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: _____
Last Name______________________ First Name_____________________
Unit:
DOB: //
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) |
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(Required) |
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__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y |
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Agency or Organization: _______________________________
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Part I. Demographics:
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American Indian or Alaska Native Asian Black or African American White Native Hawaiian/other Pacific Islander Unknown Other race |
Hispanic or Latino Not Hispanic or Latino Unknown
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Unit: ________________________ Cell#: ______________Bed#_______________ In Isolation: Yes / No
When were you admitted to this detention center? Date: ____ / ____ / ____
What work do you perform at this detention center? ______________________________
Where do you perform this work? ______________________________
Do you help in the kitchen or handle food? Yes / No
Part II. Clinical information
Have you had any symptoms of gastrointestinal illness during the week of July 10th, 2016? Yes / No
What day did your symptoms begin: ___________ / ____ / ____ / ____ (example: Tuesday MM/DD/YY)
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
Did you have any of the following symptoms during the week of July 10th, 2016?:
Symptom |
Yes/No/Unknown |
Onset Date |
Notes |
Nausea |
Yes No Unk |
___/____/_______ |
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Vomiting |
Yes No Unk |
___/____/_______ |
If yes, what is the largest number of episodes you had in a 24 hour period ? _____________
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Diarrhea |
Yes No Unk |
___/____/_______ |
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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
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Chills |
Yes No Unk |
___/____/_______ |
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Headache |
Yes No Unk |
___/____/_______ |
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Abdominal pain/cramping |
Yes No Unk |
___/____/_______ |
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Body aches |
Yes No Unk |
___/____/_______ |
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Fatigue/Tiredness |
Yes No Unk |
___/____/_______ |
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Dizziness |
Yes No Unk |
___/____/_______ |
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Other:_______ ________ |
XYes |
___/____/_______ |
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Have your symptoms stopped? Yes / No
If yes, when did your symptoms end? Date____ / ____ / ____
Did you seek medical care at the infirmary or go to sick call? Yes / No
When? Date____ / ____ / ____ Time____:____ AM/ PM
Did you receive intravenous (IV) fluids? Yes / No
Did you receive any medications? Yes / No 9a) If yes, specify: ________________________
Were you hospitalized for this illness? Yes / No
When were you admitted to the hospital? Date____ / ____ / ____
When did you return from the hospital? Date____ / ____ / ____
Part III. Food:
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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: __________________ _______________________________ _______________________________ _______________________________
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Sunday, July 10 |
Yes No |
Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________
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Monday, July 11 |
Yes No |
Yes No If yes, describe: __________________ _______________________________ _______________________________ ________________________________ |
Tuesday, July 12 |
Yes No |
Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________ _______________________________
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Wednesday, July 13 |
Yes No |
Yes No If yes, describe: __________________ _______________________________ _______________________________ _______________________________ _______________________________
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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 |
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Breakfast |
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Breakfast |
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Breakfast |
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Breakfast |
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Breakfast |
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Grits |
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Fruit Drink |
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Oatmeal |
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Biscuit |
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Oatmeal |
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Breakfast sausage |
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Sausage |
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Scrambled Eggs |
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Pancake square |
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Gravy |
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O'Brien potatoes |
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Margarine |
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Lyonnaise Potatoes |
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Biscuit |
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Maple syrup |
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Margarine |
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Margarine |
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Dairy Drink |
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Dairy Drink |
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Jelly |
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Cornbread |
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Dairy Drink |
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Lunch |
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Lunch |
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Lunch |
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Lunch |
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Lunch |
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Turkey Bologna |
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Cheese Slice |
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Ham? |
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Creamy Cole Slaw |
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Turkey Salami |
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Italian Pasta Salad |
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Bread |
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Marinated Vegetable Salad |
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Bread |
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Mustard |
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Bread |
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Mustard |
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Cookie Square |
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Mustard |
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Cookie Square |
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Fruit Drink |
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Cookie Square |
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Fruit Drink |
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Fruit Drink |
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Dinner |
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Dinner |
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Dinner |
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Dinner |
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Dinner |
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Italian Meat Sauce |
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Chili Con Carne |
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Meatloaf |
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Spaghetti Noodles |
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Plain rice |
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? |
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Seasoned Green Beans |
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Seasoned Cabbage |
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Fluffy Rice |
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Garlic Bread |
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Cornbread |
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Mixed Beans |
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Margarine |
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Cornbread |
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Sweat tea |
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Sweet Tea |
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Frosted Chocolate Cake |
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Sweet tea |
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Now, I will ask you more questions about what you ate and drank during the week of July 10th. 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 _________________________
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Part VI. Notes: (Add any comments not specifically asked on questionnaire)
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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)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Luna, Sarah (CDC/OPHSS/CSELS) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |