App 2_Data Collection Forms

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Undetermined risk factors and modes of transmission for Candida auris infection — Colombia, 2016
Appendix 1b. Ficha de registro para casos de Candida auris y Candidemia [Spanish]

Public reporting burden of 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Ficha de registro para casos de Candida auris y Candidemia
Número de caso: ________________ Sexo (M)(F) Edad: _____ (años)(meses)(días)
Dirección:_________________________
Lugar: País: ____________________ Ciudad: ___________________ Institución:_____________________________
Fecha de ingreso (DD)(MM)(AA)
Motivo de ingreso hospitalario: _______________________________________
Fecha de egreso (DD)(MM)(AA)
Condición al egreso: Vivo ( ) Muerto ( ) Hospitalizado ( ) No dato ( )
Localización durante la hospitalización:
¿Fue el paciente trasladado desde otro hospital? (Si)(No)(ND)
Nombre y Cuidad del hospital: _____________________________________________ Fecha de traslado: (DD)(MM)(AA)
Ingresó a la UCI: (Si)(No)(ND)
Fechas de ingreso a la UCI (DD)(MM)(AA) Fecha de egreso de la UCI (DD)(MM)(AA)
Describa las unidades donde el paciente ha estado hospitalizado:
Unidad: ________________ habitación: ______ Fecha de entrada: (DD)(MM)(AA) Fecha de salida: (DD)(MM)(AA)
Unidad: ________________ habitación: ______ Fecha de entrada: (DD)(MM)(AA) Fecha de salida: (DD)(MM)(AA)
Unidad: ________________ habitación: ______ Fecha de entrada: (DD)(MM)(AA) Fecha de salida: (DD)(MM)(AA)
Unidad: ________________ habitación: ______ Fecha de entrada: (DD)(MM)(AA) Fecha de salida: (DD)(MM)(AA)
Unidad: ________________ habitación: ______ Fecha de entrada: (DD)(MM)(AA) Fecha de salida: (DD)(MM)(AA)
¿Ha estado el paciente en el quirófano? (Si)(No)(ND), si la respuesta es sí, describa la información a continuación:
Sala de cirugía:____________ Fecha: (DD)(MM)(AA) Descripción del procedimiento:__________________________
Sala de cirugía:____________ Fecha: (DD)(MM)(AA) Descripción del procedimiento:__________________________
Sala de cirugía:____________ Fecha: (DD)(MM)(AA) Descripción del procedimiento:__________________________
Factores de Riesgo
Hospitalizaciones previos:
¿El paciente ha estado hospitalizado en los últimos 90 días? (Si)(No)(ND)
Hospital y Cuidad: ______________ Fecha de ingreso: (DD)(MM)(AA)
Motivo de hospitalización: _____________ Fecha de egreso:
(DD)(MM)(AA)
Hospital y Ciudad: ______________ Fecha de ingreso: (DD)(MM)(AA)
Motivo de hospitalización: _____________ Fecha de egreso:
(DD)(MM)(AA)
¿Diagnóstico previo de infección con candida? (Si)(No)(ND)
Fecha:(DD) (MM) (AA)
¿Especie(s) asociada(s)? _____________________

Comorbilidades:
Diabetes: (Si) (No) (ND)
Tumor sólido: (Si) (No) (ND)
Malignidad hematológica: (Si) (No) (ND)
Trasplante de médula ósea: (Si) (No) (ND)
Enfermedad renal crónica: (Si) (No) (ND)
Hemodiálisis (Si) (No) (ND)
Enfermedad hepática:(Si) (No) (ND)
Enfermedad inmunosupresora: (Si) (No) (ND)
Seleccione:(Autoinmunidad)(Trasplante)
(Cortiocosteroides)(Cáncer)
VIH/SIDA: (Si) (No) (ND)
CD4: ________ Carga viral:
______________
Otras: (Si) (No) (ND) ¿Cuál?:
________________

¿El paciente ha recibido algún antifúngico previamente? (Si)(No)(ND)
¿Cuál?_________________ Inicio: (DD)(MM)(AA) Finalización:
(DD)(MM)(AA)
Motivo del tratamiento previo:
_______________________________________
Hospitalización actual
Procedimientos:
Hemodiálisis: (Si) (No) (ND)
Fecha de inicio: (DD) (MM) (AA) Fecha de finalización: (DD) (MM) (AA)
Catéter venoso central: (Si) (No) (ND)
Fecha de inicio: (DD) (MM) (AA) Fecha de finalización: (DD) (MM) (AA)
Apoyo respiratorio: (BiPAP) (Intubación)
Fecha de inicio: (DD) (MM) (AA) Fecha de finalización: (DD) (MM) (AA)
Broncoscopio: (Si) (No) (ND)
Fecha de inicio: (DD) (MM) (AA) Fecha de finalización: (DD) (MM) (AA)
Fisioterapia: (Si) (No) (ND)
Fecha de inicio: (DD) (MM) (AA) Fecha de finalización: (DD) (MM) (AA)
Tratamientos:
Antimicrobianos:
Quimioterapia: (Si)(No)(ND)
¿Cuál fue el tratamiento de elección para
Inicio:(DD)(MM)(AA)
C. auris u otro
Finalización:(DD)(MM)(AA)
candidemia?:_________dosis:______
Alimentación parenteral: (Si)(No)(ND)
Inicio:(DD) (MM) (AA) Finalización:(DD) (MM)
Inicio:(DD)(MM)(AA)
(AA)
Finalización:(DD)(MM)(AA)
Corticosteroides: (Si)(No)(ND)
Otros antimicrobianos:
¿Cuál? ________________ Inicio:(DD)(MM)(AA)
Nombre y
Finalización:(DD)(MM)(AA)
dosis:_____________________________
¿Cuál? ________________ Inicio:(DD)(MM)(AA)
Inicio:(DD) (MM) (AA) Finalización:(DD) (MM)
(AA)
Finalización:(DD)(MM)(AA)
Nombre y
Vasopresores: (Si)(No)(ND)
dosis:_____________________________
Inicio:(DD) (MM) (AA) Finalización:(DD) (MM)
¿Cuál? ________________ Inicio:(DD)(MM)(AA)
Finalización:(DD)(MM)(AA)
(AA)

¿Cuál? ________________ Inicio:(DD)(MM)(AA)
Finalización:(DD)(MM)(AA)
¿Otros tratamientos?
___________________________________________
Inicio:(DD)(MM)(AA)
Finalización:(DD)(MM)(AA)

Nombre y
dosis:_____________________________
Inicio:(DD) (MM) (AA) Finalización:(DD) (MM)
(AA)
Nombre y
dosis:_____________________________
Inicio:(DD) (MM) (AA) Finalización:(DD) (MM)
(AA)
Nombre y
dosis:_____________________________
Inicio:(DD) (MM) (AA) Finalización:(DD) (MM)
(AA)
Nombre y
dosis:_____________________________
nicio:(DD) (MM) (AA) Finalización:(DD) (MM) (AA)
Hallazgos clínicos y del laboratorio
Clínicos:
Laboratorio:
Cultivo de Candida
Peso:___________ Talla:____________
(del día más cercano al
Evidencia de sepsis severa:(Si)(No)(ND)
Primer cultivo positivo para C. auris u otro
diagnóstico de
Candida: Fecha:(DD)(MM)(AA)
Sepsis: al menos 2 de los siguientes síntomas
candidemia)
Tipo de muestra: (sangre)(orina)
Fecha:(DD)(MM)(AA)
(a) temperatura >38.3C o <36C, (b) frecuencia
(herida) (lavado bronco alveolar) (otra)
cardiaca >90, (c) frecuencia respiratoria >20) con
G. blancos: ________
evidencia de infección
%PMNs:________
¿Cuál? _______________________
Sepsis severa = sepsis más falla orgánica
Hb: ________
¿El paciente desmejoró clínicamente? (Si)(No)(ND)
PQT: ________
Concentración inhibitoria mínima:
Fecha: (DD)(MM)(AA)
Creatinina: ________
Fluconazol: ____________
Detalles:___________________
BUN: ________
Voriconazol: ___________
Glucosa: _________
Anfotericina: ___________
Radiología:
AST: ________
Caspofungina: __________
Alguna alteración radiológica: (Si) (No) (ND)
ALT: ________
Anidulafungina: _________
¿Cuál?
Bilirrubina total: _______ Micafungina: ___________
______________________________________
Albúmina: ________
Fecha: (DD)(MM)(AA)
Lactato: ________
Cultivos (1 año antes y después del cultivo de Candida)
Tipo de Muestra

Fecha de
recolección

Fecha de
reporte

Resultado (microorganismo aislado)

Concentració
n inhibitoria
mínima

(DD)(MM)(AA) (DD)(MM)(AA
)
(DD)(MM)(AA) (DD)(MM)(AA
)
(DD)(MM)(AA) (DD)(MM)(AA
)
(DD)(MM)(AA) (DD)(MM)(AA
)
(DD)(MM)(AA) (DD)(MM)(AA
)
(DD)(MM)(AA) (DD)(MM)(AA
)
Información adicional para casos de candidemia en paciente menor de un año
El paciente nació prematuro: (Si)(No)(ND) Tipo de parto: (vaginal) (cesárea)
Tiempo de gestación al nacimiento: ____ (semanas) Peso al nacer: _________ (Kilos)
Seleccione el tipo de nutrición que recibió el paciente: (lecha materna)(formula)(combinación)(otro)
Si recibió formula, ¿Cuál formula recibió? _______________________________________________________________________
Tenía alguna disrupción de la piel (erupción)?: (Si)(No)(ND); ¿Cuál(es)?:
_____________________________________________
¿Recibió algún antifúngico profiláctico? (Si)(No)(ND); ¿Cuál(es)?:
____________________________________________________
¿Necesitó alguna operación? (Si)(No)(ND) ¿Cuál?: ________________________________ Fecha: (DD)(MM)(AA)
¿Cuál?: ________________________________ Fecha: (DD)(MM)(AA)
¿Cuál?: ________________________________ Fecha: (DD)(MM)(AA)
¿Necesitó otro procedimiento diferente a los mencionados anteriormente? (Si)(No)(ND)
¿Cuál?: ________________________________ Fecha: (DD)(MM)(AA)

¿Cuál?: ________________________________ Fecha: (DD)(MM)(AA)
El paciente estuvo expuesto a:
·
Incubadora (Si)(No)(ND) Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______ (horas)(días)(semanas)(meses)
·
Tubo de alimentación (Si)(No)(ND) Por dónde? (nariz) (boca) (sonda)
Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______ (horas)(días)(semanas)(meses)
·
Monitor cardiaco (Si)(No)(ND) Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______ (horas)(días)(semanas)(meses)
·
Fototerapia: (Si)(No)(ND) Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______ (horas)(días)(semanas)(meses)
·
Esteroides para el desarrollo respiratorio (Si)(No)(ND) Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______
(horas)(días)(semanas)(meses)
·
Aditivos para alimentos (Si)(No)(ND) Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______
(horas)(días)(semanas)(meses)
·
Otro: ________________________ Fecha: (DD)(MM)(AA) ¿Por cuánto tiempo? ______
(horas)(días)(semanas)(meses)
·

subjetivo a cambiar a medida que avanza la investigación y nueva información

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Undetermined risk factors and modes of transmission for Candida auris infection — Colombia, 2016
Appendix 1a. Case Report Form for Cases of Candida auris and Candidemia [English]

Public reporting burden of 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Appendix 1a. Case Report Form for cases of Candida auris and Candidemia
Case ID: ________________ Sex (M)(F) Age: _____ (years)(months)(days) Address:_________________________
Location: Country: ____________________ City: ___________________ Institution:_____________________________
Date of admission (DD)(MM)(YY)
Reason for admission: _______________________________________
Date of discharge (DD)(MM)(YY)
Condition at discharge: Alive ( ) Dead ( ) Hospitalized ( ) Unknown ( )
Location During Hospitalization:
Was the patient transferred from another facility? (Yes)(No)(UNK)
Name and City of Hospital: _____________________________________________ Date of transfer: (DD)(MM)(YY)
Admitted to the ICU: (Si)(No)(ND)
Date of admission to the ICU (DD)(MM)(YY) Date of discharge from the ICU (DD)(MM)(YY)
Locations of patient during hospitalization:
Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY)
Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY)
Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY)
Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY)
Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY)
Was the patient in the Operating Room? (Yes)(No)(UKN), If yes, please complete the following:
Operating room:____________ Date: (DD)(MM)(YY) Procedure/Operation:__________________________
Operating room:____________ Date: (DD)(MM)(YY) Procedure/Operation:__________________________
Operating room:____________ Date: (DD)(MM)(YY) Procedure/Operation:__________________________
Risk Factors
Previous Hospitalizations:
Comorbilities:
Has the patient been hospitalized in the past 90 days? (Yes)(No)(UNK)
Diabetes: (Yes)(No)(UNK)
Hospital and City: ______________ Date of Admission: (DD)(MM)(YY)
Solid tumor: (Yes)(No)(UNK)
Reason for hospitalization: _____________ Date of discharge:
Hematologic Malignancy: (Yes)(No)(UNK)
(DD)(MM)(YY)
Bone Marrow Transplant: (Yes)(No)(UNK)
Chronic renal failure: (Yes)(No)(UNK)
Hospital and City: ______________ Date of Admission: (DD)(MM)(YY)
Hemodialysis (Yes)(No)(UNK)
Reason for hospitalization: _____________ Date of discharge:
Liver disease:(Yes)(No)(UNK)
(DD)(MM)(YY)
Immunosuppressed: (Yes)(No)(UNK)
Please select:(Autoimmune)(Transplant)
Has the patient ever been previously diagnosed with candida?
(Corticosteroids)(Cancer)
(Yes)(No)(UNK)
HIV/AIDS: (Yes)(No)(UNK)
Date:(DD) (MM) (YY)
CD4: ________ Viral load: ______________
What species was isolated? _____________________
Others:(Yes)(No)(UNK) Which?: _____________
Has the patient ever previously received an antifungal? (Yes)(No)(UNK)
Which?_________________ Began: (DD)(MM)(YY) Stopped:
(DD)(MM)(YY)
Indication for treatment: _______________________________________
Current Hospitalization
Procedure:
Hemodialysis: (Yes)(No)(UNK)
Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY)
Central venous catheter (Yes)(No)(UNK)
Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY)
Respiratory support: (BiPAP) (Intubation)
Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY)
Bronchoscopy: (Yes)(No)(UNK)
Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY)
Physical Therapy: (Yes)(No)(UNK)
Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY)
Treatments:
Antimicrobials:
Chemotherapy: (Yes)(No)(UNK)
¿What treatment was used for this
Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)
candidemia?:_________dose:______
Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
TPN: (Yes)(No)(UNK)
Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)
Other antimicrobials:
Corticosteroides: (Yes)(No)(UNK)
Name and dose:_____________________________
¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)
Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)
Name and dose:_____________________________
Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
Vasopressors: (Yes)(No)(UNK)
Name and dose:_____________________________
¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)
Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)
Name and dose:_____________________________
Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
Name and dose:_____________________________
¿Other treatments?
Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
___________________________________________
Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)

Clinical and Laboratory Findings
Clinical:
Laboratory:
Candida culture
Weight:___________ Height:____________
(closest available to date
First positive Candida or C. auris culture:
Evidence of severe sepsis(Yes)(No)(UNK)
of positive candida
Date:(DD)(MM)(YY)
Sepsis: at least 2 of the following
culture)
Type of sample: (blood)(urine) (wound) (BAL) (other)
Date:(DD)(MM)(YY)
(a) temperature >38.3C or <36C, (b) heart rate >90,
Which? _______________________
WBC: ________
(c) respiratory rate >20) with evidence of infection
%PMNs:________
Severe sepsis = sepsis plus respiratory failure
MIC:
Hb: ________
Did the patient experience a decompensation during
Fluconazole: ____________
PLT: ________
the hospital stay? (Yes)(No)(UNK) Date:
(DD)(MM)(YY)
Voriconazole: ___________
Creatine: ________
Amphotericin: ___________
Details:_____________________________________ BUN: ________
Caspofungin: __________
___________________________________________ Glucose: _________
______
Anidulafungin: _________
AST: ________
Micafungin: ___________
ALT: ________
Radiology:
Bilirrubin total: _______
Any findings on imagige: (Yes)(No)(UNK)
Albumin: ________
Which?
______________________________________ Date: Lactate: ________
(DD)(MM)(YY)
Cultures (1 year before and after positive Candida culture)
Type of Sample

Date of
Collection

Date of Report

Results (microrganism isolated)

MICs

(DD)(MM)(YY) (DD)(MM)(YY)
(DD)(MM)(YY) (DD)(MM)(YY)
(DD)(MM)(YY) (DD)(MM)(YY)
(DD)(MM)(YY) (DD)(MM)(YY)
(DD)(MM)(YY) (DD)(MM)(YY)
(DD)(MM)(YY) (DD)(MM)(YY)
Additional Information for Candidemia Cases in those less than one year of age
Born prematurely: (Yes)(No)(UNK) Delivery: (vaginal) (c-section)
Gestation at time of birth: ____ (weeks) Birth weight: _________ (Kgs)
Select the type of nutrition received: (breastmilk)(formula)(combination)(other)
If formula received, what type? _______________________________________________________________________
Were any additives, probiotics or thickening agents used (Yes)(No)(UNK): Which?____________________________________
Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)
Was there any skin breakdown (eg. Rash, open wounds)?: (Yes)(No)(UNK) ; What?:____________________________________
Received prophylactic antifungals? (Yes)(No)(UNK) ; Which?: ____________________________________________________
Required an operation? (Yes)(No)(UNK)

Which?: ________________________________ Date: (DD)(MM)(YY)
Which?: ________________________________ Date: (DD)(MM)(YY)

Any additional procedures performed apart from those mentioned previously or above? ( Yes)(No)(UNK)
Which?: ________________________________ Date: (DD)(MM)(YY)
Which?: ________________________________ Date: (DD)(MM)(YY)
Was the patient exposed to any of the following:
·
Incubator (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)
·
Feeding tube (Yes)(No)(UNK) Specify: (nose) (mouth) (PEG)
Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)
·
·
·

Cardiac monitor (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)
Phototherapy: (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)
Steroids for respiratory development (Yes)(No)(UNK)
Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)

·

Other: ________________________ Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)
·

Subject to change as investigation reveals additional information about cases

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Undetermined risk factors and modes of transmission for Candida auris infection — Colombia, 2016
Appendix 2.Healthcare Provider Interview Questions

Public reporting burden of 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

1. Did you observe anything notable about patients infected with C. auris or C. haemulonii* compared with
those infected with other Candida species?
a. In terms of demographic and clinical characteristics?
b. In terms of possible prehospital exposures, including transfer from other hospitals?
c. In terms of patient outcomes?
2. Did you observe any possible evidence of transmission of C. auris or C. haemulonii between patients on
a unit or within the hospital? If so, what?
3. Did you observe recurrent C. auris or C. haemulonii infections within a patient?
4. Do you have any reason to believe that a patient was persistently colonized with C. auris or C.
haemulonii?
5. What type of daily and terminal cleaning methods are used at your hospital, and what cleaning agents
are used?
6. Are there special precautions (e.g., Contact Precautions) used for patients with certain infections or
colonization at your hospital? If so, what?
7. Do you have any hypotheses or guesses about the source of C. auris or C. haemulonii infections and why
they have recently emerged at your hospital?
8. Do you have any suggestions for this investigation in to C. auris or C. haemulonii infections?
9. Is there anything else we should know?
*Note that C. haemulonii is included in the questions because most C. auris cases in Colombia were initially
misidentified as C. haemulonii

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Undetermined risk factors and modes of transmission for Candida auris infection — Colombia, 2016
Appendix 3.Patient Open-Ended Interview Questions

Public reporting burden of 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

The following questions will be asked about activities in the 3 months before hospitalization with C.
auris infection. Patients who have been in the hospital during that entire period will not be asked.*
1. Did you work or have an occupation? If yes, what type of work?
2. If yes to 1: Did your job involve any outdoor activities? If so, what?
3. What, if any, outdoor activities did you do?
4. Did you go swimming? If so, where?
5. Did you or any household members travel outside of your city or town of residence? If so,
where?
6. Did you have any type of ear problem, including itching, infection, or discharge? If so, what?
7. Did you insert medicine or any other substance into your ears?
8. Did you use any type of probiotic medication?

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Case Interview Questionnaire Form
Shigellosis in Genesee and Saginaw Counties, MI, 2016

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)

10/25/16 08:00

Page 1

SHIGELLOSIS CASE INTERVIEW FORM
GENESEE AND SAGINAW COUNTIES, MI
October 2016
Interviewee Information: Check here if interviewee is a proxy for a case-patient who is a minor r
Last name: _________________________________
First name: ___________________________________
Relationship to reference case: ___________________ Person number (from top row of table 1): __________
County of residence: r Genesee r Saginaw MDSS ID (of minor if proxy interviewer): ____________
Telephone numbers (Add as needed; circle successful number)
(
) ____ - _____ (
) ____ - _____ (
) ____ - _____ (
) ____ - _____ (
) ____ - _____
Telephone Contact History
Call
Date
Time
(MM/DD)
1
___ / ___
_______ AM / PM
2
___ / ___
_______ AM / PM
3
___ / ___
_______ AM / PM
4
___ / ___
_______ AM / PM
5
___ / ___
_______ AM / PM
6
___ / ___
_______ AM / PM
7
___ / ___
_______ AM / PM
8
___ / ___
_______ AM / PM
9
___ / ___
_______ AM / PM
10
___ / ___
_______ AM / PM
11
___ / ___
_______ AM / PM
12
___ / ___
_______ AM / PM
OUTCOME CODES:
01 = completed interview
02 = refused interview
03 = no answer
04 = busy tone
05 = non-working number
06 = fax machine
10/25/16 08:00

Outcome
(codes below)

Caller
Initials

07 = business phone
08 = no eligible respondent
09 = language barrier
10 = interview terminated within
questionnaire
11 = physical/mental impairment

Interview
completed?
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

IF DIFFERENT TIME
REQUESTED:
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)
___ /___ (MM/DD)
________(AM/PM)

12 = answering machine
13 = setting up a better time
99 = unknown

Page 2

SECTION 1

Shigellosis

Complete the table on the last page of the packet (Table 1) based on responses to the questions in this section. To
make it easier to complete the table, you can detach it from the case interview packet.
“Since I’ll be asking you to answer questions about the time you were sick with diarrhea from Shigella, it might be
helpful to have a calendar handy. Do you need a moment to grab one?” Wait until interviewee is ready to
continue the interview. “Ok, I’d like to start by confirming the information we have in our records.”
1. It looks like you first got sick with diarrhea from Shigella on ___ / ___ / ___ (MM / DD / YY).” Refer to the
MDSS onset date you pre-populated in the table at the end of this packet. “Is that correct or did your
symptoms start on a different day?”
2. At the time you were sick, how old were you? [Confirm the information you wrote in Table 1 is correct]
“Now I’d like to know about the people in your house and if any of them also got sick with symptoms like yours.”
3. During the week before you got sick, how many people were living or staying in your household at least 4
nights a week? (include interviewee, if applicable) _________ household members
Complete 3a—3d (in Table 1) for all household members, confirming the pre-populated
information in Table 1 or adding new entries as needed:
3a. How old was the person at the time you got sick?
3b. What is this person’s gender or sex?
3c. What is this person’s race?
3d. What is this person’s ethnicity?
4. Did any of these people get sick with symptoms like yours 2 weeks before or 2 weeks after you got sick?
r No (skip to question 5)
r Yes (go to 4a)
IF YES: 4a. Without telling me their names, who got sick? You can refer to them by their age and gender
or sex. [Write this into table 1]
4b. Who was the first person in the household to get sick? (select only one person!)
[This is the “index case” – please check the box for “first person ill” in table 1]
“Now I’ll ask you some questions about [when you were/everyone in your household who got] sick.”
5. For each person in the house who was sick during this time, complete the following questions:
[Write responses into table 1]
5a. Which of the following symptoms did you [or sick member of your household] have? Read options
5b. How many days [were you/was each person] sick?
5c. Did [you/anyone] receive medical care at any of these settings? Read options and mark all the apply
Page 3

5d. Antibiotics are medicines that are sometimes used to treat infections. [Were you/Was anyone]
prescribed antibiotics when [you/they] were sick?
5e. At the time you [and other members of your household] were sick with diarrhea, did [any of] you have
a chronic medical condition for which you had to see your doctor or health care provider regularly?
5f. At the time you [and other members of your household] were sick with diarrhea, did [any of] you have
a medical condition that weakens the immune system, or were [any of] you receiving treatment that can
weaken your immune system? Examples include receiving a transplant, being on cancer treatment, or
being diagnosed with HIV/AIDS.
5g. At the time you [and other members of your household] were sick with diarrhea, [were you/was
anyone, including children or adults] wearing diapers?
6. Do you or any adults in your house have any kind of health care coverage, including health insurance,
prepaid plans such as HMOs, government plans such as Medicare, or Indian Health Service?
r No
r Yes
r Refused
IF NO: skip to question 8.
IF YES: check all that apply:
r Employer provides
r A plan that you or someone else buys on your own
r Medicare
r Medicaid or Healthy Michigan Plan
r Refused
r Military, CHAMPUS, or the VA
r Don’t know
r Other: ___________________
7. Not including the people counted in the last question, did anyone else stay in your home for at least one
night during the week before you got sick?
r No
r Yes
IF NO: skip to next section.
IF YES: 7a. How many visitors stayed in your home at least one night in the week before you got
sick?
_______ visitors
7b. Were any of these visitors sick with diarrhea at the time they visited?
r No
r Yes

Page 4

SECTION 2

Activities Outside the Home

The following questions are to be asked of the index case-patient. In the event the index case-patient is a minor, a
parent or guardian can serve as proxy, preferably one who was a case-patient reported to MDSS. Once you have
determined who will speak for the index case-patient, please indicate in Table 1: “Interviewed:” and also at the
top of page 4.
Check here if talking to the index case-patient: r
Continue interview: “Now I’m going to ask you some questions about activities outside the home.”
Check here If not talking to the index case-patient: r
Continue interview: “Now I’m going to ask you some questions about the first person in your household
to get sick. These questions are about activities outside the home. I’d like you to answer them on behalf of the
first person who got sick in your household.”
1. In the week before you/they became sick, did you/they work or volunteer at a job outside your home?
r No
r Yes
r Refused
IF NO: Skip to 2.
IF YES: 1a. Did you/they work in a:
r School (K-12) IF YES: What grade level? _____, then skip to 2.
r Healthcare or long-term care facility, continue to 1b.
r Childcare/Day Camp/Daycare, skip to 1c.
r Other: ____________________, then skip to 2.
1b. What kind of patient care were you/they involved in? Read options, mark all that
apply, then skip to 2
r Nurse
r Home health care
r Therapist (PT, ST, OT)
r MA / Patient Care Technician / Nurse’s Aid
r Physician/NP/PA
r Other: __________________
1c. What kind of childcare did you/they provide? Read options and mark all that apply.
r Daycare center worker
r Baby-sitter or Nanny
r Camp / Day Camp worker
r Other: _______________
2. In the week before you/they became sick, did you/they have contact with any children or adults outside
the house who were in diapers?
r No
r Yes
IF NO: Continue to 3.
IF YES: 2a. In the week before you/they became sick, did you/they change any diapers?
r No
r Yes
Page 5

SECTION 2

Activities Outside the Home

**This question should be asked between questions 1 and 2 in section 2. Please administer question 1 as
written regardless of the age of the patient (i.e. if patient is 3 year-old, answer to question 1 will be “No”).
Question 1 assesses if you/they are an employee, while question 1.5 assesses if you/they are an attendee.
Question 1.5:

In the week before you/they became sick, did you/they attend any of the following outside the
home: (Check all that apply)
r School (K-12) – If yes, which grade? ____
r Post-High School education (College, trade school)
r Daycare center/facility
r Childcare in someone’s home (not your own)
r Camp or Day Camp

3. In the week before you/they became sick, did you/they spend one of more nights at another address?
r No
r Yes
IF NO: Skip to 4.
IF YES: 3a. In which city is this place located?
_______________________________
3b. At the time you/they stayed there, were any of the household members sick with diarrhea?
r No
r Yes
4. Not including household members and visitors listed already, in the week before you/they became sick
did you/they come in contact with anyone outside your home who had diarrhea? Prompt for extended
family, small children, at church, at work.
r No
r Yes
IF NO: Continue to next section.
IF YES: 4a. In which of the following settings did you/they come in contact with a person with
diarrhea in the week before you/they got sick? Read options and check all that apply.
r Daycare
r Camp / Day camp
r School
r Work / volunteering
r Clinic, hospital, or emergency department
r Church
r House of friend / extended family
r Other: _________________

Page 6

SECTION 3

Travel

The following questions are to be asked of the index case-patient. In the event the index case is a minor, a parent
or guardian can serve as proxy, preferably one who was a case-patient reported to MDSS.
If talking to the index case-patient: “Now I’m going to ask you some questions about travel.”
If not talking to the index case-patient: “Now I’m going to ask you some questions about whether the first person
in your household to get sick traveled anywhere.”
1. In the week before you/they became sick, did you/they travel to any other cities in Michigan for work,
visit friends, or family, an event, or any other reason?
r No
r Yes
IF NO: Skip to 2.
IF YES: 1a. Which cities did you/they travel to?
1a1. _____________________________
1a2. _____________________________
1a3. _____________________________
1a4. _____________________________
1a5. _____________________________
1b. What type of transportation did you/they use to travel to these cities? Read options and
mark all that apply.
r Private car
r MTA rideshare
r Greyhound/AMTRAK
r Uber/Lyft/Taxi/Other rideshare company
r Other: ___________________________
1c. What activities did you/they do while you/they were traveling during this week before
you/they became sick? Read options and mark all that apply.
r Community gathering (fair, picnic, church, etc)
r Spent the night with friend/family
r Visit a friend/family (not overnight)
r Shower or bathe
r Go to work
r Other: ____________________

Page 7

2. In the week before you/they became sick, did you travel outside of Michigan?
r No
r Yes
IF NO: Skip to 3.
IF YES: 2a. Where did you/they travel? List city, state, and country if outside the United States.
2a1. _____________________________
2a2. _____________________________
2a3. _____________________________
2a4. _____________________________
2a5. _____________________________
2b. What days were you/they traveling? Include month and day: ____ / ____ -- ____ / ____
3. In the week before you/they became ill, did you/they go to any of the following events in your community?
r No (Go to Section 4)
r Yes (Go to 3a)
3a. Collect additional information about these events in the following table:
#

3a

3b

3c

3d

3e

Event Type (check all that apply)

r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r

Wedding/party/picnic/barbecue
Fair, carnival, or concert
Church or School event
Other: ________________
Wedding/party/picnic/barbecue
Fair, carnival, or concert
Church or School event
Other: ________________
Wedding/party/picnic/barbecue
Fair, carnival, or concert
Church or School event
Other: ________________
Wedding/party/picnic/barbecue
Fair, carnival, or concert
Church or School event
Other: ________________
Wedding/party/picnic/barbecue
Fair, carnival, or concert
Church or School event
Other: ________________

Location
(city, state)

Date of Event

Anyone with
diarrhea?

____ / ____
(MM/DD)

Yes

No

____ / ____
(MM/DD)

Yes

No

____ / ____
(MM/DD)

Yes

No

____ / ____
(MM/DD)

Yes

No

____ / ____
(MM/DD)

Yes

No

Page 8

SECTION 4

Food

The following questions are to be asked of the index case-patient. In the event the index case is a minor, a parent
or guardian can serve as proxy, preferably one who was a case-patient reported to MDSS.
If talking to the index case-patient: “Now I’m going to ask you where you ate during the week before you got
sick.”
If not talking to the index case-patient: “Now I’m going to ask you where the first person who got sick in your
household ate during the week before they got sick. Do your best to answer the questions on their behalf.”
1. In the week before you/they became sick, did you/they eat any meals prepared at the following types of
food establishments? Read options and mark all that apply.
r
r
r
r
r
r
r

Restaurant
Fast-food establishment
Cafeteria
Deli
Street-vended food (food truck, food cart)
Ready-to-eat food served in a supermarket or department store
Concession stand at sporting event, snack bar, or gas station

2. Can you tell me more about the food establishments where you ate during the week before you got sick?
Prompt for the following information:
Name:

_________________________________________ Date: ____ / ____ (MM / DD)

Address:

_________________________________________ Time: __________ AM / PM

Foods eaten:

______________________________________________________________________

____________________________________________________________________________________
Name:

_________________________________________ Date: ____ / ____ (MM / DD)

Address:

_________________________________________ Time: __________ AM / PM

Foods eaten:

______________________________________________________________________

____________________________________________________________________________________
Name:

_________________________________________ Date: ____ / ____ (MM / DD)

Address:

_________________________________________ Time: __________ AM / PM

Foods eaten:

______________________________________________________________________

____________________________________________________________________________________

Page 9

SECTION 5

Water

The following questions are to be asked of the index case-patient. In the event the index case is a minor, a parent
or guardian can serve as proxy, preferably one who was a case-patient reported to MDSS.
If talking to the index case-patient: “Now I’m going to ask you some questions related to water.”
If not talking to the index case-patient: “Now I’m going to ask you some questions related to water. Do your best
to answer them on behalf of the first person who got sick in your household.”
1. In the week before you got sick, did you/they swim, wade or play in water?
r No
r Yes
r Don’t know
r Refused
IF NO: Skip to 2.
IF YES: Read the following options and choose all that apply:
r Ocean Beach
r Recreational water park
r Lake, pond, river, or stream
r Natural hot spring
r Hot tub/spa, whirlpool, Jacuzzi
r Swimming Pool
“As you know, the outbreak of diarrhea caused by the Shigella germ has affected Genesee and Saginaw Counties.
Similarly, we recognize that the Flint Water Crisis has had an impact beyond Flint and Genesee County. Since
residents of this area have told us that they’ve changed the way they use water, I’d like to ask whether you’ve
made any changes to the way you use water.”
2. Which one of the following is the source of tap water in your home?
(Choose ONE answer – READ OPTIONS)
r Municipal, city, or county water (Specify name of water utility, if known: ____________)
r Private well water
r No tap water available
r Refused
r Other: _______________
“Now I’d like to ask how members of your household used water in the week before you became sick. I’ll start off
by listing the different types of water you might use, then I’ll list the things you might use water for.”
Read types of water (e.g., unfiltered tap water, filtered tap water, etc.), then read water uses (e.g., drinking,
mixing cold drinks, etc.).
“As an example, members of your household might use both bottled water and unfiltered tap water for
preparing hot food. Let’s get started. In the week before you got sick, what type of water did members of your
household use for…”
Begin reading uses of water, starting with ‘drinking’. Place a checkmark in boxes that correspond to the
interviewee’s answers. If different household members use different types of water for any single activity, place a
check in each appropriate box.
Page 10

Unfiltered
tap water

Filtered
tap water

Bottled
water

Boiled
water

Other
(write)

Don’t
know

Drinking
Mixing cold drinks (like iced
tea, lemonade, cool-aid)
Hot drinks (like coffee or tea)
Making ice
Cooking hot food
Mixing infant formula
Brushing teeth

“Now I’ll ask you how you and members of your household cleaned, cooked, and bathed during the week before
you/they got sick. In addition to the types of water we already listed, let me know if you used hand sanitizer or
cleansing wipes for any of these tasks.”
Begin reading down the first column, starting with ‘rinsing fruits, etc’. Place a checkmark in boxes that correspond
to the interviewees answers.

Unfiltered
tap water

Filtered
tap water

Bottled
water

Boiled
water

Hand
sanitizer

Cleansing
wipes

Other
(write)

Don’t
know

Rinsing fruits,
vegetables, other
foods
Washing dishes by
hand
Cleaning kitchen or
bathroom counters
Washing hands
Bathing/showering
Bathing someone
(like a baby or elder)
Cleaning diaperchanging station

3. Since the Flint water crisis, have you changed your bathing and/or showering habits?
r No
r Yes
r Refused
IF NO: Skip to 4.
IF YES: Can you tell me more about what changes you’ve made to bathing and/or showering habits?

Page 11

Here are examples of prompts you can give the participant if need be: method (e.g., cleansing wipes,
sponge bathes, bottled water), location (office, someone else’s house, etc), frequency (more/less),
duration (longer/shorter)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

4. Since the Flint water crisis, have you changed your handwashing habits?
r No
r Yes
r Refused
IF NO: Skip to script below.
IF YES: Can you tell me more about what changes you’ve made to handwashing?
Here are examples of prompts you can give the participant if need be: method (e.g., hand sanitizer,
cleansing wipes, soap without water, soap with water), location (office, someone else’s house), when
(after using the bathroom, after changing diapers, before eating, before preparing food), frequency
(more/less), duration (longer/shorter)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Page 12

“That’s the end of the interview. Thanks for taking the time to answer these questions today. Is there anything
else you’d like to share with us or any questions we can answer for you?”
Refer to FAQ; if the answer is not listed, record the question below and inform the interviewee that an expert from
the health department will call them within 24 hours.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

“Would you like us to send you information about Shigella, the germ that caused you to get sick?”
r No
r Yes

-- END OF INTERVIEW –

Page 13

Table 1

1

2

3

4

5

Onset Date
MM/DD/YY

___ / ___ (MM/DD)

___ / ___ (MM/DD)

___ / ___ (MM/DD)

___ / ___ (MM/DD)

___ / ___ (MM/DD)

Index Case
(select 1 only)

First person ill?
r Yes r No

First person ill?
r Yes r No

First person ill?
r Yes r No

First person ill?
r Yes r No

First person ill?
r Yes r No

Age

________ yrs / mo

________ yrs / mo

________ yrs / mo

________ yrs / mo

________ yrs / mo

Person #
MDSS ID
(if applicable)

M r F
Other

Sex

r
r

Race

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

Ethnicity

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

Was this
person ill?

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Symptoms

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

Duration of
illness (days)

Medical care

Antibiotics

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Chronic
medical
conditions

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Immunocompromised

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Wore diapers

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Page 14

TABLE 1 (Continued)

6

7

8

9

10

Onset Date
MM/DD/YY

___ / ___ (MM/DD)

___ / ___ (MM/DD)

___ / ___ (MM/DD)

___ / ___ (MM/DD)

___ / ___ (MM/DD)

Index Case
(select 1 only)

First person ill?
r Yes r No

First person ill?
r Yes r No

First person ill?
r Yes r No

First person ill?
r Yes r No

First person ill?
r Yes r No

Age

________ yrs / mo

________ yrs / mo

________ yrs / mo

________ yrs / mo

________ yrs / mo

Person #
MDSS ID
(if applicable)

M r F
Other

Sex

r
r

Race

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

r
r

M r F
Other

r Black/African Am.
r White
r Asian
r American Indian
r Hawaian/Pacific Isl.

Ethnicity

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

r
r
r

Hispanic/Latino
Arab/Chaldean
Neither

Was this
person ill?

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Symptoms

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Fever >100F
r Stomach ache
r Diarrhea
r Bloody stools
r Nausea
r Vomiting
r Urgency to have a
bowel movement

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

r Doctor office
r Urgent care
r Pharmacy
r Natural healer
r ED
r Hospitalized
(admitted >36 hrs)
r None

Duration of
illness (days)

Medical care

Antibiotics

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Chronic
medical
conditions

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Immunocompromised

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Wore diapers

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

r
r

Yes r No
Don’t know

Page 15