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pdfForm Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
MEDICAL CHART ABSTRCTION FORM
Public reporting burden of this collection of information is estimated to average 0 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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Fungal Bloodstream Infections Related to Oncology Practice A – Chart Abstraction Form
CDCID:____________
Clinic Chart #: ______________
1. Past Medical History
Underlying diseases (check all that apply):
X Cancer, type: _______________________________
Diabetes mellitus
Alcohol dependence/heavy alcohol use
immunosuppressive condition i.e. HIV/AIDS
Other disease (list below)
Info not available
If other, list: ________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. Clinic Visits
Visit 3
Visit 2
Visit 1
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:___________
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:_____________
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:_______________
Public reporting burden of this collection of information is estimated to average 0 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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:____________
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:__________
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:_____________
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:___________
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Vis
it 8
Visit 7
Visit 6
Visit 5
Visit 4
Visit Date: ___/___/_____ (MM/DD/YYYY)
Does the patient have any of the following access types?
Public reporting burden of this collection of information is estimated to average 0 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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Port-a-cath PICC line Central line Hickman catheter Implantable port
Other: ________________ Unknown None Peripheral IV
Did the patient receive any of the following (check all that apply):
Heparin Dexamethasone Ondansetron Aloxi
Chemo1:__________ Chemo2:____________ Chemo3:_____________
Flush1 Flush2 None Other:____________
3. Microbiology
Culture
Date/Time
1
____/____/____
____:____
Culture
Date/Time
2
____/____/____
____:____
Culture
Date/Time
3
____/____/____
____:____
Culture
Date/Time
4
____/____/____
____:____
Culture
Date/Time
5
____/____/____
____:____
Culture
Date/Time
Specimen Site
Port
PICC
Peripheral
Other__________
Unknown
Specimen Site
Port
PICC
Peripheral
Other__________
Unknown
Specimen Site
Port
PICC
Peripheral
Other__________
Unknown
Specimen Site
Port
PICC
Peripheral
Other__________
Unknown
Specimen Site
Port
PICC
Peripheral
Other__________
Unknown
Specimen Site
Culture type
Aer/Anae
Fungal
Culture type
Aer/Anae
Fungal
Culture type
Aer/Anae
Fungal
Culture type
Aer/Anae
Fungal
Culture type
Aer/Anae
Fungal
Culture type
Result
No growth final
Positive
Organism 1_____________
Organism 2_____________
Organism 3_____________
Result
No growth final
Positive
Organism 1_____________
Organism 2_____________
Organism 3_____________
Result
No growth final
Positive
Organism 1_____________
Organism 2_____________
Organism 3_____________
Result
No growth final
Positive
Organism 1_____________
Organism 2_____________
Organism 3_____________
Result
No growth final
Positive
Organism 1_____________
Organism 2_____________
Organism 3_____________
Result
Public reporting burden of this collection of information is estimated to average 0 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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
6
____/____/____
____:____
Port
PICC
Peripheral
Other__________
Unknown
Aer/Anae
Fungal
No growth final
Positive
Organism 1_____________
Organism 2_____________
Organism 3_____________
4. Symptoms at time of culture
Did patient have any of the following symptoms at the time of culture?
Yes
If yes, Temp: _____°F
Yes
Malaise (feeling poorly)
Yes
Headache
Yes
Chills
Yes
Arthralgias
Yes
Chest pain
Yes
Weakness
Yes
Fatigue
Yes
Lethargy
Yes
Night Sweats
Yes
Shortness of Breath
Yes
Anorexia
Yes
Muscle ache
Yes
Rash
If Yes, describe:________
Yes
Other symptoms
If Yes, specify:________
Fever
No UNK
_____________
No
No
No
No
No
No
No
No
No
No
No
No
No
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
UNK _
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
No UNK
_____________
5. Beta-D-glucan (if applicable)
Date performed
Specimen
Result
____/____/____
CSF
Blood
Level: __________
____/____/____
Level: __________
____/____/____
Level: __________
Public reporting burden of this collection of information is estimated to average 0 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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
____/____/____
Level: __________
____/____/____
Level: __________
____/____/____
Level: __________
6. Hospitalization Information
Admission Date: ____/____/____ (MM/DD/YY)
Discharge Date: ____/____/____ (MM/DD/YY)
Did patient have any of the following symptoms at time of admission?
Yes
If yes, Temp: _____°F
Yes
Malaise (feeling poorly)
Yes
Headache
Yes
Chills
Yes
Arthralgias
Yes
Chest pain
Yes
Weakness
Yes
Fatigue
Yes
Lethargy
Yes
Night Sweats
Yes
Shortness of Breath
Yes
Anorexia
Yes
Muscle ache
Yes
Rash
If Yes, describe:________
Yes
Other symptoms
If Yes, specify:________
Fever
No UNK
_____________
No
No
No
No
No
No
No
No
No
No
No
No
No
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
UNK
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
No UNK
_____________
Was port removed? Yes No N/A (no port)
If Yes, date of port removal: ___/___/___
Results of port culture:________________
If No, reason port was not removed: __________________________
Public reporting burden of this collection of information is estimated to average 0 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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Complete table for all antifungals and antibiotics received, if known: Unknown
Antifungal/Antibiotic
Dose
Start Date
Stop Date
Admitted to:
MICU General medicine Other__________ Unknown
Outcome:
Died Survived
If deceased, date of death:
_____/_____/_____ (MM/DD/YY) Unknown
If survived, date of discharge:
_____/_____/_____ (MM/DD/YY) Unknown
Notes:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Chart Review Completed by: _____________________________
Public reporting burden of this collection of information is estimated to average 0 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)
CHART ABSTRACTION FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM
JUNE 2016
Abstractor initials __________
Date _____________
CDC # _________________________
CASE INFORMATION
Medical facility
Correctional facility health services unit
Hospital, name ______________________________
Medical record # ______________________________
Patient Age ___________
Sex:
Male
Hispanic or Latino origin:
Yes
No
Race:
White
Female
Unknown
Black/ African American
Native Hawaiian/Other Pacific Islander
Height _________ in / cm
PAST MEDICAL HISTORY
Notes
Notes:
PAST SURGICAL HISTORY
Procedure
Notes:
Date
Other (specify): ___________
Weight _________ lb / kg
Notes:
Health condition
American Indian/Alaska Native
Notes
BMI __________
Asian
Unknown
CHART ABSTRACTION FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM
JUNE 2016
Abstractor initials __________
Date _____________
CDC # _________________________
MEDICATIONS IN PAST 6 MONTHS (Prior to hospitalization)
Name
Frequency
Duration
Dose
Notes
Notes:
BEHAVIORAL HEALTH RISK FACTORS
Behavior
Yes
No
Prior
Notes (Type, frequency, etc.)
Smoking
Other tobacco
Alcohol
Recreational drug use
Injection drug use
Notes:
EXPOSURE HISTORY
Reported consuming hooch or pruno:
Amount ______________________
Notes:
Yes
No
When _____________________
Color of hooch/pruno ____________________
CHART ABSTRACTION FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM
JUNE 2016
Abstractor initials __________
Date _____________
CDC # _________________________
HOSPITAL ADMISSION
Presentation: Date ____________ Time _________
Admitted:
Yes
No
Vital signs upon presentation:
Temperature _________ ◦C / ◦F
Blood pressure _____ / _____ mmHg
Heart Rate ___________ beats/ min Respiration Rate ___________ breaths/min
Presenting symptoms _______________________________________________________
Onset Date ____________ Time ___________
Notes:
SYMPTOMS (ER and admission note, plus neuro consult)
Symptom
Nausea
Vomiting
Diarrhea
Constipation
Abdominal Pain
Dry mouth
Hoarseness, or change in
sound of voice
Slurred Speech
Difficulty swallowing
Thick tongue
Shortness of breath
Blurred Vision
Double vision / diplopia
Dizziness
Weakness
Fatigue
Numbness or tingling
Urinary retention
Other:________________
Other:________________
Notes:
Yes
No
Unknown
Date / time first reported
CHART ABSTRACTION FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM
JUNE 2016
Abstractor initials __________
Date _____________
CDC # _________________________
PHYSICAL EXAM FINDINGS (ER and admission note, plus neuro consult)
Exam Finding
Yes
No
Unknown
Date / time first reported
Alert and Oriented
Extraocular Palsy
If yes, is it bilateral
If yes, is it symmetric
Ptosis
If yes, is it bilateral
If yes, is it symmetric
Pupils dilated
If yes, is it bilateral
Pupils constricted
If yes, is it bilateral
Pupils non-reactive
If yes, is it bilateral
Facial paralysis
If yes, is it bilateral
If yes, is it symmetric
Palatal weakness
Impaired gag reflex
Sensory deficits
Other
Notes:
Musculoskeletal Exam
Upper Extremity
Proximal
R:
/5
L:
/5
Distal
R:
/5
L:
/5
Lower Extremity
Proximal
R:
/5
L:
/5
Distal
R:
/5
L:
/5
Deep Tendon Reflexes
Upper Extremity
Bi/triceps
R:
/4
L:
/4
Brachial
R:
/4
L:
/4
Patellar
R:
/4
L:
/4
Ankle
R:
/4
L:
/4
Lower Extremity
Is muscle weakness / paralysis
present, describe progression
Notes:
Ascending
Descending
CHART ABSTRACTION FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM
JUNE 2016
Abstractor initials __________
Date _____________
CDC # _________________________
CLINICAL TESTS (ER and admission note, plus neuro consult)
Test
Yes
No
Unknown
Lumber puncture
If yes
Date:
WBC:
RBC:
Glucose:
EMG
With rapid, repetitive
stimulation
Suggestive of botulism
Date:
Endophonium (Tensilon)
Date:
Hertz:
Findings:
CT scan or MRI scan
Findings:
Toxicology screen
Urine
Serum
Blood Alcohol Conc.
Alcohol Panel
Electrolytes on admission
Na (sodium)
K (potassium)
Cl (chloride)
HCO3 (bicarbonate)
BUN
Creatinine
Glucose
Other diagnostic tests or labs
Notes:
Date:
Protein:
CHART ABSTRACTION FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM
JUNE 2016
Abstractor initials __________
Date _____________
CDC # _________________________
CLINICAL COURSE
Admitted to the ICU:
Intubated:
Yes
Yes
No
No
If yes, date ____________
If yes, date ____________
Respiratory muscle strength used to predict need for intubation
Test name
Value on admission
Value on “worst”
measurement
Date and time of “worst”
measurement
NIF (negative inspiratory
flow)
MIP (maximal inspiratory
pressure)
MEP (maximal exspiratory
pressure)
SNIP (sniff nasal inspiratory
pressure)
Tracheostomy:
Yes
Administered HBAT:
No
Yes
Adverse effects:
If yes, date ____________
No If yes, date ____________ Time __________
Anaphylaxis
Infusion Reaction
Hemodynamic instability
Other: __________________
Date that neurologic improvement was noted: ________________________
Outcome: Date ___________
Discharged alive
Died
Still hospitalized
Other ___________________________
Notes:
Additional notes:
Transfer _________________________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
QUESTIONNAIRE FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM, JUNE 2016
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)
QUESTIONNAIRE FOR PRISON OUTBREAK OF CLOSTRIDIUM BOTULINUM, JUNE 2016
Section 1: INTERVIEWER INFORMATION (Questions 1-5 to be completed by interviewer prior to questionnaire administration)
1.
3.
CDC ID: ______________________
2. Inmate #: _______________________
__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999)
M M D D Y Y Y Y
Date of Interview:
4.
Interviewer Information
5.
Location of interview:______________________________________
6.
Respondent is:
Confirmed case
7.
Staff present for interview:
State Health
8.
9.
Current cell/housing unit: __________________________________________________________________________________
Cell/housing unit on June 1st:_______________________________________________________________________________
Different from current cell/housing unit?
Yes
No
Unknown
If yes, when did the inmate change cell/housing unit?: __ __ / __ __ / __ __ __ __ Notes: _______________________________
M M D D Y Y Y Y
Name: ____________________
Agency or Organization: _______________________________
Suspected case
Correctional facility
Teleconference
Not a case
CDC
Other (Specify):_______________
Other (Specify):_______________
10. Inmate duty assignment (kitchen staff, janitorial, etc.):____________________________________________________________
Section 2: INMATE DEMOGRAPHIC DATA:
1.
Age: _________ years
2.
Sex:
3.
How would you describe your race?
4.
Do you identify as Hispanic or Latino origin?
Male
Female
Unknown
White
Black/ African American
Native Hawaiian/Other Pacific Islander
Yes
No
American Indian/Alaska Native
Other (specify): ___________
Asian
Unknown
Unknown
Section 3: FOOD ALLERGIES, SPECIAL DIETS: I am going to ask you questions about your diet.
Yes
Maybe
No
Don’t
Know
Did you have:
1.
2.
Any allergies that prevent you from eating a certain food(s)?
1a. What foods?
Milk
Eggs
Peanuts
Please check all that apply.
Soy
Wheat
Shellfish
Do you follow a special or restricted diet?
Which?______________________________
Tree nuts
Fish
other: ____________
Section 3 Comments. Please fill in any comments/notes from this section in the space provided below:
Section 4: ALTERNATE SOURCES OF FOOD AND DRINK: Now we are going to ask you about food and drink you may have
consumed outside of the prison cafeteria.
Yes
Maybe
No
Don’t
Know
Since Wednesday, June 1st, have you:
1.
Stored food in your cell?
1a. What foods? ___________________________________________________________
_____________________________________________________________________
2.
Consumed food prepared in your cell?
2a. What foods? ___________________________________________________________
______________________________________________________________________
Did you share with other inmates?
Yes
No
Unknown
Yes
Maybe
No
Don’t
Know
3.
Stored food in your housing unit?
4.
3a. What foods? ___________________________________________________________
_____________________________________________________________________
Consumed food prepared in your housing unit?
6.
4a. What foods? ___________________________________________________________
______________________________________________________________________
Did you share with other inmates?
Yes
No
Unknown
Received food from outside the prison, such as food brought to you by a friend or family
member?
5a. What foods? ___________________________________________________________
_____________________________________________________________________
Did you share with other inmates?
Yes
No
Unknown
Bought food from the commissary?
7.
6a. What foods? ___________________________________________________________
_____________________________________________________________________
Did you share with other inmates?
Yes
No
Unknown
Received food from another inmate (shared, traded, bought)?
5.
7a. What foods? ___________________________________________________________
_____________________________________________________________________
Did you share with other inmates?
Yes
No
Unknown
Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:
Section 5: HOOCH: Now I have a few questions about hooch, brew or pruno. You can skip any question you prefer not to
answer.
Yes
Maybe
No
Don’t
Know
1.
2.
Have you ever drank hooch since you entered the prison?
1a. How often do you drink hooch?
daily
weekly
monthly
less than monthly
when it is available
don’t know
Do you brew hooch yourself?
Refusal
If no, do you know how hooch is made?
3.
Yes
Refusal
No
Don’t know
Have you drunk hooch since June 1st?
Refusal
3a. On which days did you drink and how much each day?
FILL IN CALENDAR ON THE NEXT PAGE WITH DRINKING HISTORY
3b. What type of container(s) did you receive the hooch in?_____________________________
_________________________________________________________________________
Multiple containers (if multiple indicate on calendar)
3c. What type of container did you keep the hooch in?_________________________________
Same container as container received in
3d. Where did you get the hooch?
Refusal_______________________________________
_________________________________________________________________________
_________________________________________________________________________
3e. Can you describe the color of the hooch that you drank? ___________________________
________________________________________________________________________
Multiple colors (if multiple indicate on calendar)
3f. Do you know when the batch of hooch that you drank was dug up or ready to drink?
Yes
No
Don’t know
If yes, when? __ __ / __ __ / __ __ __ __
(if multiple batches, describe in comments)
3g. Did you share with other people?
Yes
No
Don’t know
How many people did you share with? __________________________________________
Did any of these people go to the hospital?
Yes
No
Don’t know
How many? __________
3h. Is the hooch you drank is still available for purchase?
Yes
No
Don’t know
3i. Can you tell me anything else about this batch of hooch? ___________________________
_________________________________________________________________________
_________________________________________________________________________
4. Before the recent outbreak, did you know hooch could make you sick (more than a hangover)?
5. Before the recent outbreak, had you heard of the illness botulism before?
Section 5 Comments. Please fill in any comments/notes from this section in the space provided below:
(Optional questions:
About how many brewers are there?
About how much do they brew per week (how often do they brew)?
How much hooch could you get right now if you wanted to?
How many stamps would a cup of hooch cost?)
JUNE
Sunday
Monday
Tuesday
Wednesday
1
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
5
6
7
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
12
13
14
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
8
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
15
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Thursday
2
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
9
Friday
3
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
10
Saturday
4
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
11
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
16
17
18
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Drank? Yes No
How much?
( ) Sip ( ) Cup
( ) Pint ( ) More
than a pint
Color:____________
Source:___________
Container:_________
Section 6: CLINICAL INFORMATION:. I am now going to ask you about your current illness and symptoms.
1.
What day/time did you first feel sick?
__ __ / __ __ / __ __ __ __ Time: __ __ : __ __ AM / PM
2.
What day/time did you first report
your symptoms to correctional staff?
What day/time did you first see a
doctor?
__ __ / __ __ / __ __ __ __ Time: __ __ : __ __ AM / PM
3.
4.
M
M
M
D
M
D
D
Y
D
Y
Y
Y
Y
Y
Not sick (Skip to Section 8)
Y
Y
__ __ / __ __ / __ __ __ __ Time: __ __ : __ __ AM / PM
M
Were you hospitalized?
M
D
D
Y
Y
Yes
Y
Y
No
Don’t know
When? __ __ / __ __ / __ __ __ __ Time: __ __ : __ __ AM / PM
M
M
D
D
Y
Y
Y
Y
Where were you first hospitalized? __________________________
5.
How many days total were you sick?
_______ days (enter 999 if unknown)
or
Still Ill
At any point during your illness, have you had:
Yes
No
Don’t
Know
Symptom
Nausea
Vomiting
Diarrhea
Constipation
Abdominal Pain
Dry mouth
Hoarseness, or change in sound of voice
Slurred Speech
Difficulty swallowing
Thick tongue
Shortness of breath
Blurred Vision
Double vision
Dizziness
Weakness
Fatigue
Numbness or tingling
Clinical history:
At any point in your life have you been told by a doctor that you have any of the following illnesses:
Don’t
Comorbidity
Yes
No
Know
Diabetes
Hypertension
TB
Hepatitis C
HIV
Other chronic illness?
Which other(s)?______________________________________________
Section 6 Comments.
Section 7: Medications: I will now ask you about medication, tobacco, and other substance use since June 1st. You can skip
any question/s you do not want to answer.
Yes
Maybe
No
Don’t
Know
Since June 1st, have you:
1.
Do you currently smoke cigarettes or other tobacco product(s)?
Refusal
How often?
at least once a day
at least once a week
at least once a month
when it is available
don’t know
If daily, how many cigarettes/tobacco per day on average?_________ (Specify_____________)
2.
3.
Do you currently chew tobacco or dip?
Refusal
How often?
at least once a day
at least once a week
when it is available
don’t know
Taken any over the counter medication(s)?
at least once a month
Which?__________________________________________________
4.
Taken medication(s) that was prescribed to you by a doctor?
Which?:_________________________________________________
5.
Taken any prescription medication(s) that was NOT prescribed to you by a doctor?
Which?__________________________________________________
6.
Have you smoked, snorted, or ingested any drug(s) for recreational use?
Which?
Marijuana
Cocaine/crack
Hallucinogen (Specify:___________)
7.
Methamphetamine
Other (Specify:____________________)
Have you injected any drug(s) for recreational use?
Which?
Cocaine
Heroin
Refusal
Refusal
Other (Specify:____________________)
Section 3 Comments. Please fill in any comments/notes from this section in the space provided below:
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
DETAILED ENTERICS QUESTIONNAIRE
Public reporting burden of this collection of information is estimated to average 60 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)
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
Thank you for all of the information you gave us so far. We are still working hard to try to understand
what caused you to become ill with Elizabethkingia infection.
Because you reported consuming some fruit or nuts in previous interviews, we have a few more specific
questions about what fruit or nuts you might have had before you became ill in 2015 or 2016, when you
might have consumed these foods, and how they were packaged.
1. Did you consume fruit or nuts purchased in bulk from a truck, delivery or mail order service, or
receive fruit or nuts from someone you know who uses one of these services in 2015 or 2016, before
you became ill?
Yes No
Maybe
2. Did you purchase or receive any fruit or nuts, or items that contain fruits or nuts, from any of the
following sources in 2015 or 2016, before you became ill? This could include any fruits or nuts that
you did not consume.
Via home delivery or mail order? Yes No
Maybe
Company/Business name: ______________________________________________________
Street address: ________________________________________________
City _______________________________ State ________ Date(s) of delivery _______________
Pick-up from truck or other pick-up location?
Yes No
Maybe
Pick-up location/business name: ______________________________________________________
Street address: ________________________________________________
City _______________________________ State ________ Date(s) of pick-up _______________
From a friend, family member, or co-worker?
Yes No
Maybe
Name of friend/family member: __________________________________________________
Telephone number: ____________________________________Date(s) _______________________
From a fundraiser (e.g., school, church, FFA)?
Yes No
Maybe
Name of organization/ school /club: __________________________________________________
Street address: ________________________________________________
City _______________________________ State ________ Date(s) of pick-up _______________
From a farmer’s market?
Yes No
Maybe
Market name/location: ______________________________________________________
Street address: ________________________________________________
City _______________________________ State ________ Date(s) of pick-up _______________
From another source (specify)?
Yes No
Maybe
Location/source: ______________________________________________________
Street address: ________________________________________________
City _______________________________ State ________ Date(s) of pick-up _______________
Updated 7/22/2016
2
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
3. Which of the following fruit or nuts, or items that contain fruits or nuts, did you purchase or
consume from the above source(s)? (please circle)
Specific fruit/nuts
Source of fruit/nuts based on above information
Blueberries
Peaches
Grapefruit
Honeybells / Minneola tangelos
Oranges (any type)
Navel oranges
Cranberries
Dried fruit
Other fruit purchased in bulk from the above source
(specify) _________________________________
Pecans
Chocolate-covered pecans
Other nut purchased in bulk from the above source
(specify)
____________________________________
4. For the fruits that you reported having in 2015 or 2016 before you became ill (see question 3), please
answer each item individually by circling Yes, No, or Maybe and provide as many details as
possible.
Produce / Beverages / Nuts
Item
Y
N
M
Unk
Additional information: variety or brand, purchase
location, how prepared, when and where consumed
etc.
Fruits
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Blueberries
Y
N
M
Unk
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Updated 7/22/2016
3
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
Date(s) consumed: ______________________________
If you froze, made, or received anything with the blueberries,
have you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Peaches (fresh, frozen, in
desserts or
jams/preserves)
Dates(s)received (if not purchased): ___________________
Y
N
M
Unk
Date(s) consumed: ______________________________
If you froze or made, or received anything with the peaches,
have you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Grapefruit
Y
N
M
Unk
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
If you froze, made, or received anything with the grapefruit, have
you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Updated 7/22/2016
4
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Honeybells / Minneola
tangelos
Y
N
M
Unk
Date(s) consumed: ______________________________
If you froze, made, or received anything with the honeybells,
have you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Orange(s) (any type)
Y
N
M
Unk
Date(s) consumed: ______________________________
If you froze, received, or made anything with the oranges, have
you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Navel oranges
Y
N
M
Unk
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Updated 7/22/2016
5
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
If you froze, received, or made anything with the navel oranges,
have you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / dried / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Date purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Cranberries (fresh, frozen,
dried, in desserts or
sauces)
Dates(s) received (if not purchased): ___________________
Y
N
M
Unk
Date(s) consumed: ______________________________
If you froze, received, or made anything with the cranberries,
have you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Other fresh fruit purchased
in bulk
Y
N
M
Unk
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
If you froze, received, or made anything with the fruit, have you
used or eaten them since?
Y / N / Not sure
____________________________________________________
Updated 7/22/2016
6
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Dried fruit purchased in
bulk
Date(s) consumed: ______________________________
Y
N
M
Unk
If you froze, received, or made anything with the fruit, have you
used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
Other fruit purchased in
bulk
Y
N
M
Unk
If you froze, received, or made anything with the fruit, have you
used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
Nuts
Pecans (by themselves or
in pies, desserts, ice
cream, cheese ball)
Updated 7/22/2016
Not in shell / in-shell (circle)
Fresh / frozen / in desserts or jams/preserves (circle)
Description/type: _______________________________
7
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
If you froze, received, or made anything with the pecans, have
you used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Chocolate-covered nuts
Y / N
/ Not sure
Specify nut: _____________________________
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
If you froze, received, or made anything with the nuts, have you
used or eaten them since?
Y / N / Not sure
____________________________________________________
___________________________________________________
___________________________________________________
Are there any left?
Other nuts purchased in
bulk
Y
N
M
Unk
Y / N
/ Not sure
Description/type: _______________________________
Where purchased: ______________________________
Date(s) purchased: ________________________________
Where received (if not purchased): __________________
Received from (if not purchased): __________________
Dates(s) received (if not purchased): ___________________
Date(s) consumed: ______________________________
If you froze, received, or made anything with the nuts, have you
used or eaten them since?
Y / N / Not sure
____________________________________________________
Updated 7/22/2016
8
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
___________________________________________________
___________________________________________________
Are there any left?
Y / N
/ Not sure
5. How were these fruits or nuts (or items with fruits or nuts) packaged when you purchased or
received them?
_________________________________________________________________________
6. Did you freeze any of the above fruits/nuts purchased or received in 2015 or 2016, before you
became ill?
Yes No
Maybe
7. Did you dry/dehydrate any of the above fruits/nuts purchased or received in 2015 or 2016, before
you became ill?
Yes No
Maybe
8. Did you make jams or preserves from any of the above fruits/nuts purchased or received in 2015 or
2016, before you became ill?
Yes No
Maybe
9. Did you make anything from else from the above fruits/nuts purchased or received in 2015 or 2016,
before you became ill?
Yes No
Maybe
10. Did you give or donate any of the above fruits/ nuts to other people or facilities in 2015 or 2016,
before you became ill?
Yes No
Maybe
11. Did you eat at the following restaurants, or receive any food from the following restaurants located
in Milwaukee, during 2015 or 2016, before you became ill?
Honeypie Café
Yes No
Maybe
Lulu Café
Yes No
Maybe
Palomino Bar
Yes No
Maybe
Juniper 61
Yes No
Maybe
Updated 7/22/2016
9
INTERVIEW DATE: _______/______/______
INTERVIEWER:___________
PATIENT ID:____________
CULTURE POSITIVE DATE:____________
Amilinda
Yes No
Maybe
12. Did you receive any products from Tree Ripe Citrus during 2015 or 2016, before you became ill?
Yes No
Maybe
13. Did you receive any products delivered by Spee-dee Delivery regional shipping company during
2015 or 2016, before you became ill?
Yes No
Maybe
Updated 7/22/2016
10
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
ETHNOGRAPHIC INTERVIEW GUIDE
Public reporting burden of this collection of information is estimated to average 120 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)
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
Patient identifier 1:
Date of Positive Elizabethkingia
___________________ Test PI 1: ___/___/_______
Patient History PI 1:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Patient identifier 2:
Date of Positive Elizabethkingia
___________________ Test PI 2: ___/___/_______
Patient History PI 2:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Patient identifier 3:
Date of Positive Elizabethkingia
___________________ Test PI 3: ___/___/_______
Patient History PI 3:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Patient identifier 4:
Date of Positive Elizabethkingia
___________________ Test PI 4: ___/___/_______
Patient History PI 4:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Patient identifier 5:
Date of Positive Elizabethkingia
___________________ Test PI 5: ___/___/_______
Patient History PI 5:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
Page 2 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
I. Daily activities
I. Typical daily routine
Our first step will be to have everyone to introduce themselves. Let’s go around the room and have
you say your name as it appears on your name card. Remember, this can just be a made up name, if
you want it to be; we just want a way to be able to identify each of you during the discussion today.
Along with your name, I would like to ask you about some of your daily activities in the 3 months
before you got ill [refer to calendar visual for everyone.] Could you tell me VERY briefly what do you
all do on a typical day or week? We can just quickly go around the room. [Gauge discussion of below
topics based on responses from participants. Limit to about 2 minutes per person]
I. Home environment
1. Could you describe where you live? Tell me about your neighborhood.
a. Are you in an urban or rural area?
b. Who else lives in your household?
II. Consumption of foods and drinks
Thank you for sharing this information with us. Now we’re going to specifically talk about what you
ate or drank you did in the 90 days before you became ill.
1. What did you eat and drink on a typical day from during the 3 months before you became ill?
a. How is your food typically prepared?
i. Do you cook your own food?
ii. Do you get your food from the grocery store?
iii. Do people bring you food? (either prepared or from a grocery store)
a. Probe for: fruit or pecan pies, ice creams with fruit or pecans, jams/jellies,
specifically oranges, grapefruit, tangelos, honeybells, blueberries, peaches
b. Fruit baskets? (especially around the holidays)
iv. Do you eat packaged or frozen foods?
v. If your food comes from a market, does it come from…
a. A regular grocery store?
b. Local store or farmer’s market?
c. Ethnic markets?
vi. Do you get your food from other sources, like:
a. Bulk food shops
Page 3 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
b. Food delivery trucks or systems, e.g., Schwann’s, seafood truck, FFA
c. Specially ordered bulk fruit, typically brought in from out of state that you or
someone you know ordered (if yes use fruit supplemental)
d. Fruit as gift, in gift baskets or seasonally delivered (if yes use fruit supplemental)
e. Specifically ask about Tree Ripe Citrus Fruit company? (mail order/pick up)
i. If picked up food from Tree Ripe Citrus, which location?
ii. Pick up from high school; from door-to-door sellers
f. Do you freeze fruit? If so, how old is this fruit (if you buy in bulk, how long does
your supply last in the freezer)? Do you still have the fruit from the time period
in question? (**Is it available for testing?)
iii. Probe for pecans, oranges, grapefruit, tangelos, honeybells, blueberries, peaches
from this or other delivery trucks during 2015
2. Did you go to any restaurants during this time? If so, did you consume any…
a. Dairy?
b. Meats?
c. Seafoods?
(Have participants elaborate)
d. Did you eat at: Honeypie Café, Lulu Café, Palomino Bar, Juniper 61, Amilinda in Milwaukee?
(these restaurants serve products that contain Tree Ripe Citrus products)
3 . Now I’d like to ask specifically about food you may have eaten that would have been produced
locally, meaning somewhere in South or Southeastern Wisconsin.
a. Dairy (milk, cheese, yogurt)
Spreadable cheese
Artisanal cheese or from a local cheesemaker
b. Produce (fruits, vegetables)
i. Sources of fruit: fruit delivery trucks, fruit stand on side of road or in parking lots
ii. Do you freeze fruit? If so, how old is this fruit (if you buy in bulk, how long does your
supply last in the freezer)? Do you still have the fruit from the time period in question? (**Is it available
for testing?)
iii. Mail order any fruit?
iv. Probe for pecans, oranges, grapefruit, tangelos, honeybells, blueberries, peaches
from this or other delivery trucks during 2015
c. Meats (hunted, grocery store, fresh vs. processed such as sausages or salami)
From local meat markets or butcher shops
Did you receive or order any holiday or specialty meat/cheese baskets or gifts
d. Seafood
4. Did you drink any…
a. Alcohol? (probe for any new or local alcoholic drinks like beer or wine)
Page 4 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
b. Juices? (probe for new or local juices)
c. Teas? (e.g., kombucha, herbal)
d. Milk? (probe for unpasteurized sources)
5. Did you use any local spice blends?
III. Employment
Thank you for telling us about your experiences so far. We know this is a long discussion so we
appreciate your patience. We will now talk a little bit about where you might have worked or
volunteered outside your home in the 3 months before you became ill. Even though we are moving on
to a different topic, you can feel free to tell us at any point if there is something you might have
forgotten to tell us earlier.
1. Did you work or volunteer outside your home during the 3 months before you became ill? How
would you describe your work environment (Was it dusty or clean? Was it a warehouse or office
building)?
2. What kind of work did you do? Describe what your typical day was like.
a. Welding
b. Factory work
c. Farm/garden
d. Office work
3. Did you work in areas that had a lot of:
a. Dust?
b. Sawdust or other small particles?
c. Chemicals around the area?
4. Did you interact with many people around you while working?
a. How many people did you typically interact with daily?
b. Do you remember if any of these people were typically healthy or at all ill?
5. Were there any birds or other animals nesting in areas where you were working?
6. Were there many insects in the area where you worked?
IV. Leisure activities/hobbies
Now we will talk about how you spend your free time. This can include any hobbies or pastimes you
might have. Could we quickly go around the room and talk about how you spent your free time in the
3 months before you became sick? [Limit to 2 minutes per person]
1. Do you like to spend time outdoors? If so, tell me what that looked like during the 3 months before
you got sick when you were not traveling. For example, did you do any:
a. Hunting
Page 5 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
i. Location of activity:
ii. Frequency of activity:
iii. How many other people were involved and how often?:
b. Bird watching
i. Location of activity:
ii. Frequency of activity:
iii. How many other people were involved and how often?:
c. Hiking
i. Location of activity:
ii. Frequency of activity:
iii. How many other people were involved and how often?:
d. Gardening
i. Location of activity:
ii. Frequency of activity:
iii. How many other people were involved and how often?:
e. Fishing
i. Location of activity:
ii. Frequency of activity:
iii. How many other people were involved and how often?:
f. Any other outdoor activities that you might think of?
2. Now I’d like to discuss time you’ve spent around animals. First, I am going to ask if any of you
had a variety of different exposures. Please say yes or raise your hand if you had the exposure.
Then we will talk about some of them in more detail. Did you spend time with or were around
any of the following:
a. Household pet, even if you didn’t touch it (cat, dog, rabbit)
b. Farm animals
c. Wild Birds (birdbath, birdfeeder, waterfowl watching or hunting)
d. Other wild animals (e.g., deer hunting)
e. Did you visit any areas with animals, such as farms, petting zoos, gardens or green
spaces?
f. Mice, rats (such as handling a mousetrap)
g. Did you find insects in or around your home or anywhere you might have spent a lot of
time during this period? Did you get any insect bites? Did a pet have insect bites, such
as from fleas or ticks?
h. Any other animal exposures you’d like to share?
3. Did you go to any social gatherings or regular meet-ups with friends or family? This could be on
a routine basis (like you go play cards every Saturday night) or gatherings that you might have
attended for special occasions.
a. What did you do during these gatherings? Where were they?
b. What did you eat?
Page 6 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
c. What did you drink?
d. Did you smoke any tobacco or other products?
e. Do you consume any tobacco or illicit products?
4. Did you keep any plants or flowers around the house, either inside or outside?
a. What kind of plants? (Probes: from where, newly acquired?, did patient plant or re-pot
them)
i. Did you have any seasonal plants? (this can include things like cacti, poinsettias,
Christmas tree, Easter lilies…)
b. How did you take care of these plants? ( e.g., water, re-pot them, give plant food or
fertilizer if needed)
c. Were there cut flowers in your home?
i. Were these plants/flowers from your garden or somewhere else?
ii. Were the plants/flowers delivered? (probe for source)
d. Were there cut flowers or plants anywhere else you spent time? This could be at work,
in a hospital, at a family member’s home, etc.
V. Health and wellness activities
Thank you for sharing your experiences with us so far. We know this is a long discussion so we
appreciate your patience. I know we have talked a lot in the past about your medical care before you
got sick. Now we’re going to ask you about some wellness activities and some other activities in the 3
months before you became ill. Even though we are moving on to a different topic, you can feel free to
tell us at any point if there is something you might have forgotten to tell us earlier.
1. Did you receive any massages during this time?
2. Did you receive acupuncture?
3. Did you receive any other health-related treatments that you did not get from your physician’s
office? (like alternative or holistic medicine)?
a. Did you go to a pain clinic?
b. Did you take anything, or receive any injections, to help with your health that you did not
receive at your physician’s office?
4. Did you ever visit a sauna or hot tub?
5. Did you take any products or supplements for your health and wellness, such as…
a. Probiotics
b. Herbal teas
c. Other supplements or vitamins
6. Did you do anything for exercise during this time?
a. What do you do for exercise? Where do you exercise?
b. Did you attend any gyms or exercise classes? What kind of classes did you attend, if any?
c. Did you ever visit a swimming pool or water park?
Page 7 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
7. Did you use a neti-pot?
VI. Any visitation periods/ travel
Let’s now talk about any travel you might have had or times when someone (such as a family member
or friend) came to visit you during the 3 months before you became ill. For the purpose of our
conversation, travel is anywhere outside your home where you stayed for the day, or overnight. This
could include routine travel or travel for special occasions.
1. Did you travel during the 3 months before you became ill?
a. Where did you go? When?
b. For how long did you travel during each of these trips?
2. Did anyone visit you during the 3 months before you became ill?
a. Who visited you?
b. How long did they visit you? (Were these regular visits?)
For each travel or visitation period, ask the following:
3. What was the purpose of your travel / visitation period (if visited by someone)?
a. Visit family
b. Vacation
c. Work
d. Event
4. Who did you see during this travel / visitation period?
a. What was the occupation of these people?
b. Did anyone have much contact with [especially probe for people with outdoor
occupations and grandchildren]:
i. Dirt or soil?
ii. Plants?
iii. Insects?
iv. Animals?
v. Manure?
vi. Chemicals?
5. How did you spend your time? (prompts: dining out, shopping, spa, gym, outdoor activities)
a. Did you participate in any outdoor activities?
i. Hunting
ii. Bird watching
iii. Hiking
iv. Gardening
v. Fishing
b. Did you spend time with animals? This includes time spent around household pets or
farm animals, as well as visiting a petting zoo or aquarium.
Page 8 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
i. What animals did you interact with? (e.g., dog, cat, fish in fish tank, exotic
animals)
ii. Tell me more about time spent with this animal.
c. Did you go to any social gatherings or events with family or friends?
d. Where did you eat or drink on these trips… (restaurant, family/friend house, brought
food from home)
i. Did you have any…
1. Local or home brews of alcohol beverages (e.g., beer, wine)
2. Homemade beverages, such as sodas or teas
3. Fermented drinks, like kefir
4. Local dairy products, like milk, cheese, or yogurt?
5. Local produce, like fruits or vegetables?
6. Meats?
a. Game meats obtained through hunting
b. Meats obtained from butcher or grocery store
c. Processed meats, like sausages or meat sticks?
e. Did you smoke or spend time with people who were smoking tobacco or other
products? Smoking includes cigarettes, e-cigarettes, pipes, cigars, and water pipes, often
called hookahs.
(if yes - what were they smoking?, where? Who was smoking if it wasn’t the patient?)
VII. Miscellaneous
1. Did it snow in the 3 months before you became ill? If so, did you or someone else shovel snow from
around where you live? If so, did you or they use any products to treat ice, like gravel, salt, or kitty litter?
2. How did you heat your home?
a. Did you have central heat?
b. Did you use a wood stove, pellet stove, or fireplace? If so, what did you burn in the fireplace?
3. Did you go anywhere else, either inside or outside (e.g., neighbor or friend’s home, outside next to
fire pit), with another source of heat?
2. Did you have any home deliveries during the 3 months before you became ill?
a. Regular delivery of medicines or other items?
b. Special deliveries of gifts or ordered items?
c. Did you receive any deliveries of flowers?
d. Did you receive deliveries of fruit or nuts from anywhere? (probe for Tree Ripe fruit)
Specifically: pecans, oranges, grapefruit, tangelos, honeybells, blueberries, peaches
e. Do you remember which company might have delivered these items (fedex, ups, usps)?
3. Did you take any free samples of items, such as foods, drinks lotions, soaps from any stores or
through the mail during the 3 months before you got sick?
Page 9 of 10
Version 7/21/2016
Interviewer: _____________________________________
Date: ___________________________
Time: ________________ AM/PM
Location: _______________________________________
Focus Group #: _________________
Thank you again for all of your responses. We so appreciate all of your patience. As you might know,
we have talked to a lot of people and spent a lot of time trying to figure out what is causing people to
become ill with this infection. We are still looking for clues as to what happened. Could you all briefly
tell me what YOU think might have caused you to become sick?
[Limit this to < 5 minute discussion.]
[COLLECT ACTIVITY SHEETS BEFORE EVERYONE LEAVES.]
Page 10 of 10
Version 7/21/2016
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Undetermined Mode of Transmission: Zika Virus among Utah Community Members, 2016
Public reporting burden of this collection of information is estimated to average 10 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)
Household Member Log
Household ID
Home Address
Street address: ______________________________________________________
City: ________________ State: _____ Zip: _________County: ___________________
(Best way to contact them in the future) Phone: ______________________________or e-mail: ________________________________________
List first and last name for each person who meets definition of a Household Resident and verify that they have been at this address for the last month.
Can you tell me the names of all the people who stayed in your house for at least two nights per week since mid-June (June 15) until now?
No.
Name of Resident
Age (*Record in
complete months if
child <2 years)
Sex
01
o years
o months
oF
oM
02
o years
o months
oF
oM
03
o years
o months
oF
oM
04
o years
o months
oF
oM
Record of consent for
INTERVIEW
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
Date interview
conducted
Record of consent for
SPECIMENS
Specimens
collected
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
oBlood
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
05
o years
o months
oF
oM
06
o years
o months
oF
oM
07
o years
o months
oF
oM
08
o years
o months
oF
oM
09
o years
o months
oF
oM
10
o years
o months
oF
oM
11
o years
o months
oF
oM
12
o years
o months
oF
oM
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
oBlood
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached)
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
o Consent obtained
o Consent refused
o Parental consent provided
o Parental consent refused
o Person never reached
oBlood
oUrine
oNone
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
oBlood
oUrine
oNone
Community Evaluation Questionnaire
HH ID:___________________________
Interviewer Information
Interviewer Name (First, Last): ________________________________________________________
State/Local/Territorial Health Department: ______________________________________________
Language survey was conducted in: __________________________
Informant Information o Not applicable
If not the specific individual, who is providing information for this form?
HH ID Number: ______________________________________________
Relationship to resident: ____________________________________________
Reason individual unable to provide information him/herself:
o Child
o Mentally handicapped
o Other: _______________________
Exposures
Now I would like to ask you about your time outdoors or potential exposure to mosquitoes.
Since June 15, 2016, how much time on average have you spent outdoors each day?
o less than 1 hour
o 1-4 hours
o 5-10 hours
o more than 10 hours
o Don’t know
How often did you wear mosquito repellant when you were outdoors for 15 minutes or more?
o Always o Most of the time
oSometimes
oNever
o Don’t know
Since June 15, 2016, did you get any mosquito bites?
o Yes
o No
o Don’t know
For windows and outside doors that you have left open this summer, how many of these have screens?
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Resident’s Travel and Potential Flavivirus exposure
Now I would like to ask you about if you might have been exposed to Zika virus or related viruses before.
Did you travel outside the United States (or to a US territory: Puerto Rico, USVI, Am Samoa) in the last
year (since July 2015)? o Yes
o No
If yes: Name of country(s): _____________________________________
Dates of travel: Start date:____/_____/______ End date: ____/_____/______
Name of country(s): _____________________________________
Dates of travel: Start date:____/_____/______ End date: ____/_____/______
Name of country(s): _____________________________________
Dates of travel: Start date:____/_____/______ End date: ____/_____/______
Name of country(s): _____________________________________
Dates of travel: Start date:____/_____/______ End date: ____/_____/______
Name of country(s): _____________________________________
Dates of travel: Start date:____/_____/______ End date: ____/_____/______
Name of country(s): _____________________________________
Dates of travel: Start date:____/_____/______ End date: ____/_____/______
Were you born or lived for several years outside the United States? o Yes
Unknown
o No
If yes, where? _________________________________________________________________
o
Medical Information
Since June 15, 2016, have you had any of these symptoms? We are talking about symptoms that would have
been new for you, not long standing problems?
Fever
o Yes
o No
If yes, first date with this ____/_____/______
How many days did it last? ________
(Note, here we would count their report of subjective fever. Interviewer, please use calendar aid)
o Yes
Rash
o No
If yes, first date with this ____/_____/______
How many days did it last? ________
(here we are NOT asking about a rash that was just on one arm or one leg, like poison ivy)
Conjunctivitis (redness of the white part of the eyes)
o Yes
o No
If yes, first date with this ____/_____/______
How many days did it last? ________
(here we are NOT asking about red, itchy eyes that you may know you get because of allergies)
Joint Pain
o Yes
o No
If yes, first date with this ____/_____/______
How many days did it last? ________
(here we are NOT asking about pain that was definitely from an injury)
For this illness, did you go to a clinic/hospital to be checked? o Yes
o No
If yes, what did the doctor/nurse decide that you had? __________________________________
((Use this additional space if more than one episode, or additional notes))
For females age ≥12 years and <45 years: Are you pregnant or think you might be pregnant?
o Yes
o No
o Unknown
Information related to blood specimens and interpretation of results
If NO blood specimen is consented for. Thank you again for your willingness to provide the information. If we
have any additional questions, is it okay to contact you again?
o Yes
o No
(If yes, verify contact details on household list)
If blood specimen is consented for, complete specimen collection form, and ask these additional questions:
We would like to ask you just a few more questions about your health so we can better understand your blood
test results.
To the best of your knowledge, have you ever received these vaccines (these are vaccines that may be
given to persons who travel out of the country)
Yellow fever vaccine
o No
Japanese encephalitis vaccine
o No
Tick-borne encephalitis vaccine o No
o Unsure
o Unsure
o Unsure
o Yes, year of last dose__________
o Yes, year of last dose__________
o Yes, year of last dose__________
Has your doctor told you that you have any medical conditions that limit your ability to fight infections?
o Yes
o No
o Unknown
Are you taking any medications that suppress your immune system?
o Yes
o No
o Unknown
In the past 2 months, did you receive a blood transfusion or organ transplant?
o Yes
o No
o Unknown
For this last question, we will ask you to read it and point to the answer.
In the last year, have you ever had unprotected sex with someone who had recently returned from a
country where Zika has been spreading? (By recently returned, we mean your partner had returned
sometime during the 2 months before the time you had unprotected sex)
Your Answer o Yes
o No
o Unknown
Thank you very much for your willingness to answer these questions and provide a blood sample.
We will next contact you directly about your results of the blood test. It may take several weeks to get the final
results.
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Healthcare Personnel Risk Assessment Questionnaire and Serosurvey for Zika Virus Exposure—Utah, 2016
Public reporting burden of this collection of information is estimated to average 3 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)
ID _____ _____ _____ _____ _____
Zika Virus Exposure Assessment for
Date of interview:
Healthcare Personnel
Name of interviewer:
Subject name:
Job Title:
Is contact information correct?
If no, please provide
Address:
Phone:
Where was interview administered (circle one)?
Wellness clinic
Phone
Home
Other (please specify)______________
Has sample been collected?
Yes
No
Not indicated at this time
Case or Control (circle one)
1
ID _____ _____ _____ _____ _____
Section 1: Demographics, Role---------------------------------------------------------------------------1.
Gender
2.
Age
3.
Please indicate your job title at this facility
Laboratory staff
Male
Female
___________ years
Environmental services
Physician/Advanced Care Provider
Nurse
Respiratory therapy
Radiology tech
Certified nursing assistant/Health care assistant
Other (please specify) ______________________
4.
How long have you been working in your current role (at any facility)? _____________ months/years
2
ID _____ _____ _____ _____ _____
Section 2: Risks and symptoms---------------------------------------------------------------------------Country of origin:
Have you lived outside of the US?
Yes
No
If yes, what countries have you lived in and when did you live there?
Country
Start date
End date
Travel history (past year)
Region/country
Mexico
Cape Verde
Caribbean (please specify) __________________
Puerto Rico
Central America (please specify) __________________
Pacific Islands (please specify) __________________
South American (please specify) __________________
Africa (please specify) __________________
Asia (please specify) __________________
Start date (XX/XX/XXXX)
End date (XX/XX/XXXX)
Vaccination history
Previous vaccinations:
Yellow Fever
Last dose:
Tick-borne Encephalitis
Last dose:
Japanese Encephalitis
Last dose:
Pregnancy
Are you or your partner currently
pregnant?
Are you or your partner trying to
become pregnant now?
Yes
No
Unknown
If yes, test (group A)
Yes
No
Unknown
If yes, test (group A)
3
ID _____ _____ _____ _____ _____
Are you or your partner planning to
become pregnant in the next 6
months?
Yes
No
Unknown
If yes, test
Symptoms (developed since patient interaction)
Fever
If yes,
Yes
dates
Subjective
Rash
No
_________ to __________
Measured
(Max measured temperature: _______F/C)
Arthralgia
If yes,
dates
Yes
No
_________ to __________
Yes
No
If yes,
Type:
dates
_________ to __________
Maculopapular
Petechial
Purpuric
Other
Yes
No
Pruritic:
Distribution:_____________________________
Conjunctivitis
If yes,
dates
Yes
No
_________ to __________
Do they have 2 or more symptoms occurring within one week?
If no
If yes
Asymptomatic
Symptomatic
If symptomatic, are you currently symptomatic or have been symptomatic in the past 14 days?
No
Yes
Call Dr. Rubin for further instructions
If symptomatic, were symptoms more than 14 days ago?
No
Yes
If yes, test (group B)
4
ID _____ _____ _____ _____ _____
Section 4: PPE training--------------------------------------------------------------------------------------Have you received training on proper selection of PPE for standard precautions?
Yes
No
Gloves?
Yes
No
Gown?
Yes
No
Eye protection?
Yes
No
Gloves?
Yes
No
Gown?
Yes
No
Eye protection?
Yes
No
Have you received training on how to don:
Have you received training on how to doff (so as not to contaminate):
How often does this training occur?
______________________________________
When did you last receive training?
______________________________________
Were you required to demonstrate competency?
Yes
No
5
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Healthcare Personnel Risk Assessment Questionnaire and Serosurvey for Zika Virus Exposure—Utah, 2016
Public reporting burden of this collection of information is estimated to average 10 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)
ID _____ _____ _____ _____ _____
Zika Virus Exposure Assessment for
Date of interview:
Healthcare Personnel
Name of interviewer:
Subject name:
Job Title:
Is contact information correct?
If no, please provide
Address:
Phone:
Where was interview administered (circle one)?
Wellness clinic
Phone
Home
Other (please specify)______________
Has sample been collected?
Yes
No
Not indicated at this time
Case or Control (circle one)
1
ID _____ _____ _____ _____ _____
Section 1: Demographics, Role---------------------------------------------------------------------------1.
Gender
2.
Age
3.
Please indicate your job title at this facility
Laboratory staff
Male
Female
___________ years
Environmental services
Physician/Advanced Care Provider
Nurse
Respiratory therapy
Radiology tech
Certified nursing assistant/Health care assistant
Other (please specify) ______________________
4.
How long have you been working in your current role (at any facility)? _____________ months/years
2
ID _____ _____ _____ _____ _____
Section 2: Risks and symptoms---------------------------------------------------------------------------Country of origin:
Have you lived outside of the US?
Yes
No
If yes, what countries have you lived in and when did you live there?
Country
Start date
End date
Travel history (past year)
Region/country
Mexico
Cape Verde
Caribbean (please specify) __________________
Puerto Rico
Central America (please specify) __________________
Pacific Islands (please specify) __________________
South American (please specify) __________________
Africa (please specify) __________________
Asia (please specify) __________________
Start date (XX/XX/XXXX)
End date (XX/XX/XXXX)
Vaccination history
Previous vaccinations:
Yellow Fever
Last dose:
Tick-borne Encephalitis
Last dose:
Japanese Encephalitis
Last dose:
Pregnancy
Are you or your partner currently
pregnant?
Are you or your partner trying to
become pregnant now?
Yes
No
Unknown
If yes, test (group A)
Yes
No
Unknown
If yes, test (group A)
3
ID _____ _____ _____ _____ _____
Are you or your partner planning to
become pregnant in the next 6
months?
Yes
No
Unknown
If yes, test
Symptoms (developed since patient interaction)
Fever
If yes,
Yes
dates
Subjective
Rash
No
_________ to __________
Measured
(Max measured temperature: _______F/C)
Arthralgia
If yes,
dates
Yes
No
_________ to __________
Yes
No
If yes,
Type:
dates
_________ to __________
Maculopapular
Petechial
Purpuric
Other
Yes
No
Pruritic:
Distribution:_____________________________
Conjunctivitis
If yes,
dates
Yes
No
_________ to __________
Do they have 2 or more symptoms occurring within one week?
If no
If yes
Asymptomatic
Symptomatic
If symptomatic, are you currently symptomatic or have been symptomatic in the past 14 days?
No
Yes
Call Dr. Rubin for further instructions
If symptomatic, were symptoms more than 14 days ago?
No
Yes
If yes, test (group B)
4
ID _____ _____ _____ _____ _____
Section 3: Patient Interaction-----------------------------------------------------------------------------Days with any patient interaction?
6/19
6/20
6/22
6/23
6/24
6/25
Site interaction occurred
ER
ECU
Ward ICU Other ________________
Patient care
Device reprocessing
Environmental cleaning
Food service needs
Other (please specify)
____________________
Did you enter patient’s room or care area?
Yes No
Did you touch patient?
Yes No
Did you (circle all that apply):
Have any contact with blood or body fluids?
Clean up vomit?
Clean up stool?
Draw blood?
Collect urine sample or empty Foley bag?
Collect stool sample?
Wipe away sweat?
Wipe away tears?
Suction or manipulate airway?
Place Foley?
Place or manipulate rectal tube?
Reposition the patient?
Bathe the patient?
Change linens?
Perform physical exam?
Perform radiology exam or Echo?
Device reprocessing?
Perform procedure (please specify)?____________________________
Cumulative time in room in hours
< 1 hour
1 to 2 hours 59 minutes
3 to 5 hours 59 minutes
6 or more hours
If yes, then low
If yes, then medium and test
(group B)
If any circled, then high and test
(group B)
5
ID _____ _____ _____ _____ _____
Did you have any contact with blood or body fluids?
Body fluid
What were you
doing?
Blood
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Respiratory
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Stool
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Was this
protected
(PPE)?
Yes
No
Yes
No
Yes
No
What PPE did you
typically wear?
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
specify):__________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
Did you
have
visible
soilage of
PPE?
Yes
No
Yes
No
specify):__________
Yes
No
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
specify):__________
Yes
No
Areas of contact
(pick all that
apply)?
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
6
ID _____ _____ _____ _____ _____
Body fluid
What were you
doing?
Urine
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Vomitus
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Tears
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Was this
protected
(PPE)?
Yes
No
Yes
No
What PPE did you
typically wear?
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
specify):__________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
Did you
have
visible
soilage of
PPE?
Areas of contact
(pick all that
apply)?
Yes
Protected
No
Yes
No
specify):__________
Yes
No
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
specify):__________
Yes
No
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
7
ID _____ _____ _____ _____ _____
Body fluid
What were you
doing?
Sweat
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Other
(Please
specify)
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
# times
Other
(Please
specify)
# times
Phlebotomy
Procedure
Equipment
Soiled linen
Contaminated
surface
Biohazard waste
Cleaning
Other (please
specify)________
Was this
protected
(PPE)?
Yes
No
Yes
No
What PPE did you
typically wear?
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
specify):__________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
Did you
have
visible
soilage of
PPE?
Areas of contact
(pick all that
apply)?
Yes
Protected
No
Yes
No
specify):__________
Yes
No
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other
(please
specify):__________
Yes
No
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
Protected
Not protected
Intact skin
Broken skin
Mucous
membranes
(please
specify)________
Percutaneous
exposure
Other (please
specify_________
8
ID _____ _____ _____ _____ _____
Were you involved with any procedures (either performing or in room)?
Intubation
Central line
placement
Bronchoscopy
CPR
Sputum induction
Extubation
Airway suctioning
Nasogastric tube
placement
Nebulizer
treatment
Dialysis
Rectal tube
placement or
manipulation
Arterial line
placement
Peripheral IV
placement
Noninvasive
ventilation
Lumbar puncture
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Performed or assisted with
procedure
Present in room
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
9
ID _____ _____ _____ _____ _____
Other (please
Performed or assisted with
specify)
procedure
_______________
Present in room
Face shield
Goggles
Facemask
Respirator/N95
Gloves
Gown
Other (please specify): _______________________
Did you come into contact with body following death? Yes
No
Did you have any other contact with the patient not previously mentioned?
10
ID _____ _____ _____ _____ _____
Section 4: PPE training--------------------------------------------------------------------------------------Have you received training on proper selection of PPE for standard precautions?
Yes
No
Gloves?
Yes
No
Gown?
Yes
No
Eye protection?
Yes
No
Gloves?
Yes
No
Gown?
Yes
No
Eye protection?
Yes
No
Have you received training on how to don:
Have you received training on how to doff (so as not to contaminate):
How often does this training occur?
______________________________________
When did you last receive training?
______________________________________
Were you required to demonstrate competency?
Yes
No
11
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Hepatitis A: Supplemental Case Questionnaire
Public reporting burden of this collection of information is estimated to average 5 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)
Section 1: Interviewer information (Questions 1-3 to be completed by interviewer prior to questionnaire
administration)
1. Date of Interview:
__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999)
M M D D Y Y Y Y
2. Interviewer Information:
a. Name: ________________
b. Contact phone number: (____) ______-________
c. Agency or Organization: _____________________________
3. Respondent was:
Self
Parent
Spouse
Other (Specify):_______________
MAVEN ID: __ __ __ __ __ __ __ __ __
Section 2: Food Recall
1. In the period 15 to 50 days before you became ill, did you eat at a Sushi Restaurant A location in
Hawaii?
(This date must be on or before August 15, 2016. If a later date is provided, ask about dates on or before August
15.)
Yes
No
Unknown
****If No or Unknown, proceed to QUESTION #7
2. If yes, at which Sushi Restaurant A location or locations did you eat? (ask each location)
Aina Hana, Honolulu
Ala Moana Center, Honolulu
Ewa Town Center, Ewa
Kaneohe, Kaneohe
Kapahulu, Honolulu
Kapolei Commons, Kapolei
Pearlridge Center, Uptown
Waikele Center, Waipahu
Waiau, Pearl City
Ward Center, Honolulu
Kukui Grove Shopping Center, Lihue
Other (write in location) __________________________________
Don’t know
Refused
3. What were the date(s) of your most recent visit(s) to Sushi Restaurant A within this period?
4. Did you eat raw or undercooked fish or seafood while at Sushi Restaurant A during this period?
Yes
No
Unknown
5. If yes, did you eat scallops?
Yes
No
Unknown
6. Did you eat scallops anywhere besides Sushi Restaurant A in the 15 to 50 days before becoming ill?
Yes
No
Unknown
****If No or Unknown, proceed to QUESTION #9
7. Were the scallops raw or undercooked?
Yes
No
Unknown
8. Where did the scallops come from? (Please specify restaurant/store name and location)
_________________________________________________
Unknown
9. Did you eat at a potluck in the 15 to 50 days before becoming ill?
Yes
No
Unknown
****If No or Unknown, proceed to End of Survey Instructions.
10. Did you eat raw or undercooked fish or seafood at the potluck?
Yes
No
Unknown
****If No or Unknown, proceed to End of Survey Instructions.
11. Did you eat scallops at the potluck?
Yes
No
Unknown
****If No or Unknown, proceed to End of Survey Instructions.
12. Were these scallops raw or undercooked?
Yes
No
Unknown
13. Where did the potluck scallops come from? (Please specify restaurant/store name and location)
_______________________________________
Unknown
Notes from call:
Data Entry By: ____________________________________________
Form Approved
OMB No. 0920-1101
Exp. Date 03/31/2017
CASE INTERVIEW FORM
Date:
CDC ID:
/
/2016
Data collector initials: _____
1. Last Name______________________ First Name_____________________
2. Unit:
3. Room:
4. DOB:
/
/
Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton
Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
1
CDC ID:
Foodborne disease outbreak questionnaire
Part I. Demographics:
1. Age: _____
2. Race (check all that apply)
Sex_____(M/F)
American Indian or Alaska Native
Black or African American
Native Hawaiian/other Pacific Islander
Other race
4.
When were you admitted to this detention center?
5.
Do you help in the kitchen? Yes / No
6.
Do you help serve the food on the food cart?
Yes /
3.
Asian
White
Unknown
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Date: ____ / ____ / ____ (MM/DD/YY)
No
2
CDC ID:
Part II. Clinical information: We’re going to ask you some questions about your symptoms when you got sick.
7.
Have you had any symptoms of gastrointestinal illness during the week of July 10th, 2016?
8.
9.
What day did your symptoms begin: ___________ / ____ / ____ / 2016 (example: Tuesday MM/DD)
Please circle when you began feeling sick:
1 AM
2
3
4
5
6 AM
7 AM
8
9
10
11
12 Noon
1 PM
2
3
4
5
6 PM
Yes / No
7 PM
8
9
10
11
12 Midnight
10. Did you have any of the following symptoms during the week of July 10th, 2016?:
Symptom
Yes/
Onset Date
Resolution date
No/Unknown
Nausea
Yes
No
Unk
___/____/2016
/////////////////////////////////
Vomiting
Yes
No
Unk
___/____/2016
___/____/2016
Notes
If yes, what is the largest number of
episodes you had in a 24 hour period ?
_____________
If yes, what is the largest number of
episodes you had in a 24 hour period ?
_____________
Diarrhea
Yes
No
Unk
___/____/2016
___/____/2016
Did you provide a stool sample?
Yes
Bloody Diarrhea
Yes
No
Unk
___/____/2016
/////////////////////////////////
Fever
Yes
No
Unk
___/____/2016
___/____/2016
Headache
Yes
No
Unk
___/____/2016
/////////////////////////////////
Abdominal
pain/cramping
Yes
No
Unk
___/____/2016
/////////////////////////////////
___/____/2016
/////////////////////////////////
Other:__________
11. Did you seek medical care at the medical unit?
a.
No
If yes, what is the largest number of
episodes you had in a 24 hour period ?
_____________
Highest temperature, if measured
______ °C or °F
Yes / No
When? Date____ / ____ / 2016 Time____:____ AM/ PM
12. Did you receive any medications? Yes / No
13. If yes, specify: ________________________
14. Were any of your cube/room/bunk mates vomiting or having diarrhea during those days?
Yes / No
3
CDC ID:
Part III. Food: Now we are going to ask your some questions about the foods that you ate on July 9 through July 12. We know that it
may be difficult to remember what you ate a month ago, but please try to answer these questions as best as you can.
15. Did you eat food from the food cart on Saturday, July 9? Yes / No
16. Did you eat a special meal on Saturday, July 9? Yes / No
17. If yes, specify:_______________________________
18. Did you eat food from the food cart on Sunday, July 10?
19. Did you eat a special meal on Sunday, July 10? Yes
Yes
/
/
No
/
No
/
No
No
20. If yes, specify:_______________________________
21. Did you eat food from the food cart on Monday, July 11?
22. Did you eat a special meal on Monday, July 11?
Yes
Yes
/
No
24. Did you eat food from the food cart on Tuesday, July 12?
Yes
23. If yes, specify:_______________________________
25. Did you eat a special meal on Tuesday, July 12?
Yes
/
No
26. If yes, specify:_______________________________
4
CDC ID:
27. Please place an X next to any food item the inmate ate on any of these days:
Saturday, July 9
Sunday, July 10
Monday, July 11
Tuesday, July 12
Breakfast
Breakfast
Breakfast
Breakfast
Grits
Oatmeal
Grits
Fruit Drink
Breakfast Sausage
Scrambled Egg
Biscuit
Oatmeal
Pancake Square
Oven Brown Potatoes
Sausage
Scrambled Eggs
Margarine
Biscuit
Gravy
O'Brien potatoes
Maple Syrup
Margarine
Lyonnaise Potatoes
Biscuit
Dairy Drink
Jelly
Margarine
Margarine
Dairy Drink
Dairy Drink
Jelly
Dairy Drink
Lunch
Lunch
Lunch
Lunch
Cheese Slice
Ham
Turkey Bologna
Cheese Slice
Turkey Salami
Lettuce/Cabbage Salad
Creamy Cole Slaw
Turkey Salami
Pasta Salad
Bread
Bread
Marinated Vegetable Salad
Bread
Mustard
Mustard
Bread
Mustard
Salad Dressing
Cookie Square
Mustard
Cookie Square
Cookie square
Fruit Drink
Cookie Square
Fruit Drink
Fruit Drink
Dinner
Dinner
Dinner
Dinner
Roast Turkey
Chicken Patty
Italian Meat Sauce
Chili Con Carne
Poultry Gravy
Rice Pilaf
Spaghetti Noodles
Plain rice
Mashed Potatoes
Seasoned Mixed
Vegetables
Seasoned Carrots
Seasoned Green Beans
Seasoned Cabbage
Cornbread
Garlic Bread
Cornbread
Cornbread
Margarine
Dessert Bar
Margarine
Margarine
Brownie
Sweat tea
Sweet Tea
Frosted cake
Sweet Tea
Fruit Drink
Sweet Tea
5
28. Do you purchase food from the canteen?
If yes, please indicate which foods you
ate on July 9 through July 12.
Jalapeno cheese packets
Honey bun glazed
Honey bun iced
Jalapeno pretzel pieces
Dill pickle
Hot pickle
Beef & cheese stick
Hickory beef stick
BF summer sausage
Hot sausage
Hot BF summer sausage
Tuna in pouch
Mayonnaise packet
BBQ sauce 1.25oz
Peanut butter pkt
Ranch dressing 1.5oz
Grape jelly pkt
Chex mix
Trail mix
Salted peanuts
Strawberry cheese claw
Cinnamon roll
Chocolate cupcakes
Banana pudding cupcake
Donut sticks
Instant grits 12CT
Oatmeal pkts
Nutty bar
Oatmeal cream pie
Brownie
Pop-tarts – Strawberry
Granola bar
Peanut butter crème
Duplex crème
Strawberry crème
Chocolate crème cookies
Toastchee
Jalapeno cheddar cracker
Grill cheese cracker
Saltine crackers
S.F. wafers – vanilla
S.F wafers – chocolate
Cheetos
Krispie treat
Chocolate moon pie
Snack crackers
Banana moon pie
Chocolate chip cookies
Salt & vinegar chips 1oz
Jalapeno cheese puffs 1oz
BBQ chips
Plain chips
BBQ corn chips
Yes
/
CDC ID:
No
Nacho cheese chips
Cheddar & sour cream (chips) 1oz
Buffalo chips
Voodoo chips
BBQ pork skins
Cheez-its
White cheddar popcorn
Cheese curls – 10oz
Spicy hot chips 5.5oz
Ridged potato chips 5.5oz
GF 5.5oz BBQ chips
Salsa verde tortilla chips
Sour cream & onion chips 5.5oz
Chicken cup-a-soup
Shrimp cup-a-soup
Beef cup-a-soup
Chili soup
Beef soup
Lime chili shrimp soup
Chicken soup
Cajun chicken soup
Oriental soup
Spam (pouch)
Mackerel fillet – 3.53oz
Flour tortilla
Sardines n hot sauce
Loaded mashed potatoes
Chicken breast – 3oz
Sweet & salty nut mix 2oz
Iced oatmeal cookies
6
CDC ID:
Now, I will ask you more questions about what you ate and drank during July 9-12th. Try to remember and answer as best as
you can.
29. Was any of the food you ate undercooked? Yes / No / Don’t Know
30. If yes, Specify: ___________________________________________________________________________________
31. Did you eat any food that was not provided on the food cart or in the canteen? Yes / No
32. Specify: ___________________________________________________________________________________
33. If yes, where was that food obtained?
34. Specify: ___________________________________________________________________________________
35. Did you drink any beverages that were not provided on the food cart or in the canteen? Yes / No
36. Specify: ___________________________________________________________________________________
37. If yes, where was that drink obtained?
38. If yes, Specify: ___________________________________________________________________________________
39. Did you eat any leftover food from the food cart from previous days? Yes / No
40. If yes, Specify: ___________________________________________________________________________________
41. If yes, do you remember when you got that food? _____/______ (MM/DD)
42. Did you prepare any food in your room (e.g. “spread”)? Yes / No
43. If yes, specify:_______________________________________________________________________________
44. Did you share the food that you prepared in your barracks with anyone else? Yes / No
45. If yes, specify: _______________________________________________________________________________
46. Do you have any food allergies? Yes / No
47. If yes, specify: _______________________________________________________________________________
48. Are there any foods that you refuse to eat here? Yes / No
49. If yes, specify: _______________________________________________________________________________
50. What time do you typically eat? Breakfast ________AM
Other_______________
Lunch _______AM / PM
Dinner: ________ PM
Part IV. Handwashing Practices
51. Do you typically wash your hands? Yes / No
52. How many times per day do you usually wash your hands? ____________
53. Can you tell me when you wash your hands? (keep prompting for additional responses)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
54. Do you have your own soap? Yes
/
No
55. Do you use soap every time you wash your hands? Yes
/
No
Part V.
Notes: (Add any comments not specifically asked on questionnaire)
___________________________________________________________________________________________________________
7
Form Approved
OMB No. 0920-1101
Exp. Date 03/31/2017
CASE INTERVIEW FORM
Date:
CDC ID:
/
/
Data collector initials: _____
1. Last Name______________________ First Name_____________________
2. Unit:
3. Room:
4. DOB:
/
/
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)
CDC ID _________________________
Foodborne disease outbreak questionnaire
Screening question for controls
Between Saturday, July 9th and Tuesday, July 19th, did you experience any vomiting or diarrhea, which we define as three or more
loose stools in a 24 hour period?
YES / NO
If, yes: Thank you for participating. That is the only information that we need to collect.
If no: Thank you. Now we would like to collect some background information.
Part I. Demographics:
1. Age: _____
2. Race (check all that apply)
Sex_____(M/F)
American Indian or Alaska Native
Black or African American
Native Hawaiian/other Pacific Islander
Other race
4.
When were you admitted to this detention center?
5.
Do you help in the kitchen? Yes / No
6.
Do you help serve the food on the food cart?
Yes /
3.
Asian
White
Unknown
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Date: ____ / ____ / ____
No
Part II. Illnesses
14. Were any of your cube/room/bunk mates vomiting or having diarrhea during the week of July 10th?
1
Yes / No
CDC ID _________________________
Part III. Food: Now we are going to ask your some questions about the foods that you ate on July 9 through July 12. We know that it
may be difficult to remember what you ate a month ago, but please try to answer these questions as best as you can.
7.
Did you eat food from the food cart on Saturday, July 9? Yes / No
8.
Did you eat a special meal on Saturday, July 9? Yes / No
9.
If yes, specify:_______________________________
10. Did you eat food from the food cart on Sunday, July 10?
11. Did you eat a special meal on Sunday, July 10? Yes
Yes
/
/
No
/
No
/
No
No
12. If yes, specify:_______________________________
13. Did you eat food from the food cart on Monday, July 11?
14. Did you eat a special meal on Monday, July 11?
Yes
Yes
/
No
16. Did you eat food from the food cart on Tuesday, July 12?
Yes
15. If yes, specify:_______________________________
17. Did you eat a special meal on Tuesday, July 12?
Yes
/
No
18. If yes, specify:_______________________________
2
CDC ID _________________________
19. Please place an X next to any food item the inmate ate on any of these days:
Saturday, July 9
Sunday, July 10
Monday, July 11
Tuesday, July 12
Breakfast
Breakfast
Breakfast
Breakfast
Grits
Oatmeal
Grits
Fruit Drink
Breakfast Sausage
Scrambled Egg
Biscuit
Oatmeal
Pancake Square
Oven Brown Potatoes
Sausage
Scrambled Eggs
Margarine
Biscuit
Gravy
O'Brien potatoes
Maple Syrup
Margarine
Lyonnaise Potatoes
Biscuit
Dairy Drink
Jelly
Margarine
Margarine
Dairy Drink
Dairy Drink
Jelly
Dairy Drink
Lunch
Lunch
Lunch
Lunch
Cheese Slice
Ham
Turkey Bologna
Cheese Slice
Turkey Salami
Lettuce/Cabbage Salad
Creamy Cole Slaw
Turkey Salami
Pasta Salad
Bread
Bread
Marinated Vegetable Salad
Bread
Mustard
Mustard
Bread
Mustard
Salad Dressing
Cookie Square
Mustard
Cookie Square
Cookie square
Fruit Drink
Cookie Square
Fruit Drink
Fruit Drink
Dinner
Dinner
Dinner
Dinner
Roast Turkey
Chicken Patty
Italian Meat Sauce
Chili Con Carne
Poultry Gravy
Rice Pilaf
Spaghetti Noodles
Plain rice
Mashed Potatoes
Seasoned Mixed
Vegetables
Seasoned Carrots
Seasoned Green Beans
Seasoned Cabbage
Cornbread
Garlic Bread
Cornbread
Cornbread
Margarine
Dessert Bar
Margarine
Margarine
Brownie
Sweat tea
Sweet Tea
Frosted cake
Sweet Tea
Fruit Drink
Sweet Tea
3
Now, I will ask you more questions about what you ate and drank during July 9-12th. Try to remember and answer as best as
you can.
20. Was any of the food you ate undercooked? Yes / No / Don’t Know
21. If yes, Specify: ___________________________________________________________________________________
22. Did you eat any food that was not provided on the food cart or in the canteen? Yes / No
23. Specify: ___________________________________________________________________________________
24. If yes, where was that food obtained?
25. Specify: ___________________________________________________________________________________
26. Did you drink any beverages that were not provided on the food cart or in the canteen? Yes / No
27. Specify: ___________________________________________________________________________________
28. If yes, where was that drink obtained?
29. If yes, Specify: ___________________________________________________________________________________
30. Did you eat any leftover food from the food cart from previous days? Yes / No
31. If yes, Specify: ___________________________________________________________________________________
32. If yes, do you remember when you got that food? _____/______ (MM/DD)
33. Did you prepare any food in your room (e.g. “spread”)? Yes / No
34. If yes, specify:_______________________________________________________________________________
35. Did you share the food that you prepared in your barracks with anyone else? Yes / No
36. If yes, specify: _______________________________________________________________________________
37. Do you have any food allergies? Yes / No
38. If yes, specify: _______________________________________________________________________________
39. Are there any foods that you refuse to eat here? Yes / No
40. If yes, specify: _______________________________________________________________________________
41. What time do you typically eat? Breakfast ________AM
Other_______________
Lunch _______AM / PM
Dinner: ________ PM
Part IV. Handwashing Practices
42. Do you typically wash your hands? Yes / No
43. How many times per day do you usually wash your hands? ____________
44. Can you tell me when you wash your hands? (keep prompting for additional responses)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
45. Do you have your own soap? Yes
/
No
46. Do you use soap every time you wash your hands? Yes
/
No
Part V.
Notes: (Add any comments not specifically asked on questionnaire)
| File Type | application/pdf |
| Author | lmp2 |
| File Modified | 2016-12-12 |
| File Created | 2016-12-12 |