Form CDC 52.13 CDC 52.13 NORS - Foodborne, Person-to-Person, Animal Contact, Envi

General

National Outbreak Reporting System

Foodborne Disease Transmission, Person-to-Person Disease Transmission, Animal
Contact, Environmental Contamination, Unknown Transmission Mode
This form is used to report investigations of foodborne disease outbreaks and enteric disease outbreaks transmitted by contact with persons, animals, or environmental sources, or by an unknown mode
of transmission. This form has 5 sections, General, Etiology, Settings, Animal Contact, and Food, as indicated by tabs at the top of each page. Complete the General and Etiology tabs for all modes of
transmission and complete additional sections as indicated by the mode of transmission. Please complete as much as possible of all applicable sections.
CDC USE ONLY

CDC ID

Form Approved
OMB No. 0920-0004

State ID

General Section – complete for all modes of transmission except water
Primary Mode of Transmission (Check one)

¨¨Food (complete General, Etiology, and Food tabs)
■■ Water (complete CDC 52.12)
¨¨Animal contact (complete General, Etiology, and Animal Contact tabs)
Investigation Methods (Check all that apply)
¨¨Interviews only of ill persons
¨¨Case-control study
¨¨Cohort study
¨¨Food preparation review
¨¨Water system assessment: Drinking water
¨¨Water system assessment: Nonpotable water

¨¨Person-to-person (complete General, Etiology, and Settings tabs)
¨¨Environmental contamination other than food/water
(complete General, Etiology, and Settings tabs)
¨¨Other/Unknown (complete General, Etiology, and Settings tabs)
¨¨Treated or untreated recreational water venue assessment
¨¨Investigation at factory/production/treatment plant
¨¨Investigation at original source (e.g., farm, water source, etc.)
¨¨Food product or bottled water traceback
¨¨Environment/food/water sample testing
¨¨Other

Comments
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Dates (mm/dd/yyyy)
Date first case became ill (required) ____________________

Date last case became ill ____________________

Date of initial exposure ____________________

Date of last exposure ____________________

Date of report to CDC (other than this form) ____________________
Date of notification to State/Territory or Local/Tribal Health Authorities _____________________
Geographic Location

Exposure state: ___________________________________________________________________________________________
¨¨Exposure occurred in multiple states
¨¨Exposure occurred in a single state, but cases resided in another state or multiple states
Other states: _______________________________________________________________________________________
(For multistate exposure or multistate residency outbreaks, enter the case count for each state)

Exposure county: _________________________________________________________________________________________
¨¨Exposure occurred in multiple counties in exposure state
¨¨Exposure occurred in a single county, but cases resided in another county or multiple counties
Other counties: _____________________________________________________________________________________

City/Town/Place of exposure: ____________________________________________________________________________

(Do not include proprietary or private facility names)

Primary Cases
Number of primary cases
Lab-confirmed primary cases

Sex (Number or percent of the primary cases)
# Male
#

%

Probable primary cases

# Female

#

%

Estimated total primary cases

# Unknown

#

%

Primary case outcomes

# Cases

Total # of cases
for whom info is
available

Age (Number or percent of the primary cases)

Died

#

#

<1 year

#

%

20–49 years

#

%

Hospitalized

#

#

1–4 years

#

%

50–74 years

#

%

Visited Emergency Room

#

#

5–9 years

#

%

> 75 years

#

%

#

# 10–19 years

#

%

Unknown

#

%

Visited health care provider
(excluding ER visits)
CDC 52.13 Rev. 3 2017

National Outbreak Reporting System

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General

Incubation Period, Duration of Illness, Signs or Symptoms for Primary Cases Only
Incubation Period (Select appropriate units)
Shortest

Min, Hours, Days

Duration of Illness (Among recovered cases-select appropriate units)
Shortest
Min, Hours, Days

Median

Min, Hours, Days

Median

Min, Hours, Days

Longest

Min, Hours, Days

Longest

Min, Hours, Days

Total # of cases for whom info is available

Total # of cases for whom info is available

¨¨Unknown incubation period
¨¨Unknown duration of illness
Signs or Symptoms (*Refer to terms from appendix E, if appropriate, to describe other common characteristics of cases.)
Sign or symptom
# cases with signs or symptoms
Total # cases for whom info is available
Vomiting
Diarrhea
Bloody stools
Fever
Abdominal cramps
HUS

*
*
*
*
Secondary Cases
Mode of secondary transmission (Check all that apply)
¨¨Food
¨¨Water
¨¨Animal contact
¨¨Person-to-person
¨¨Environmental contamination other than food/water
¨¨Other/unknown

Number of secondary cases
Lab-confirmed secondary cases

#

Probable secondary cases

#

Estimated total secondary cases

#

Estimated total cases (Primary + Secondary)

#

Other CDC System IDs (If applicable)
NEARS ID: 1)________________________ 2)________________________ 3)________________________ 4)_______________________
OHHABS ID: 1)________________________ 2)________________________
Traceback (For food and bottled water only, not public water)
¨¨Please check if traceback conducted
Source name
Source type (e.g., poultry farm, tomato
(if publicly available)

processing plant, bottled water factory)

Location of source
State

Traceback comments

Country

Recall
¨¨Please check if any food or bottled water product was recalled
Type of item recalled: _________________________________________________________________________________________
Comments: _________________________________________________________________________________________________
Reporting Agency
Reporting site: ________________________________________
E-mail: __________________________________________
Agency name: _________________________________________
Phone #: _______________________________________
Contact name: ________________________________________
Fax #: __________________________________________
Contact title: _________________________________________
General Remarks

Briefly describe important aspects of the outbreak not covered above. Please indicate if any adverse outcomes occurred in special
populations (e.g., pregnant women, immunocompromised persons)

_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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Etiology

Etiology Section – complete for all modes of transmission except water
Clinical and Environmental Testing
1. Were any samples collected and tested?

£ Yes

2. How many samples of each type were tested?
Type of sample

£ No

£ Unknown (If no or unknown, skip to Q6)

Tested? (yes/no/unknown)

Number of samples tested

Human specimen
Animal specimen
Food
Water
Other environmental (specify in general remarks)
3. What were they tested for? (check all that apply)
¨¨Bacteria (or bacterial toxins)
¨¨Viruses
¨¨Parasites
¨¨Chemicals/Toxins
¨¨Unknown
4. Test types (select all test types used for clinical specimens)
¨¨Chemical testing
¨¨Culture
¨¨DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR)
¨¨Microscopy (e.g., Fluorescent, EM)
¨¨Serological/immunological test (e.g., EIA, ELISA)
¨¨Tissue culture infectivity assay
¨¨Other (specify in general remarks)
¨¨Unknown
5. Was antimicrobial susceptibility testing (AST) performed? ¨ Yes ¨ No
If yes, where was AST performed? ¨ Clinical lab ¨ Public health lab
If yes, were any antimicrobial resistant isolates associated with the outbreak?

¨ Unknown
¨ CDC-NARMS
¨ Yes ¨ No

¨ Other
¨ Unknown
¨ Unknown

6. Is there at least one confirmed* or suspected outbreak etiology(s)?
¨ Yes
¨ No (unknown etiology) If no, skip to next section
*See http://www.cdc.gov/foodsafety/outbreaks/investigating-outbreaks/confirming_diagnosis.html

Etiology

(Name the bacterium, chemical/toxin, virus, or parasite. If available, include the serotype and other characteristics
such as phage type, virulence factors, and metabolic profile.)

Genus

Species

Serotype/genotype

Other
characteristics

Etiology confirmed # of labor suspected
confirmed cases

Detected in~

~Detected in (choose all that apply): 1 – patient specimen; 2 – food specimen; 3 – environmental specimen; 4 – food-worker specimen; 5 – water sample; 6 – animal specimen

Isolates/Strains
CDC system

CDC 52.13 Rev. 3 2017

(For bacterial pathogens, provide a representative for each distinct pattern. For norovirus outbreaks, provide CaliciNet key,
outbreak number, sequenced region, and genotype for each distinct strain.)

State lab ID/
Accession ID/
CaliciNet key/
PulseNet Key

CDC PulseNet
CDC PulseNet
cluster code
pattern designation
or CaliciNet
for enzyme 1
outbreak number

CDC PulseNet
pattern
designation for
enzyme 2

National Outbreak Reporting System

CaliciNet sequenced
region/whole genome
sequencing ID

CaliciNet genotype/
other molecular
designation

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Settings

Animal Contact

Settings Section – complete for person-to-person, environmental contamination, and other/unknown primary mode of transmission
Major Setting of Exposure (choose one)
¨¨Camp
¨¨Child day care
¨¨Event space
¨¨Festival/fair

¨¨Hospital
¨¨Hotel/motel
¨¨Long-term care/nursing
home/assisted living facility

¨¨Office/indoor workplace ¨¨Private home/residence
¨¨Shelter/group home/
¨¨Other healthcare facility
¨¨Religious facility
transitional housing
¨¨Restaurant
¨¨Ship/boat
¨¨Other (specify)
¨¨School/college/university
¨¨Unknown
¨¨Prison/jail
Specify setting _____________________________________________________________________________________________________

Attack Rates for Major Setting of Exposure
Group (based on setting)

Estimated exposed in
major setting*

Estimated ill in
major setting

Crude attack rate [(estimated ill /
estimated exposed) x 100]

Residents, guests, passengers, patients, etc.
Staff, crew, etc.
*e.g., number of persons on ship, number of residents in nursing home or affected ward

Other Settings of Exposure (choose all that apply)
¨¨Camp
¨¨Child day care
¨¨Event space
¨¨Festival/fair

¨¨Hospital
¨¨Hotel/motel
¨¨Long-term care/nursing
home/assisted living facility

¨¨Office/indoor workplace ¨¨Private home/residence
¨¨Shelter/group home/
¨¨Other healthcare facility
¨¨Religious facility
transitional housing
¨¨Restaurant
¨¨Ship/boat
¨¨Other (specify)
¨¨School/college/university
¨¨Unknown
¨¨Prison/jail
Specify setting _____________________________________________________________________________________________________

Additional Shigella Questions (Complete this section for Shigella outbreaks)
1. Did any case-patients report travel prior to illness onset? ¨ Yes ¨ No ¨ Unknown
If yes, was travel international, domestic, or both? ¨ International
¨ Domestic
¨ Both
¨ Unknown
2. Were any confirmed, suspected, or probable case-patients immunocompromised (e.g., HIV/AIDS)? ¨ Yes
¨ No ¨ Unknown
3. Were there any confirmed, suspected, or probable cases among men who have sex with men? ¨ Yes ¨ No ¨ Unknown

Animal Contact Section – complete for animal contact primary mode of transmission
Reason(s) animal contact, but undetermined vehicle (enter all that apply from list
in appendix E): __________________________________________________

¨ Animal vehicle undetermined
Animal

1

2

3

Animal Type (select one from list in appendix E)
Animal Type (specify)
Confirmed or suspected vehicle
Reason(s) confirmed or suspected

(enter all that apply from list in appendix E)

1. Settings of exposure (check all that apply)
¨ Agricultural
feed store
¨ Animal shelter
or sanctuary
¨ Camp
¨ Child day care
¨ Farm/dairy
¨ Festival or fair
¨ Hospital
¨ Laboratory

¨ Live animal market
¨ Long-term care/
nursing home/
assisted living
facility
¨ Pet store or other
retail location
¨ Petting zoo
¨ Prison/jail

¨ Private home/
residence
¨ School/college/
university
¨ Veterinary clinic
¨ Zoo or animal
exhibit
¨ Other (specify*)
¨ Unknown

3. Did any cases have exposure to livestock or household pets that
were experiencing diarrhea?
¨ Yes ¨ No ¨ Unknown
4. Was the “Compendium of Measures to Prevent Disease
Associated with Animals in Public Settings” used in the
investigation? ¨ Yes
¨ No ¨ Unknown

2. Was pet food or animal feed implicated as a potential
source of the outbreak? ¨ Yes ¨ No
¨ Unknown
If yes, please specify:
¨ Prepackaged pet food
¨ Pet treats or chews
¨ Homemade pet food
¨ Commercially prepared ‘raw’ pet food
¨ Frozen or fresh feeder rodents
¨ Blended feed
¨ Other (specify*)
¨ Unknown
5. What prevention measures or recommendations were used to
stop the outbreak and prevent additional infections? (check all that
apply)
¨¨Handwashing
¨¨Quarantine/stop movement
¨¨Venue or event closure
¨¨Removal of animals from setting

¨¨None
¨¨ Other (specify*)
¨¨Unknown

Animal contact remarks (*If “Other” was chosen, specify here):

CDC 52.13 Rev. 3 2017

National Outbreak Reporting System

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Food

Food Section – complete for foodborne primary mode of transmission
¨¨Food vehicle undetermined

Reason(s) foodborne, but undetermined vehicle (enter all that apply from list in appendix E): _______________

Food

1

2

3

¨¨Yes, country _____________
¨¨Yes, unknown
¨¨No
¨¨Unknown
¨¨Yes ¨ No ¨ Unknown

¨¨Yes, country _____________
¨¨Yes, unknown
¨¨No
¨¨Unknown
¨¨Yes ¨ No ¨ Unknown

¨¨Yes, country _____________
¨¨Yes, unknown
¨¨No
¨¨Unknown
¨¨Yes ¨ No ¨ Unknown

Name of food

(excluding any preparation)

Confirmed or suspected vehicle
Reason(s) confirmed or suspected

(enter all that apply from list in appendix E)

Ingredient(s)

(enter all that apply)

Contaminated ingredient(s)
(enter all that apply)

Total # of cases exposed to
implicated food
Method of processing

(enter all that apply from list in appendix E)

Method of preparation

(select one from list in appendix E)

Level of preparation

(select one from list in appendix E)

Contaminated food imported to US?

Was product both produced under
domestic regulatory oversight and sold?

Location where food was prepared

Location of exposure (where food was eaten)

¨¨Banquet facility (food prepared
¨¨Other healthcare facility
and served on-site)

¨¨Banquet facility (food prepared
¨¨Other healthcare facility
and served on-site)

¨¨Camp

¨¨Prison/jail

¨¨Camp

¨¨Prison/jail

¨¨Caterer (food prepared off-site
from where served)

¨¨Private home/residence

¨¨Caterer (food prepared off-site
from where served)

¨¨Private home/residence

¨¨Child day care

¨¨Religious facility

¨¨Child day care

¨¨Religious facility

¨¨Fair, festival, other temporary
or mobile services

¨¨Restaurant- Buffet

(check all that apply)

¨¨Farm/dairy
¨¨Grocery store

(check all that apply)

¨¨Fair, festival, other temporary
¨¨Restaurant – Buffet
or mobile services
¨¨Restaurant – ‘Fast-food’ (drive
¨¨Restaurant – ‘Fast-food’ (drive
¨¨Farm/dairy
up service or pay at counter)
up service or pay at counter)
¨¨Restaurant – Other or
¨¨Restaurant – Other or
¨¨Grocery store
unknown type
unknown type

¨¨Hospital

¨¨Restaurant – Sit-down dining

¨¨Hospital

¨¨Restaurant – Sit-down dining

¨¨Hotel/motel

¨¨School/college/university

¨¨Hotel/motel

¨¨School/college/university

¨¨Long-term care/nursing home/
¨¨Ship/boat
assisted living facility

¨¨Long-term care/nursing home/
¨¨Ship/boat
assisted living facility

¨¨Office/indoor workplace

¨¨Office/indoor workplace

¨¨Unknown

¨¨Unknown

¨¨Other (specify in ‘where prepared remarks’)

¨¨Other (specify in ‘where eaten remarks’)

Where prepared remarks:

Where eaten remarks:

Was there a kitchen manager certified in food safety at the location of preparation? ¨ Yes
CDC 52.13 Rev. 3 2017

National Outbreak Reporting System

¨ No

¨ Unknown
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Food
Contributing Factors (check all that contributed to this outbreak)
¨¨Contributing factors unknown
Contamination factor
¨¨C1 ¨ C2

¨ C3

¨ C4

¨ C5

¨ C6 ¨ C7

¨ C8

¨ C9

¨ C10

¨ C11

¨ C12

¨ C13

¨ P9

¨ P10

¨ P11

¨ P12

¨ P-N/A

¨ C14 ¨ C15

¨ C-N/A

Proliferation/amplification factor (bacterial outbreaks only)
¨¨P1 ¨ P2

¨ P3

¨ P4

¨ P5

¨ P6 ¨ P7

¨ S3

¨ S4

¨ S5

¨ S-N/A

¨ P8

Survival factor
¨¨S1 ¨ S2

Confirmed or Suspected Point of Contamination (check one)
¨¨Before preparation
If ‘before preparation’:

¨ Preparation
¨ Pre-Harvest

¨ Unknown
¨ Processing

¨ Unknown

Reason suspected (check all that apply)
¨¨Environmental evidence

¨¨Laboratory evidence

¨¨Epidemiologic evidence

¨¨Prior experience makes this a likely source

Was food-worker implicated as the source of contamination?
¨ Yes ¨ No ¨ Unknown
If yes, please check only one of the following:
¨¨Laboratory and epidemiologic evidence
¨¨Laboratory evidence

¨¨Epidemiologic evidence
¨¨Prior experience makes this a likely source

School Questions

(Complete this section only if “school” is checked in either sections “Location where food was prepared” or “Location of exposure (where food was eaten)”).

1. Did the outbreak involve a single or multiple schools?
¨ Single

¨ Multiple (number of schools:______)

2. School characteristics (for all involved students in all involved schools)

a. Total approximate enrollment: _________________ (number of students)

£ Unknown or undetermined

b. Grade level(s)
¨¨Grade school (grades K-12)
Please check all grades affected: ¨ K ¨ 1st ¨ 2nd ¨ 3rd ¨ 4th ¨ 5th ¨ 6th ¨ 7th ¨ 8th ¨ 9th ¨ 10th ¨ 11th ¨ 12th
¨¨College/university/technical school
¨¨Unknown or undetermined
c. Primary funding of involved schools
¨¨Public ¨ Private ¨ Unknown
4. How many times has the state, county or local health department
inspected this school cafeteria or kitchen in the 12 months before
the outbreak?*
¨¨Heat and serve (item mostly prepared or cooked off-site, reheated on-site)
¨¨Once
¨¨Served a-la-carte
¨¨Twice
¨¨Serve only (preheated or served cold)
¨¨More than two times
¨¨Cooked on-site using primary ingredients
¨¨Not inspected
¨¨Provided by a food service management company
¨¨Unknown or undetermined
¨¨Provided by a fast-food vendor
3. Describe the preparation of the implicated item:
(check all that apply)

¨¨Provided by a pre-plate company
¨¨Part of a club or fundraising event
¨¨Made in the classroom
¨¨Brought by a student/teacher/parent
¨¨Other (specify in General Remarks)
¨¨Unknown or undetermined

*If multiple schools are involved, please answer for the school with the most cases.

6. Was implicated food item provided to the school through the
National School Lunch/Breakfast Program?
¨¨Yes
¨¨No
¨¨Unknown or undetermined

If yes, was the implicated food item donated/purchased by:
¨¨USDA through the Commodity Distribution Program
¨¨The state/school authority
¨¨Other (specify in General Remarks)
¨¨Unknown or undetermined

CDC 52.13 Rev. 3 2017

5. Does the school have a HACCP plan in place for the school
feeding program?*
¨¨Yes
¨¨No
¨¨Unknown or undetermined
*If multiple schools are involved, please answer for the school with the most cases.

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Food
Ground Beef
1. What percentage of ill persons, for whom information is available, ate ground beef raw or undercooked? ________________ %
2. Was ground beef case-ready?
¨ Yes
¨ No

¨ Unknown

(Case-ready ground beef is meat that comes from a manufacturer packaged for sale that is not altered or repackaged by the retailer.)

3. Was the beef ground or reground by the retailer?
¨ Yes
¨ No
¨ Unknown

If yes, was anything added to the beef during grinding (e.g., shop trim or any product to alter the fat content)?: __________________

Eggs
1. Were eggs (check all that apply)
¨¨in shell, unpasteurized
¨¨in shell, pasteurized
¨¨packaged liquid or dry
¨¨stored with inadequate refrigeration during or after sale
¨¨consumed raw
¨¨consumed undercooked
¨¨pooled

2. Was Salmonella Enteritidis found on the farm?
¨ Yes ¨ No
¨ Unknown
Egg comment
(e.g., eggs and patients isolates matched by phage type):
__________________________________________________

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, Project Clearance
Officer, 1600 Clifton Road, MS D-24, Atlanta, GA, 30333, ATTN: PRA (0920-0004) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESS-->

CDC 52.13 Rev. 3 2017

National Outbreak Reporting System

CS262092-B

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