Salmonella Infantis Infections among Detention Center In

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Undetermined source for Salmonella Infantis infections among

detention center inmates — South Carolina, 2016

CASE INTERVIEW FORM

CDC ID: Date: // Data collector initials: _____

1. Last Name______________________ First Name_____________________

2. Unit:

3. DOB: //

4. When was the first documented episode of diarrhea: //

Foodborne disease outbreak questionnaire (Prison A) Interviewer name: ___________________

Interviewer information (Questions 1-4 to be completed by interviewer prior to questionnaire administration)
PulseNet ID #: ______________________ (Required)		State/Local/Other ID #: _______________________
Date of Interview:	__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y
Interviewer Information Contact phone number: (____) ______-________ Agency or Organization: _______________________________
Stool sample: Yes/No      Result: ______________________________

Part I. Demographics:

Age: _____ Sex_____(M/F)

Race (check all that apply) American Indian or Alaska Native Asian Black or African American White Native Hawaiian/other Pacific Islander Unknown Other race

Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown

9. Unit: ________________________ Cell#: ______________Bed#_______________ In Isolation: Yes / No

10. When were you admitted to this detention center? Date: ____ / ____ / ____

11. What work do you perform at this detention center? ______________________________

12. Where do you perform this work? ______________________________

13. Do you help in the kitchen or handle food? Yes / No

Part II. Clinical information

1. Have you had any symptoms of gastrointestinal illness during the week of July 10^th, 2016? Yes / No

2. What day did your symptoms begin: ___________ / ____ / ____ / ____ (example: Tuesday MM/DD/YY)

3. Please circle when you began feeling sick:

1 AM 7 AM 1 PM 7 PM

2 8 2 8

3 9 3 9

4 10 4 10

5 11 5 11

6 AM 12 Noon 6 PM 12 Midnight

4. Did you have any of the following symptoms during the week of July 10^th, 2016?:

Symptom	Yes/No/Unknown	Onset Date	Notes
Nausea	Yes No Unk	___/____/_______
Vomiting	Yes No Unk	___/____/_______	If yes, what is the largest number of episodes you had in a 24 hour period ? _____________
Diarrhea	Yes No Unk	___/____/_______
Bloody Diarrhea	Yes No Unk	___/____/_______	If yes, what is the largest number of episodes you had in a 24 hour period ? _____________ Did you provide a stool sample? Yes No
Fever	Yes No Unk	___/____/_______	Highest temperature, if measured ______°C or °F
Chills	Yes No Unk	___/____/_______
Headache	Yes No Unk	___/____/_______
Abdominal pain/cramping	Yes No Unk	___/____/_______
Body aches	Yes No Unk	___/____/_______
Fatigue/Tiredness	Yes No Unk	___/____/_______
Dizziness	Yes No Unk	___/____/_______
Other:_______ ________	XYes	___/____/_______

5. Have your symptoms stopped? Yes / No

6. If yes, when did your symptoms end? Date____ / ____ / ____

7. Did you seek medical care at the infirmary or go to sick call? Yes / No

   1. When? Date____ / ____ / ____ Time____:____ AM/ PM

8. Did you receive intravenous (IV) fluids? Yes / No

9. Did you receive any medications? Yes / No 9a) If yes, specify: ________________________

10. Were you hospitalized for this illness? Yes / No

11. When were you admitted to the hospital? Date____ / ____ / ____

12. When did you return from the hospital? Date____ / ____ / ____

Part III. Food:

	Did you eat in the cafeteria on this day?	Did you eat an alternate meal?
Saturday, July 9	Yes No	Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________
Sunday, July 10	Yes No	Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________
Monday, July 11	Yes No	Yes No If yes, describe: __________________ _______________________________ _______________________________ ________________________________
Tuesday, July 12	Yes No	Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________ _______________________________
Wednesday, July 13	Yes No	Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________ _______________________________

Please place an X next to any food item you ate on any of these days:

Saturday, July 9		Sunday, July 10		Monday, July 11		Tuesday, July 12		Wednesday, July 13
Breakfast		Breakfast		Breakfast		Breakfast		Breakfast
				Grits		Fruit Drink		Oatmeal
				Biscuit		Oatmeal		Breakfast sausage
				Sausage		Scrambled Eggs		Pancake square
				Gravy		O'Brien potatoes		Margarine
				Lyonnaise Potatoes		Biscuit		Maple syrup
				Margarine		Margarine		Dairy Drink
				Dairy Drink		Jelly		Cornbread
						Dairy Drink
Lunch		Lunch		Lunch		Lunch		Lunch
				Turkey Bologna		Cheese Slice		Ham?
				Creamy Cole Slaw		Turkey Salami		Italian Pasta Salad
				Bread		Marinated Vegetable Salad		Bread
				Mustard		Bread		Mustard
				Cookie Square		Mustard		Cookie Square
				Fruit Drink		Cookie Square		Fruit Drink
						Fruit Drink
Dinner		Dinner		Dinner		Dinner		Dinner
				Italian Meat Sauce		Chili Con Carne		Meatloaf
				Spaghetti Noodles		Plain rice		?
				Seasoned Green Beans		Seasoned Cabbage		Fluffy Rice
				Garlic Bread		Cornbread		Mixed Beans
				?		Margarine		Cornbread
				Sweat tea		?		?
						Sweet Tea		Frosted Chocolate Cake
								Sweet tea

Now, I will ask you more questions about what you ate and drank during the week of July 10^th. Try to remember and answer as best as you can.

Please circle or specify any other food-related items that you ate:

ice spread mayonnaise other condiments

Other specify: ________________________________________________________________________

Was any of the food you ate undercooked? Yes / No / DK

If yes, Specify: ___________________________________________________________________________________

Did you eat any food not provided by the cafeteria? Yes / No

Specify: ___________________________________________________________________________________

If yes, where was that food obtained?

Specify: ___________________________________________________________________________________

Did you drink any beverages not provided by the cafeteria? Yes / No

Specify: ___________________________________________________________________________________

If yes, where was that drink obtained?

If yes, Specify: ___________________________________________________________________________________

Did you eat any leftover food from previous days? Yes / No

If yes, Specify: ___________________________________________________________________________________

If yes, do you remember when you obtained that food? _____/______ (MM/DD)

Did you prepare any food in your barracks (e.g. “spread”)? Yes / No

If yes, specify:_______________________________________________________________________________

Did you eat the food that you prepared in your barracks? Yes / No

Date of preparation ____/_____ (MM/DD)

Date of consumption ____/_____ (MM/DD)

Did you share the food that you prepared in your barracks with anyone else? Yes / No

If yes, specify: _______________________________________________________________________________

Do you have any food allergies? Yes/No

If yes, specify: _______________________________________________________________________________

Are there any foods that you do not eat? Yes/No

If yes, specify: _______________________________________________________________________________

What time do you typically eat? Breakfast ________AM Lunch _______AM / PM Dinner: ________ PM

Other_______________

Part IV. Handwashing Practices

How many times per day do you usually wash your hands? ____________

Describe the times of day when you wash your hands. _____________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________

Part V. Medical History:

Do you have any of the following conditions? (check all that apply) None Unknown

Asplenia Autoimmune disease Cancer, any (incl. leukemia/lymphoma) Chronic kidney disease (with or without dialysis) Chronic liver disease (incl. cirrhosis) Chronic pulmonary disease (incl. COPD/emphysema, asthma) Congestive heart failure Connective tissue disease Diabetes mellitus Gastroesophageal reflux disease (GERD) HIV/AIDS

Ischemic heart disease/Myocardial infarction/Peripheral vascular dz IV drug use in past year Peptic ulcer disease Pregnancy (current) Prosthetic device or vascular graft Recurrent cystitis or urinary tract infection Sickle cell disease Smoking in past year Transplant (incl. solid organ, hematopoietic stem cell, bone marrow) Other _________________________

Part VI. Notes: (Add any comments not specifically asked on questionnaire)

Public reporting burden of this collection of information is estimated to average 45 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)