Hepatitis A Virus (hav) Outbreak Hawaii, 2016—control Qu

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

HEPATITIS A VIRUS (HAV) OUTBREAK

HAWAII, 2016—CONTROL QUESTIONNAIRE

Hepatitis A Virus (HAV) Outbreak

Hawaii, 2016—Control questionnaire

Section 1: Interviewer information (Questions 1-5 to be completed by interviewer prior to questionnaire administration)
CDC ID #: ______________________			State/Local/Other ID #: _______________________
Date of Interview:	__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y
Interviewer Information Name: ________________ Contact phone number: (____) ______-________ Agency or Organization: _______________________________
Before this interview, how many times has the case been interviewed about their illness by a local, state, or federal public health representative?				None Once Twice Three times Other (specify # times):________ Unknown
Respondent was:		Self Parent Spouse Other (Specify):_______________
Time Period in question:		__ __ / __ __ / __ __ __ __ — __ __ / __ __ / __ __ __ __ — (if unknown, enter 99/99/9999) M M D D Y Y Y Y M M D D Y Y Y Y

Section 2: Demographic Data: I’d like to begin by asking a few questions about yourself (your child) and your household.
What are your state, county, and zip code?			State abbr. _____ County ____________ Zip Code _____________
Birth month and year	__ __ / __ __ __ __ (if unknown, enter 99/9999) M M Y Y Y Y
Sex: Male Female Unknown
Hispanic or Latino origin? Yes No Unknown
How would you describe your race?		White Black/ African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Other (specify): ___________ Unknown

Section 3: Travel: Next I have a couple of questions about any travel you (your child) might have done, either as part of your work or for pleasure.
Yes	Maybe	No	Don’t Know
				Did you spend all, or some, of the selected time period outside your home state?
				1a. List all US states where you might have purchased or eaten foods. This would include foods eaten at airports, bus or train stations.	Enter 2-letter postal abbrv(s): __________ __________________________________ Unknown Did not travel to other US states
				1b. List all countries outside the US where you might have purchased or eaten foods.	List countries & Travel dates: __________ __________________________________ Unknown Did not travel to outside the US
Section 3 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 4: Food allergies, special diets, vitamins, & supplements: Now I have a few questions about food allergies and any special diets you (your child) may follow. I will also ask a few questions about vitamins and supplement you may have taken in the selected time period before your illness began.
Yes	Maybe	No	Don’t Know	Did you (your child) have:
				Any allergies that prevent you from eating a certain food(s)?
				1a. What foods? Please check all that apply.		milk eggs peanuts tree nuts fish soy wheat shellfish other: ____________
				Vegetarian or vegan diet?
				Special or restricted diet (medical, weight-loss, religious, cultural, etc.)?
				3a. Please describe	: ___________________________________________ Unknown
				Any vitamins, nutritional or herbal supplements, such as teas, tablets, and pills, etc.?
				4a. Please describe	Type, variety, brand: ___________________________ Unknown
Section 5 Comments. Please fill in any comments/notes from this section in the space provided below:

For Sections 6 and 50: Read each type of store, point of purchase, or food outlet in the top section and ask respondent to list names for each category. The lists of store/restaurant types are meant to prompt the respondent. Please list the names of all points of purchase/restaurants mentioned, regardless of category, in the space provided below. You do not need to record a yes or no response for each category, only record the specific names and approximate locations reported in the space below.

Section 5: Sources of food at home: Now I have a few questions about where the food came from that you ate at home in the selected time period before your illness began. This isn’t necessarily where you shopped during that week, but where what you actually ate came from. I’m going to list several types of stores, for each type please tell me the names of each store you would have eaten food from during the selected time period before you were sick.

1. Did you (your child) eat foods from?

Grocery stores or Supermarkets	Health food stores or Co-ops
Warehouse stores such as Costco or Sam’s Club	Fish or meat specialty shops (butcher’s shop, etc.)
Small markets or Mini markets (convenience stores, gas stations, etc.)	Farmer’s markets, Roadside stands, Open-air markets, or food purchased directly from a farm
Ethnic specialty markets ( Mexican, Asian, or Indian groceries)	Any other sources of food at home that you ate during the selected time period before your illness began?

List Store/Retail Names and Locations: _______________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 5.1: Sources of food outside the home: Now I have a few questions about where the food came from that you ate outside your home such as restaurants or fast food chains. I’m going to list several types of restaurant, for each type please tell me the names of each place you would have eaten food from during the selected time period.

1. Did you (your child) eat at any?

National fast food chains	Vegetarian or Vegan	All-you-can-eat Buffet
Mexican-style	Barbeque or Home-style	Sandwich shops or Delis
Italian	Steakhouse or Grill	Any take away/ take-out food
Seafood/Sushi	Diner or Neighborhood Café	Breakfast or Brunch-style
Jamaican, Cuban, or Caribbean	Middle Eastern, Arabic, Lebanese, or African	A school or other institutional setting
Chinese, Indian, Japanese or other Asian-style	An event where food was served, such as a catered event, food festival, church or community meal, etc.	Any other restaurants or places you might have eaten at in the selected time period before your illness began?

List Restaurant Names and Locations: _______________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Fish and Seafood: Now I have some questions about fish and seafood you (your child) might have eaten in the selected time period. You (your child) may have eaten this at home or away from home. This does not include canned items, but these foods could have been eaten alone or as part of a dish, sauce, or dip. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the selected time period before you (your child) got sick.

Yes

Maybe

No

Don’t Know

Did you (your child) eat any:

1. Sushi or Sashimi?

1a. From where?

Restaurant(s) Meal Date(s): _____________________________

Restaurant Name: _____________________ Address: ________________________

Grocery Store(s) Purchase Date(s): ____________________

Meal Date(s): ______________________________

Store Name: ______________________ Address: ___________________________

Other: ________________ Meal Date(s): ___________________________

Name: __________________________ Address: ___________________________

1b. What are the name(s) of the sushi item(s) (for Instance Spicy Tuna, Dragon Roll, California Roll, Maguro Nigiri)? This may include items you shared with meal companions. (Investigator: use an online restaurant menu if available). Please note where (i.e. restaurant, store) each roll was purchased/consumed, if case has multiple sushi exposures.

1c. What were the types of sushi you ate? For example did your meal include:

Special Roll (examples California or Dragon Roll): ____________________________

Spicy Tuna Roll

Nigiri (small clump of rice with piece of seafood on top)

Maki (smaller roll usually with seaweed)

Inari (pouch of fried tofu filled with rice)

Sashimi (Raw fish without rice)

Poke (Hawaiian-style Sashimi of Raw fish chunks)

Other (specify): ___________________________________

1d. What were the seafood ingredients in the Sushi?

Spicy Tuna Raw Tuna (Maguro) Smoked Tuna Yellowtail (Hamachi) Raw Salmon Smoked Salmon Shrimp (ebi) Eel (Unagi) Squid (Ika) Other White Fish (Specify):

Crab stick (imitation crab) Alaskan/Real Crab Roe/caviar (fish eggs) Scallop Other Seafood (Specify):

1e. What were the other ingredients in the sushi?

Other Ingredients: Rice Seaweed (Nori) Cucumber Avocado Egg Mushroom Sprouts Ume (Pickled Plum) Asparagus Carrots Cream Cheese

Tofu Black sesame seeds White sesame seeds Other Vegetables (Specify) Other (Specify):

1f. What were the sides/garnishes eaten with your sushi?

wasabi soy sauce white/yellow ginger pink ginger

ginger color unknown eel sauce ponzu sauce mayo tempura flakes

spicy mayo sriracha radish sprouts sprouts (other) sesame seeds shiso leaves masago (generally orange-red, about the size of a pencil tip, and a bit crunchy) other sauce/side/garnish (specify): ________________________________

1g. What other food items did you eat during your sushi/sashimi meal?

Soy Beans (Edamame)

Seaweed Salad

Garden/House Salad If yes, what salad dressing?:___________________________

Dumplings/Pot Stickers

Soup: If yes, What kind: Miso, Wonton, Hot & Sour (CIRCLE) Other (Specify):____________

Deep Fried Spring Roll or Egg Roll, If yes, Type: Vegetarian, Shrimp (CIRCLE) Other (Specify):______________

Fresh (Non-fried) Spring Roll, Type: Vegetarian, Shrimp (CIRCLE) Other (Specify):______________

Ice Cream: Green Tea, Red Bean, Mango (CIRCLE) Other (Specify):______________

Other (Specify):

1h. How did you pay for your sushi items?

Credit card Cash Check Other: ____________________

1i. Do you have a receipt from your sushi meal/purchase?

2. Did you eat any other fresh or fresh-frozen fish?

2a. Was it eaten at home?

Was it Fresh Frozen Unknown

Type/Brand of fish:____________________________________________________

Describe the dish: ____________________________________________________

Place purchased: ____________________________________________________

Purchase date(s): ____________________________________________________

Meal date(s): ____________________________________________________

2b. Was it eaten away from home?

Was it Fresh Frozen Unknown

Type/Brand of fish: ____________________________________________________

Describe the dish: ____________________________________________________

Place eaten: ____________________________________________________

Meal date(s): ____________________________________________________

3. Ceviche? Specify: __________________________________________________

4. Shrimp or prawns?

5. Crab, lobster, or crayfish? (CIRCLE)

6. Oysters?

7. Clams, mussels, scallops, or other shellfish? (CIRCLE)

8. Squid or octopus? (CIRCLE)

9. Smoked or dried fish?

10. Frozen fish product (fish sticks, nuggets, etc.)? Specify: _______________________________

11. Any other fish or seafood?

11a. What was the: Type, variety, brand:____________________________ Unknown

Section 9 Comments. Please fill in any comments/notes from this section in the space provided below:

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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)