, answer #3-#5 once.

For multiple samples, fill out #3-#5 for EACH sample.

3. What type of sample was taken?

 Environmental Go to #3a

 Specific Food Ingredient If specific food ingredient, skip to #3b

 Multi-Ingredient Food If multi-ingredient food, skip to #3c

a. Where was the sample taken from? Answer #3a and Skip to#4.

 Floor Drain

 Food Prep Table

 Utensil (Tongs, Knife, Pan)

 Sink

 Slicer

 Inside Any Cooling Unit (Walk-In, Reach-in, etc.)

 Inside Any Heating Unit

 Wall, Ceiling

 Floor (Floor Surface, Floor Mat, etc.)

 Other (describe) ___________________

b. What was the name of the specific food sampled? This should match the name of a specific food characterized in Part V. _______________________________________________ Skip to #4

c. What was the name of the multi-ingredient food sampled? This should match the name of the multi-ingredient food characterized in Part V. ______________________________________

4. Comments: Please provide any comment or additional information about the specific sample.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Was an agent identified in this sample?

 Yes

 No If No, skip to Part VII (Contributing Factors)

a. How many agents were isolated from this sample? ______________

Agent Description

Please answer #6, #6a, and #6b separately for each agent found in one specific sample taken during the environmental assessment.

If only one agent was isolated in the sample, fill out #6, #6a, and #6b one time.

If multiple agents were isolated from this specific sample, answer questions #6, #6a, and #6b for EACH agent isolated.

6. 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

 Chemical hazard (Please describe) ____________________________________

 Physical hazard (Please describe) _____________________________________

 Toxic agent (Please describe) ________________________________________

 Other agent (Please describe) ________________________________________

a. Was a serotype of the agent identified?

 Yes (Please describe) _____________________________________

 No

b. Was a PFGE pattern identified for the agent?

 Yes (Please describe) _____________________________________

 No

Part VII – Contributing Factors

1. Were any contributing factors identified in this outbreak?  Yes

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

2. 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: ____________________________________________________)

3. 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.

4. Were any contamination factors identified in this foodborne illness outbreak?  Yes

 No If No, skip to #5

a. How many contamination factors were identified in this 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 before the vehicle was ingested.

5. Were proliferation/amplification factors identified in this foodborne illness outbreak?

 Yes

 No If No, skip to #6

a. How many proliferation/amplification factors were identified in this outbreak? _______

Survival Factors (primarily bacterial 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.

6. Were any survival factors identified in this foodborne illness outbreak?

 Yes

 No If No, skip to #7

a. How many survival factors were identified in this outbreak? _______

Contributing Factor Description

Please answer #7-10 separately for each contributing factor identified in this outbreak. Contributing factors are defined in the Definitions of Factors Contributing to Outbreaks section of the NVEAIS Instruction Manual.

If one contributing factor is identified, answer #7-10 one time.

If multiple contributing factors are identified, answer #7-10 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 (Define) ___________

8. In your judgment, was this the primary contributing factor for this outbreak?

 Yes

 No

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

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. When did this factor most likely occur?

 Before vehicle entry into the food service establishment

 While the vehicle was at the food service establishment

 After the vehicle left the food service establishment

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