Cyclosporiasis National Hypothesis Generating Questionna

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx

Cyclosporiasis National Hypothesis Generating Questionnaire (CNHGQ)
Public reporting of this collection of information is estimated to average 45 minutes per response, including the
time for reviewing instructions and completing and reviewing the collection of information. An agency many not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
current 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 (XXXX-XXXX)

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CNHGQ

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State ID#: ______________

Interview Information (Questions to be completed by interviewer prior to questionnaire administration)
1. State/Local/Other ID ____________ 2. Date of Interview ____________
3. Does the interviewee have a lab-confirmed case of cyclosporiasis?
Yes

No

Unknown

Pending

Interviewer Information:
4. Name ____________________________________________________________________________________
5. Agency or Organization ______________________________________________________________________
6. Contact phone number __________________
7. Before this interview how many times has the case-patient been interviewed about his/her illness?

7a. If other, please specify: ____________
8. Respondent of previous interview was
Self

Parent

Spouse

Other

8a. If other, specify: ____________
Begin Interview
Hello, my name is [state
your Name
name]. I am from [state
your Health
health Department
department]. We are contacting you
Interviewer
Interviewer
because of your recent infection with Cyclospora, which is a parasite that causes intestinal illness. We are
trying to determine how people become infected with Cyclospora so we can prevent others from getting sick.
You may have already been contacted by someone at the health department, but I would like to ask you
questions in a standard way about your illness, and about any travel you may have had or foods you may
have eaten before becoming ill. The interview will take about 20 minutes. Your help in the investigation is very
important. Your participation is voluntary, and you may refuse to answer any question at any time. All
information you give will be kept confidential to the extent permitted by law. No individual names or other
identifying information will be used in any official reports about the results of the investigation.
Are you willing to participate in this investigation?
If yes: Most of the questions relate to the 2-week period before you became ill. Therefore, it may help to have
a calendar nearby. Do you need a few moments to get one? [Then proceed to start of interview]
If no: Thank you for your time.

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State ID#: ______________

Section 1: Demographic Data

I'd like to begin by asking a few questions about you (your child) and your household.
1. State________ 2. County___________________ 3. Zip Code____________
4. Date of birth (MM/YYYY) ____________ 5. Age_____ 6. Sex

Male

Female

7. How would you describe your race?
White
Black/African American
Asian
Native Hawaiian/Other Pacific Islander
Unknown
Other

American Indian/Alaska Native

7a. If other, specify:_______________
8. Hispanic or Latino origin?

Yes

No

Unknown

Section 2: Clinical Information
Now I have a few questions about your (your child's) illness.

9. What date did you (your child) first feel sick? _________________________________________

Unknown

10. Did you (your child) have any diarrhea (defined as loose or watery stools that you do not normally have)?
Yes

Maybe

No

Don’t know

10a. What date did it start?___________________________________________________
11. Has your (your child's) diarrhea stopped?

Yes

Maybe

No

Unknown
Don’t know

11a. What date did it stop?____________________________________________________
12. Have your (your child's) other symptoms stopped?

Yes

Maybe

No

Unknown
Don’t know

12a. What date did they stop?_________________________________________________
13. Were you (your child) hospitalized overnight?

Yes

Maybe

No

Unknown
Don’t know

13a. How many nights were you (your child) hospitalized? _______
Hospital Name ______________________ Admission Date: ___________ Discharge Date: ___________
14. Have you (has your child) submitted a stool specimen for Cyclospora testing?
Yes

Maybe
No
Don’t know
14a. If yes, what was the date of stool collection?____________
14b. If known, what was the result of the test for Cyclospora?
Positive

Negative

Indeterminate

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State ID#: ______________

14c. Additional information on stool specimen (e.g., patient has appointment to submit stool)
If multiple stools were submitted, include information on those specimens below. If multiple stools were
submitted and only one was positive for Cyclospora, include the information on the positive result above
in questions 14a-b.
_____________________________________________________________________________________
_____________________________________________________________________________________
Section 3: Travel and Events
Next I have a couple of questions about any travel you (your child) might have done or events you
(your child) might have attended during the 14 days before onset of illness. The travel or events
could have been part of your work or for pleasure.

15. Did you (your child) spend all, or some, of the 14 days before becoming ill outside your home state?
Yes

Maybe

No

Don’t know

15a. List all US states where you (your child) might have purchased or eaten foods. This includes
airports, bus or train stations. ______________________________________
Unknown

Did not travel to other US states

15b. List all countries outside the US where you (your child) might have purchased or eaten foods.
___________________________________________

Unknown

Did not travel outside the US

15c. If you (your child) traveled with others, did any of the travel partners also become ill?
Yes

Maybe

No

Don’t know

15d. If yes, please provide information on other ill person(s), including number of ill persons and
relationship to you (e.g. son, mother, neighbor, friend, etc.)*.
___________________________________________________________________________________
16. Did you (your child) attend any events where food was served (e.g., parties, fairs, concerts, tournaments,
conventions)?

Yes

Maybe

No

Don’t know

16a. Please list the name of the event(s), date(s), and locations (s). _____________________________
____________________________________________________________________________________
16b. Do you know of any other ill person(s) who attended the event(s)?
Yes
Maybe
No
Don’t know
16c. If yes, please provide information on other ill person(s), including number of ill persons and
relationship to you (e.g. son, mother, neighbor, friend, etc.)*.
_____________________________________________________________________________________
Additional Comments
*Note: Please DO NOT enter names or other personally identifiable information in this form; State IDs to
reference ill contacts are acceptable.
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State ID#: ______________

Note to Interviewer: Does the interviewee meet the case definition for this outbreak? Consider whether the
person has a laboratory-confirmed cyclosporiasis case, the date of onset of illness, and travel history during
the 14 days before onset of illness.
If yes, continue with interview on next page.
If no, thank the interviewee for his/her time and end the interview
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State ID#:_______________

Section 4: Sources of food at home
Now I have a few questions about where the food came from that you ate at home during the 14
days 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 from which you would have eaten food during the 14 days
before you became sick.
17. Did you (your child) eat foods from: grocery stores or supermarkets, warehouse stores, small markets
(such as gas stations), ethnic specialty markets, health food stores, co-ops, fish or meat specialty shops,
farmer's markets or food directly from a farm, or any other sources?
Store Name

Address

City

State Zip Code

Date shopped

Items purchased

17a. Do you have a shopper card or membership card for any of the grocery stores or wholesale clubs
mentioned above?
Yes

Maybe

No

Don’t know

17b. If "Yes", may we have your shopper card number(s)? [Enter information below]
__________________________________________________________________________________________
__________________________________________________________________________________________
Section 5: 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 restaurants and commercial
food establishments; for each type please tell me the names of each place from which you would
have eaten food during the 14 days before you became sick.
18. Did you (your child) eat foods from: national fast food chains, Mexican-style, Italian, seafood,
Jamaican/Cuban/Carribean, Chinese/Indian/Japanese/Asian, vegetarian or vegan, barbeque or home-style,
steakhouse or grill, diner, Middle Eastern/Arabic/Lebanese/African, all-you-can-eat buffet, sandwich shop or
deli, salad bar, take-out, breakfast or brunch, school or institution, food truck, or other restaurants or
commercial food establishments?
Restaurant Name

Address

City

State Zip Code Date patronized

Food eaten

Additional Comments: _________________________________________________________________________
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Section 6: Fresh berries
Now I have some questions about fresh berries, not canned, cooked, or frozen, you (your child)
might have eaten during the 14 days before your illness began. You could have eaten these either
in your home or away from home. I am only interested in fresh berries that were not grown at
home. As I mention each food item, please answer as yes, no, may have eaten, or can't remember
eating the food during the 14 days before you got sick. Please remember that berries are often
served as garnishes on top of or on the sides of salads and desserts.

Yes

19. Did you (your child) eat any fresh red raspberries?

Maybe

No

Don’t know

If eaten at home, what was the:
19a. Brand(s) ____________________________________________________

Unknown

19b. Place(s) and date(s) of purchase _________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, what was the:
19c. List name(s) of establishment(s) _________________________________

Unknown

19d. List location(s) and date(s)________________________________________

Unknown

Not applicable (did not eat outside the home)

Yes

20. Did you (your child) eat any fresh blackberries?

Maybe

No

Don’t know

If eaten at home, what was the:
20a. Brand(s) ____________________________________________________

Unknown

20b. Place(s) and date(s) of purchase _________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, what was the:
20c. List name(s) of establishment(s) _________________________________

Unknown

20d. List location(s) and date(s)________________________________________

Unknown

Not applicable (did not eat outside the home)
Did you (your child) eat any:
21. Black raspberries?

Yes

Maybe

No

Don’t know

22. Golden raspberries?

Yes

Maybe

No

Don’t know

23. Strawberries?

Yes

Maybe

No

Don’t know

24. Blueberries?

Yes

Maybe

No

Don’t know

25. Boysenberries?

Yes

Maybe

No

Don’t know

26. Other fresh berries?

Yes

Maybe

No

Don’t know

26a. Type(s)____________________________________________________________
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State ID#:_______________

Section 7: Fresh fruits
Now I have some questions about fresh fruits, not canned, cooked, or frozen, you (your child)
might have eaten during the 14 days before your illness began. You could have eaten these either
in your home or away from home. I am only interested in fresh fruits that were not grown at
home. As I list each food item, please answer as yes, no, may have eaten, or can't remember
eating the food during the 14 days before you got sick.
Did you (your child) eat any:
27. Apples?

Yes

Maybe

No

Don’t know

28. Grapes?

Yes

Maybe

No

Don’t know

29. Pears?

Yes

Maybe

No

Don’t know

30. Peaches?

Yes

Maybe

No

Don’t know

31. Nectarines?

Yes

Maybe

No

Don’t know

32. Plums?

Yes

Maybe

No

Don’t know

33. Oranges?

Yes

Maybe

No

Don’t know

34. Grapefruit?

Yes

Maybe

No

Don’t know

35. Tangerines?

Yes

Maybe

No

Don’t know

36. Fresh lemon or lime? This could include a garnish on a drink.

Yes

Maybe

No

Don’t know

37. Cherries?

Yes

Maybe

No

Don’t know

38. Cantaloupe?

Yes

Maybe

No

Don’t know

39. Honeydew melon?

Yes

Maybe

No

Don’t know

40. Watermelon?

Yes

Maybe

No

Don’t know

41. Precut melon or melon salad?

Yes

Maybe

No

Don’t know

42. Other melon?

Yes

Maybe

No

Don’t know

43. Pineapple?

Yes

Maybe

No

Don’t know

44. Mango?

Yes

Maybe

No

Don’t know

45. Coconut (whole or shredded)?

Yes

Maybe

No

Don’t know

46. Other tropical fruit (kiwi, papaya, guava, pomegranate, etc.)?

Yes

Maybe

No

46a. Type(s)____________________________________________________________

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State ID#:_______________

Additional Comments
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Section 8: Iceberg Romaine
Now I have some questions about lettuce you (your child) might have eaten raw or uncooked
during the 14 days before your illness began. You could have eaten this either in your 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. I am only interested in lettuce that was not grown at home. As I read each
food, please answer as yes, no, may have eaten, or can't remember eating the food during the 14
days before you got sick. Please include lettuce you may have eaten on on sandwiches or burgers
or as a garnish.
47. Did you (your child) eat any prepackaged salad mix?

Yes

Maybe

No

Don’t know

If eaten at home, what was the:
47a. Brand(s), store(s), and date(s) purchased_________________________________

Unknown

47b. What were the ingredients (lettuce, cabbage, carrots, etc)?___________________

Unknown

Yes

48. Did you (your child) eat any iceberg lettuce?

Maybe

No

Don’t know

If eaten at home, what was the type:
Prepackaged

Head/Loose

Topping/garnish

Unknown

48a. Brand(s)__________________________________________________________

Unknown

48b. Place(s) and date(s) of purchase_______________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, where?
48c. List name(s) of establishment(s)_______________________________________

Unknown

48d. List location(s) and date(s)____________________________________________

Unknown

Not applicable (did not eat outside the home)

Yes

49. Did you (your child) eat any romaine lettuce?

Maybe

No

Don’t know

If eaten at home, what were the type:
Prepackaged

Loose

Topping/garnish

Unknown

49a. Brand(s)___________________________________________________________

Unknown

49b. Place(s) and date(s) of purchase________________________________________

Unknown

Not applicable (did not eat at home)

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If eaten outside the home, where?
49c. List name(s) of establishment(s)________________________________________

Unknown

49d. List location(s) and date(s)____________________________________________

Unknown

Not applicable (did not eat outside the home)
Section 9: Mesclun, Cabbage, Spinach and Other Leafy Greens
Now I have some questions about fresh mesclun, cabbage, spinach, and other lettuce or leafy
greens you (your child) might have eaten raw or uncooked during the 14 days before your illness
began. You could have eaten these either in your 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. I am only
interested in greens that were not grown at home. As I list each food item, please answer as yes,
no, may have eaten, or can't remember eating the food during the 14 days before you got sick.
50. Did you (your child) eat any mesclun lettuce (aka, spring mix, field greens, baby greens, gourmet salad)?

Yes

Maybe

No

Don’t know

If eaten at home, what was the:
50a. Brand(s) ____________________________________________________

Unknown

50b. Place(s) and date(s) of purchase _________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, what was the:
50c. List name(s) of establishment(s) _________________________________

Unknown

50d. List location(s) and date(s)________________________________________

Unknown

Not applicable (did not eat outside the home)

Yes

51. Did you (your child) eat any fresh cabbage?

Maybe

No

Don’t know

If eaten at home what was the type?
Red

Green

Savoy (aka, curly)

Napa

Bok choy

Brussels sprouts

Other/Unknown

51a. Brand(s)___________________________________________________________
51b. Place(s) and date(s) of purchase________________________________________

Unknown
Unknown

Not applicable (did not eat at home)
If eaten outside the home, where?
51c. List name(s) of establishment(s)________________________________________

Unknown

51d. List location(s) and date(s)____________________________________________

Unknown

Not applicable (did not eat outside the home)

Yes

52. Did you (your child) eat any fresh spinach?

Maybe

No

Don’t know

53. Did you (your child) eat any other lettuce or leafy greens (e.g., arugula, endive, mustard greens,

Yes

radicchio)?

Maybe

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State ID#:_______________

53a. Type(s), variety(-ies), brand(s)_________________________________________

Unknown

Additional Comments
________________________________________________________________________________________
Section 10: Fresh Herbs
Now I have questions about herbs that you (your child) may have eaten during the 14 days before
illness began. Remember, these could have been part of a dish such as pesto, salsa, sauces, etc. I
am interested in fresh herbs, not dried or bottled herbs. I am also only interested in fresh herbs
that were not grown at home. Please remember that fresh herbs are often served as garnishes on
top of or on the sides of entrees and desserts.
54. Did you (your child) eat any fresh basil?

Yes

If eaten at home what was the type:

Purple basil (i.e., purple leaves and stems)

Sweet basil

Thai basil (i.e., green leaves and purple stems)

Maybe

No

Don’t know

Other/Unknown

54a. Brand(s)____________________________________________________________

Unknown

54b. Place(s) and date(s) of purchase_________________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, where?
54c. List name(s) of establishment(s)_________________________________________
54d. List location(s) and date(s)____________________________________________

Unknown
Unknown

Not applicable (did not eat outside the home)

Yes

55. Did you (your child) eat any fresh cilantro?

Maybe

No

Don’t know

If eaten at home, what was the:
55a. Brand(s) ____________________________________________________

Unknown

55b. Place(s) and date(s) of purchase _________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, what was the:
55c. List name(s) of establishment(s) _________________________________

Unknown

55d. List location(s) and date(s)________________________________________

Unknown

Not applicable (did not eat outside the home)

Yes

56. Did you (your child) eat any fresh parsley?

No

Don’t know

57. Did you (your child) eat any other fresh herbs (sage, thyme, dill, rosemary, etc.)?

Yes

Maybe

No

57a. Type(s), variety(-ies), brand(s)?____________________________________

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State ID#:_______________

Additional Comments
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Section 11: Other Fresh Vegetables
Now I have some questions about other fresh vegetables, not grown at home, that you (your child)
may have eaten in the 14 days before your illness began. This does not include canned items, but
these foods could have been eaten alone or as part of a dish. I am only interested in vegetables
that were not grown at home. As I read each food, please answer as yes, no, may have eaten, or
can't remember eating the food in the 14 days before you got sick.
Did you (your child) eat any:
58. Cucumbers, zucchini, squash?

Yes

Maybe

No

Don’t know

59. Bell peppers (green, red, orange, or yellow)?

Yes

Maybe

No

Don’t know

60. Hot chili/chile peppers (e.g., jalapenos or serranos)?

Yes

Maybe

No

Don’t know

61. Celery?

Yes

Maybe

No

Don’t know

62. “Mini" carrots?

Yes

Maybe

No

Don’t know

63. Other fresh carrots?

Yes

Maybe

No

Don’t know

No

Don’t know

64. Other raw root vegetables (radishes, beets, turnips, etc)?

Yes

Maybe

64a. Type(s), variety(-ies)?_________________________________________________

Unknown

65. Did you (your child) eat any fresh, raw peas? May be shelled or in the pod.

Yes
If eaten at home what type?

Garden peas

Maybe

No

Don’t know

Snow peas (i.e., flat, shiny pods containing tiny peas)

Sugar snap peas (i.e, plump, crisp, edible pods)

Other/Unknown

65a. Brand(s)___________________________________________________________

Unknown

65b. Place(s) and date(s) of purchase_________________________________________

Unknown

Not applicable (did not eat at home)
If eaten away from home, where?
65c. List name(s) of establishments__________________________________________

Unknown

65d. List location(s) and date(s)_____________________________________________

Unknown

Not applicable (did not eat outside of home)

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Did you (your child) eat any:
66. Broccoli?

Yes

Maybe

No

Don’t know

67. Cauliflower?

Yes

Maybe

No

Don’t know

Yes

Maybe

No

Don’t know

69. Raw onions (white, yellow, or red/purple)?

Yes

Maybe

No

Don’t know

70. Raw green onions/scallions?

Yes

Maybe

No

Don’t know

71. Fresh tomatoes?

Yes

Maybe

No

Don’t know

72. Fresh salsa or pico de gallo (not from a jar)?

Yes

Maybe

No

Don’t know

68. Sprouts (alfalfa, bean, clover, broccoli, daikon radish, etc.)?

If eaten at home, what was the:
72a. Brand(s) ____________________________________________________

Unknown

72b. Place(s) and date(s) of purchase _________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, what was the:
72c. List name(s) of establishment(s) _________________________________

Unknown

72d. List location(s) and date(s)________________________________________

Unknown

Not applicable (did not eat outside the home)
73. Did you (your child) eat any fresh guacamole (not from a jar)?

Yes

Maybe

No

Don’t know

If eaten at home, what was the:
73a. Brand(s) ____________________________________________________

Unknown

73b. Place(s) and date(s) of purchase _________________________________

Unknown

Not applicable (did not eat at home)
If eaten outside the home, what was the:
73c. List name(s) of establishment(s) _________________________________

Unknown

73d. List location(s) and date(s)________________________________________

Unknown

Not applicable (did not eat outside the home)

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Additional Comments
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Section 12: Other Ill Persons
74. We are trying to identify other cases of illness similar to yours. Do you know anyone else (for example, a
family member, friend, co-worker, neighbor, church/temple/mosque member, health club or other club
member) whom you have NOT already told me about who has been ill recently with a similar illness?

Yes

Maybe

74a. If yes, please provide information on other ill person(s), including

No

Don’t know

number of ill persons and

relationship to you (e.g. son, mother, neighbor, friend, etc.)*.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

*Note: Please DO NOT enter names or other personally identifiable information in this form; State IDs to
reference ill contacts are acceptable.
This is the end of the questionnaire. Thank you very much for your time. These interviews are
extremely valuable in helping us understand how and why people are getting sick. Depending on
what we find out when we put these interviews together, we may need to talk to you again about a
few details.
Would you like to provide any additional thoughts or perspective about anything we've discussed or about this
outbreak investigation?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

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