Form 0920-0997 Hypothesis Generating Questionnaire

Form approved

OMB No. 0920-0997

Expires xx/xx/xxxx

Hypothesis Generating Questionnaire for [__________ __________] (enter pathogen)

PulseNet cluster code: [_____________] (enter Cluster Code)

Section 1: Interviewer & Patient Information (Questions 1-10 to be completed by interviewer prior to questionnaire administration)
PulseNet ID #: ______________________		State/Local/Other ID #: _______________________
Date of Interview:	__ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y
Interviewer Information Name: ______________________________________ Agency or Organization: _______________________________
Before this interview, how many times has the case been interviewed about their illness by a local, state, or federal public health representative? None Once Twice Other (specify # times):________
Language interview conducted in English Spanish Other (specify):_______________
Respondent was: Self Parent Spouse Other (specify):_______________
State and county of residence? State _______ County ____________________
Birth month and year: __ __ / __ __ __ __ (if unknown, enter 99/9999) M M Y Y Y Y
Sex: Male Female Unknown

Section 2: Clinical Information: Now I have a few questions about your (your child’s) illness.
What date did you first feel sick? __ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y
How many days total were you sick? _______ days (enter 999 if unknown) or Still sick
Yes	Maybe	No	Don’t Know	Did you (your child)
				Have any diarrhea (defined as at least 3 loose stools in 24 hours) Refused
				a. What day did it start __ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y b. What day did it end __ __ / __ __ / __ __ __ __ (if unknown, enter 99/99/9999) M M D D Y Y Y Y
				Have any close contact with anyone with diarrhea or vomiting?
				a. When did this person first become ill less than 24 hours before you ≥ 24 hours before you Unknown

Section 3: Travel: Next I have a couple of questions about any travel you (your child) might have done, either as part of your work or for pleasure.
Yes	Maybe	No	Don’t Know
				Did you spend all, or some, of the 7 days before you were ill outside of your home state?
				List all US states where you might have purchased or eaten foods. This would include foods eaten at airports, bus or train stations. List states: ___________________________________ ii. Dates of travel: ____________________ iii. List hotels/resorts stayed in during travel: _____________________________________________ Did not travel outside state of residence Did not purchase or eat food outside state of residence
				List all countries outside the United States where you might have purchased or eaten foods. This would include foods eaten at airports, bus or train stations. List countries: _________________________________ ii. Dates of travel: __________________ iii. List hotels/resorts stayed in during travel: ____________________________________________ Did not travel outside of United States Did not purchase or eat food outside United States
Section 3 Comments. Please fill in any comments/notes from this section in the space provided below:
If the case spent the entire 7 days before illness onset outside the US, please be sure countries and travel dates are noted and skip to the end of the interview (page 11). If the case spent only part of the 7 days before illness onset outside the US, please complete the remainder of the interview collecting only foods purchased or eaten in the US.

Section 4: Food allergies, special diets, vitamins, & supplements: Now I have a few questions about general food preferences, food allergies, and any special diets you (your child) may follow.

Yes

Maybe

No

Don’t Know

1. Do you make it a point to select organic foods when you shop?

2. Are there foods that you avoid eating or never eat, due to restriction or preference?

a. If yes, please specify: ________________________________________________________________

3. Do you follow any of the following special or restricted diets?

Kosher	Halal	Raw foods
Low carb	Paleo (high protein, low carb)	Vegetarian/Vegan
Dairy-free	Gluten-free	Weight loss/low fat
Other, please describe: ________________________________________________________________

4. Did you (your child) have any vitamins, nutritional or herbal supplements, such as teas or other liquids, tablets, or pills, etc.?

a. Please describe Type, variety, brand: ___________________________ Unknown

Section 4 Comments. Please fill in any comments/notes from this section in the space provided below:

For Sections 5 and 6: Read each type of store, point of purchase, or food outlet in the top section and ask respondent to list names for each category. The lists of store/restaurant types are meant to prompt the respondent. Please list the names of all points of purchase/restaurants mentioned, regardless of category, in the space provided below.

Section 5: Sources of food at home: Now I have a few questions about where the food came from that you ate at home in the 7 days before your illness began. This isn’t necessarily where you shopped during that week, but where what you actually ate came from. I’m going to list several types of stores, for each type please tell me the names of each store you would have eaten food from during the 7 days before you were sick.

1. Did you (your child) eat foods from:

Grocery stores or supermarkets	Home delivery grocery services (CSA, grocery delivery, Amazon Fresh, Peapod, etc)	Fish or meat specialty shops (butcher shop, etc)
Warehouse stores (Costco, Sam’s Club, etc)	Meal delivery services (Blue Apron, Meals on Wheels, Schwan’s, NutriSystem, etc)	Live animal market, custom slaughter facility
Small markets/Mini markets (convenience stores, gas stations, etc)	Health food stores or co-ops	Any others?
Ethnic specialty markets (Mexican, Asian, Indian)	Farmers’ markets, roadside stands, open-air markets, food purchased directly from a farm

Please list store names, address/location, and shopper card # (if applicable) mentioned by the interviewee below:

Store/Supermarket Name	Address/Location	Shopper Card #

2. May we have permission to retrieve purchases based on your member card information? This information will be kept confidential

Yes No

3. May we share this information with other public health officials to help with this outbreak investigation? This information will be kept confidential Yes No

Section 5: Additional Store/Retail Names and Locations.

Section 6: Sources of food outside the home: Now I have a few questions about where the food came from that you ate outside your home such as restaurants or fast food chains. I’m going to list several types of restaurant, for each type please tell me the names of each place you would have eaten food from during the 7 days before you were sick.

1. Did you (your child) eat foods from:

Fast casual (Chipotle, Panera, etc)	Fast food (McDonald’s, Burger King, Wendy’s)	Sandwich shop, deli
Jamaican, Cuban, or Caribbean	Ready-to-eat prepared food from grocery or deli	An event where food was served (catered event, festival, church or community meal)
Mexican, Salvadorian, other Hispanic/Latino-style	Food trucks, food stalls/stands	School, hospital, senior center, or other institutional setting
Chinese, Japanese, Vietnamese, other Asian-style	All-you-can-eat buffet	Breakfast, brunch, diner, or café
Middle Eastern, Greek/Mediterranean, Arabic, Lebanese, African	Any take-out from a restaurant	Any others?
Healthy restaurant (vegetarian, vegan, salad-based)	Salad bar at a grocery store or restaurant

Please list restaurant/store names and address/location mentioned by the interviewee below:

Restaurant Name	Address/Location	Meal Date(s)	Food Ordered/Eaten

Section 6: List Additional Restaurant/Retail Names and Locations.

Section 7: Poultry, Meat, and Meat Alternatives: Now I have a few questions about meat, poultry, and meat alternatives (like tofu) that you (your child) might have eaten in the 7 days before your (your child’s) illness began. This does not include canned items, but the meat and poultry could have been fresh, frozen, or could have been eaten as part of dish. You (your child) could have eaten these either in your home or outside the home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
First, I have questions about CHICKEN & OTHER POULTRY products.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Whole chicken, including rotisserie or roasted chicken?
				a. If eaten at home, what was the: Type, variety, brand:__________________________________________________ Place purchased from (names, locations): _________________________________ Did not eat whole chicken at home
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Did not eat whole chicken outside the home
				Pre-cut chicken parts or pieces, such as just breasts, drumsticks, thighs, wings?
				a. If eaten at home, what was the: Type, variety, brand:__________________________________________________ Place purchased from (names, locations): _________________________________ Did not eat chicken parts at home
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Did not eat chicken parts outside the home
				Ground chicken?
				a. If eaten at home, what was the: Type, variety, brand:__________________________________________________ Place purchased from (names, locations): _________________________________ Did not eat ground chicken at home
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Did not eat ground chicken outside the home
				Whole turkey or cut turkey pieces/parts, not including turkey deli meats or other processed meat?
				a. If eaten at home, what was the: Type, variety, brand:__________________________________________________ Place purchased from (names, locations): _________________________________ Did not eat turkey at home
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Did not turkey eat outside the home
				Ground turkey?
				a. If eaten at home, what was the: Type, variety, brand:__________________________________________________ Place purchased from (names, locations): _________________________________ Did not eat ground turkey at home
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Did not eat ground turkey outside the home
				Other poultry, like duck, game hen, or squab?
Section 7: Chicken/Poultry Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about BEEF products.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (your child) eat any:
				Beef steaks, roasts, or other whole cuts of beef?
				a. If eaten at home, what was the: Type, variety, brand:__________________________________________________ Place purchased from (names, locations): _________________________________ Purchased Frozen Purchased Fresh Was pink or red inside when eaten Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Fresh or frozen pre-made or pre-formed hamburger patties at home?
				a. If eaten at home, what was the: Type, variety, brand:_______________________________________ What percentage fat/lean? ________________________ Place purchased from (names, locations): _________________________________ Was pink or red inside when eaten
				Any dish with ground beef at home, such as hamburger patties, casseroles, tacos, soups, or pasta sauces?
				a. If eaten at home, what was the: Dish (please describe):_______________________________________ Place ground beef purchased from (names, locations): _____________________________ What percentage fat/lean? ________________________ Was pink or red inside when eaten
				Any ground beef outside the home? This could include foods such as hamburger or other dishes such as casseroles, tacos, soups, or pasta sauces.
				a. Where did you eat this? List name(s) and location(s): _____________________________________________________ Was pink or red inside when eaten
				Any veal?
Section 7: Beef Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about PORK, LAMB, PROCESSED MEAT PRODUCTS, & MEAT ALTERNATIVES.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (your child) eat any:
				Pork prepared at home (like, whole pig, chops, tenderloin, roast, shoulder, ground, etc)?
				Type/cut: Ground Whole pig Other: __________________ Unknown Brand(s): ______________________________________________________ Unknown Place purchased:________________________________________________ Type of market: Ethnic market (Asian, Hispanic, etc.) Other grocery store / supermarkets Custom slaughter / local butcher Live animal market Other: _________________________ Unknown
				Pork prepared outside the home? This would include pig roasts, sit-down restaurants, fast food restaurants, take-out, food trucks, and delivery from restaurants, cafeterias, etc.
				Place name(s): _______________________________________________ Unknown Dish(es): ____________________________________________________ Unknown
				Any other pork product, excluding deli meats or cured meats like ham or bacon?
				a. What was the : Type, variety, brand:____________________________ Unknown
				Bacon?
				What was the : Type (beef, pork, turkey, etc), variety, brand:____________________________ Unknown
				Lamb?
				Goat?
Now I have questions about PROCESSED MEAT products.
				Sausage, like Polish sausage, kielbasa, Bratwurst, or other similar product?
				Hot dogs or corn dogs?
				Pepperoni? This could have been on a sandwich or pizza.
				Store-bought, dried meat strips or jerky?
				Deli meat or cold cuts purchased in a commercially sealed package, like Oscar Mayer or Hillshire Farms?
				If eaten at home, what was the: Type: Turkey Ham Beef (like pastrami, roast beef) Italian meats (like salami, prosciutto) Other (specify)_________________________________________________ Variety, brand:______________________________________________________________ Place purchased from (names, locations): _______________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List type, variety, brand and location(s): ________________________________________ Not applicable (did not eat outside the home)
				Deli meat or cold cuts sliced at the deli counter?
				If eaten at home, what was the: Type: Turkey Ham Beef (like pastrami, roast beef) Italian meats (like salami, prosciutto) Other (specify)_________________________________________________ Variety, brand:______________________________________________________________ Place purchased from (names, locations): _______________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List type, variety, brand and location(s): ________________________________________ Not applicable (did not eat outside the home)
				Any other meat and/or poultry products, including organ meats (wild game, bison, or parts like heart, giblets, tongue, intestines, blood), not mentioned already? Please describe: ______________________________________________________________________________
				Liver pâté? (specify type: chicken, beef, duck, pork, etc) _______________________________________
				Pink or undercooked liver or liver pâté? (specify type: chicken, beef, pork, etc) _____________________________________________________________________________________
Now I have a question about MEAT ALTERNATIVES.
				Any tofu, tempeh, seitan, or other meat alternatives? Type, variety, brand: ________________________________________________________________
Section 7: Pork, Lamb, other Meats, and Meat Alternatives Comments. Please fill in any comments/notes from this section in the space provided below:

Section 8: Fish and Seafood: Now I have some questions about fresh fish and seafood you (your child) might have eaten in the 7 days before your (your child’s) illness began. I will ask you about frozen seafood later. You (your child) may have eaten this at home or away from home, such as in a restaurant, take-out, or at a catered event. This does not include canned items, but these foods could have been eaten alone or as part of a dish, sauce, or dip. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Store-bought fresh fish, not including shellfish?
				Raw fish or fish products, such as sushi, sashimi, ceviche, or poke?
				a. Raw tuna? Yes No Maybe Don’t know b. Other raw fish, specify: _______________________________________________________________ c. Describe the dish: ___________________________________________________________________ d. Where was it purchased/consumed? ____________________________________________________
				Smoked or dried fish, like smoked salmon, lox, bonita, fish jerky?
				Shrimp or prawns?
				Crab, lobster, or crayfish?
				Oysters?
				a. Were the oysters raw? Yes No Maybe Don’t know
				Clams, mussels, scallops, or other shellfish?
				Any other fish or seafood?
				a. What was the: Type, variety, brand:____________________________ Unknown
Section 8 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 9: Eggs, Dairy, and Cheese: Now I have a few questions about eggs, dairy, and cheese products you (your child) might have eaten in the 7 days before your (your child’s) illness began. You (your child) could have eaten these either in your home or away from home, such as in a restaurant, take-out, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Eggs or egg-containing dishes eaten at home?
				a. Type, variety, brand:______________________________________________________________ Place purchased from (names, locations): _____________________________________________
				Eggs or egg-containing dishes eaten outside the home?
				a. List name(s) and location(s): _________________________________ Describe the type of dish: __________________________________
				Anything made with raw eggs (cookie dough, cake batter, sauces, homemade ice cream, mayo, salad dressing etc.)?
				Dairy milk from a cow or other animal source?
				a. What was the: Type (cow, goat, etc), variety, brand:______________________________________
				b. Raw or unpasteurized? Yes No Maybe Unknown
				Dairy milk alternatives, such as almond, hemp, coconut, cashew, rice, or soy milk?
				a. What was the type, variety, brand: _________________________________ Unknown
				Any yogurt?
				a. What was the type, variety, brand: _________________________________ Unknown
				Any other yogurt product, like kefir?
				Cheese made from pasteurized milk?
				Cheese made from unpasteurized or raw milk, including homemade, farm-fresh, and door-to-door cheeses?
				Non-dairy cheese alternative?
				a. What was the type, variety, brand: _________________________________ Unknown
				Mexican- or Latin-style cheese such as queso fresco or queso blanco?
				Blue-veined cheese such as Bleu or gorgonzola?
				Feta?
				Goat cheese?
				Brie or Camembert?
				Any other soft cheese?
				a. What was the: Type (cow, goat, etc), variety, brand:______________________________________
				b. Raw or unpasteurized? Yes No Maybe Unknown
				Any other gourmet or artisanal cheese? These are often cheeses that are cut and packaged on-site at cheese shops, cheese counters at grocery stores, and farmers markets.
				a. What was the: Type, variety, brand:______________________________ Unknown
				Any other dairy or dairy-alternative products?
				a. What was the: Type, variety, brand:______________________________ Unknown
Section 9 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 10: Fresh Vegetable: Now I have some questions about fresh vegetables you (your child) might have eaten raw or uncooked in the 7 days before your (your child’s) illness began. You (your child) could have eaten these either in your home or away from home, such as in a restaurant, take-out, or at a catered event. This does not include canned items, but these foods could have been eaten alone or as part of a dish. I am only interested in vegetables that you’ve purchased from a store or farm stand, and are not grown at home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 day before you (your child) got sick.
First, I have questions about TOMATOES & LEAFY GREENS that are not homegrown.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Fresh tomatoes?
				a. If eaten at home, what was the: Type: Red Round Roma (oval-shaped) small, bite-sized tomato, like grape or cherry Other, (specify)__________________________________________________ Place purchased from (names, locations): ___________________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Fresh tomatoes on sandwich, burger, or salad?
				Fresh salsa or pico de gallo (not from a jar or can)?
				a. If eaten at home, what was the: Type, variety (red, green, etc.): _________________________________________ Place purchased from (names, locations): _________________________________ Prepared from fresh ingredients at home Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Avocado or guacamole?
				Fresh, uncooked leafy greens (such as lettuce, spinach, or kale) in a salad, on a sandwich, or burger?
				Iceberg lettuce?
				a. Prepackaged or whole head/loose? Prepackaged Whole head/Loose Unknown
				b. If eaten at home, what was the: Type, variety, brand: _________________________________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				c. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Romaine lettuce?
				a. Prepackaged or whole head/loose? Prepackaged Whole head/loose Unknown
				b. If eaten at home, what was the: Type, variety, brand: _________________________________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				c. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Fresh spinach?
				a. Prepackaged or loose/bundled? Prepackaged Loose/bundled Unknown
				b. If eaten at home, what was the: Type, variety, brand: _________________________________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				c. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Cabbage?
				Kale?
				a. What was the: Type, variety, brand:_______________________________________ Unknown
				Arugula?
				Spring mix/mesclun mix or other lettuce blend?
				a. What was the: Type, variety, brand:_______________________________________ Unknown
				Other leafy greens, like Swiss chard, mustard greens, dandelion, watercress?
				a. What was the: Type, variety, brand:_______________________________________ Unknown
				Other pre-packaged leafy greens or salad kits?
				a. What was the: Type, variety, brand:_______________________________________ Unknown
				Pre-made, single-serving salads (these are ready-to-eat, single-serve salads with toppings, meats, dressing)?
				a. What was the: Type, variety, brand:_______________________________________ Unknown
Section 10 – Tomatoes/Leafy Greens Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about herbs and sprouts you (your child) might have eaten in the 7 days before your (your child’s) illness began. Remember, these could have been part of a dish, such as pesto, salsa, sauces, etc. We are interested in fresh herbs, not dried or bottled herbs.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (your child) eat any:
				Fresh basil, sometimes in pesto or as a garnish?
				Fresh cilantro, sometimes in salsa, Mexican food, Asian food, or as a garnish?
				Other fresh herbs (parsley, chives, dill, sage, thyme, etc.)?
				a. What was the: Type, variety: ________________________________ Unknown
				Bean sprouts, such as mung bean or soy bean, usually served in stir fries or Asian salads or soups
				a. If eaten at home, what was the: Type, variety, brand: _________________________________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)

				Alfalfa sprouts, sometimes served on sandwiches or salads?
				a. If eaten at home, what was the: Type, variety, brand: _________________________________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Other sprouts (clover, daikon radish, microgreens, etc.)?
				a. If eaten at home, what was the: Type, variety, brand: _________________________________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
Section 10 – Herbs/Sprouts Comments. Please fill in any comments/notes from this section in the space provided below:
Next I have a few questions about other fresh vegetables, eaten raw, that are not homegrown that you (your child) may have eaten in the 7 days before your illness.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (your child) eat any:
				Cucumbers?
				a. If eaten at home, what was the: Type, variety: Mini (like Persian) large, wrapped in plastic (like English or European) “Regular” sold loose, not wrapped in plastic Other (specify): ________________________ Place purchased from (names, locations): _________________________________ Not applicable (did not eat at home)
				b. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Zucchini or other “soft” or summer squash?
				Sweet or bell peppers (green, red, orange, or yellow)?
				Mini or snack-sized sweet peppers, usually sold in a bag or clamshell?
				Fresh hot, spicy peppers, such as jalapenos or serranos?
				Celery?
				Carrots?
				“Mini” carrots? These are often peeled and sold in a sealed bag
				Other raw root vegetables (radishes, beets, turnips, fennel, etc.)?
				a. What was the: Type, variety:________________________________ Unknown
				Fresh, raw pea pods, snap peas, or snow peas?
				Broccoli or cauliflower?
				Raw onions (white, yellow, or red/purple)?
				Raw green onions/scallions?
				Fresh mushrooms?
				Fermented vegetables (like kimchi, sauerkraut)?
				a. What was the: Type, variety, brand:________________________________ Unknown b. Was this homemade? Yes No Don’t know
Section 10 Other Vegetable Comments. Please fill in any comments/notes from this section in the space provided below:

Section 11: Fresh fruits & Berries: Now I have some questions about fresh fruits, not canned or cooked, that you (your child) might have eaten in the 7 days before your (your child’s) illness began. I will ask you about frozen fruits later. You (your child) could have eaten these either in your home or away from home, such as in a restaurant, take-out, or at a catered event. I am only interested in fruits and berries that you’ve purchased from a store or farm stand, and are not grown at home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Any fruit that was already cut?
				a. Did you eat any of the following: Pre-cut melon (sometimes sold halved & wrapped in plastic or cut into pieces) Pre-cut apples Pre-cut fresh fruit salad Other (specify)________________________________
				Apples?
				a. What was the: Type, variety:________________________________ Unknown
				Grapes?
				a. What was the: Type, variety:________________________________ Unknown
				Pears?
				Peaches or nectarines?
				Apricots?
				Plums?
				Cherries?
				Oranges, tangerines, grapefruit, mandarins, or clementines?
				Strawberries?
				Raspberries?
				Blueberries?
				Blackberries?
				Any other fresh berries?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Cantaloupe?
				Honeydew melon?
				Watermelon?
				Any other melon?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Pineapple?
				Mango?
				Papaya?
				Any other tropical fruit (kiwi, guava, pomegranate, coconut, etc.)?
				a. What was the: Type, variety:________________________________ Unknown
				Any unpasteurized or raw juices or ciders?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Smoothies made with fresh or frozen fruit or produce, usually made at home or purchased, fresh-made from a store, restaurant, or café?
				Bottled, pre-made smoothie?
Section 11 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 12: Frozen Foods: Now I have a few questions about frozen foods you (your child) might have eaten in the 7 days before your (your child’s) illness began. You (your child) could have eaten these either in your home or outside the home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Ice cream, ice cream products, frozen yogurt, or non-dairy frozen desserts?
				a. If eaten at home, what was the: Type or brand (bar, tub, carton, etc.):___________________________ Variety or flavor: _________________________________ Unknown
				Frozen vegetables (in bag or box)?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Frozen pot pies?
				Frozen pizza?
				Frozen, breaded chicken products, such as chicken tenders, strips, or nuggets?
				Frozen, stuffed chicken products, such as chicken Kiev or chicken Cordon Bleu?
				Frozen fish product (fish sticks, nuggets, etc.)?
				Frozen Mexican-style foods (burritos, etc.)?
				Frozen snack foods like mozzarella sticks, jalapeno poppers, potato skins, or hot pockets?
				Frozen breakfast items (waffles, breakfast sandwiches, etc.)?
				Frozen vegetarian foods such as a veggie burger?
				Frozen pre-mixed meals in a bag or box (stir fry, pasta meals, etc.)?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Frozen dinners or box entrees?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Other frozen, prepackaged product not mentioned previously?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Frozen berries, including those used in a smoothie?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Other frozen fruit, including those used in a smoothie?
				a. What was the: Type, variety, brand:________________________________ Unknown
Section 12 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 13: Nuts, Cereal, Processed, and Dried Foods: Now I have some questions about nuts, cereals, and processed foods you (your child) might have eaten in the 7 days before your (your child’s) illness began. You (your child) could have eaten these either in your home or away from home, such as in a restaurant, take-out, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (your child) got sick.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Peanut butter?
				a. Was the peanut butter commercially packaged or fresh-ground? Commercial Fresh-ground
				b. If eaten at home, what was the: Type, variety, brand: Jif Skippy Peter Pan Other (specify)_____________________ Unknown brand Not applicable (did not eat at home)
				c. If eaten outside the home, where? List name(s) and location(s): _________________________________ Not applicable (did not eat outside the home)
				Peanut butter containing foods (cookies, crackers, candies, ice cream, etc.)?
				a. What was the: Type, variety, brand:________________________________ Unknown
				Ground nut butter or spread other than peanut butter (Nutella, almond butter)?
				a. Type(s): Almond Hazelnut Sunflower Unknown Cashew Nutella Other: __________________
Next I have questions about dried fruits, nuts, and seeds you (your child) might have eaten. Remember that these may be used as toppings or mixed into many foods. If you (your child) ate any of the nuts below as part of another food please answer "yes". Did you (your child) eat any of the following:
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Dried fruit?
				a. What was the: Type, variety:______________________________________ Unknown
				Peanuts?
				Almonds (whole, sliced, chopped, etc.)?
				Walnuts?
				Cashews?
				Pistachios?
				Hazelnuts or filberts?
				Pecans?
				Pine nuts, including in pesto?
				Other whole nuts or mixed nuts?
				Sunflower seeds?
				Sesame seeds or other products made from sesame seeds, including tahini or halva?
				Other seeds?
				a. What was the: Type, variety:________________________________ Unknown
				Hummus?
Section 13: Peanut butter/Nuts/Seeds Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about pre-packaged snack foods and cereals you (your child) might have had in the 7 days before your (your child’s) illness began.
Yes	Maybe	No	Don’t Know
				Did you (your child) eat, taste, or lick any uncooked or unbaked dough or batter (such as cookie, cake, biscuit, muffin batter)?
				Did you (your child) eat any:
				Granola, breakfast, power, or protein bars?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Trail mix (or similar product)?
				Chips or pretzels?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Pre-packaged crackers, cookies, or snack cakes?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Chocolate or chocolate-containing candy?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Cold breakfast cereal?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Hot breakfast cereals like oatmeal, cream of wheat, etc.?
				a. What was the: Type, variety, brand:_______________________________ Unknown
Section 13: Snack foods/Cereal Comments. Please fill in any comments/notes from this section in the space provided below:
And finally I have questions about dried, powdered products and supplements you (your child) might have had in the 7 days before your (your child’s) illness began.
Yes	Maybe	No	Don’t Know	Did you (your child) eat any:
				Flavored milk powder (such as chocolate, vanilla, Carnation, or Ovaltine)?
				Powdered nutritional supplement products, such as protein powders, meal replacement powders, vitamin boosters, etc?
				Hemp, chia, or flax seed?
				Was it: hemp chia flax Was it: whole seed powdered seed
				Powdered green supplements?
				a. What was the: Type, variety, brand:_______________________________ Unknown
				Bottled, pre-made health drinks, like Kombucha or coconut water?
Section 13: Dried/Powdered foods Comments. Please fill in any comments/notes from this section in the space provided below:

Section 14: We have covered a wide variety of foods, drinks, etc. After answering all these questions are there any other things you (your child) ate or drank in the 7 days before becoming ill that have not been mentioned?
Please describe any other foods, drinks, etc. including as much detail as possible regarding type, variety, or brand.

Section 15: Animal contact and Pets: Now I have some questions about contact with pets or other animals in the 7 days before your (your child’s) illness began. This could have been at your home or another home, at a pet store, petting zoo, school, daycare, or other location.
Yes	Maybe	No	Don’t Know
				Did you (your child) visit a petting zoo?
				Did you (your child) live/work/visit a farm with livestock like cattle, sheep, goats, etc.?
				a. Do you live on work at visit a farm?
				Did you (your child) visit or work at an agricultural ‘Farm and Feed’ stores, like Tractor Supply?
				a. Did you work at visit a feed store?
				Did you (your child) visit or work at a pet store, swap meet, other place where animals/birds were sold or shown?
				Did you (your child) visit or work at county/state fairs, 4-H events, or similar event where animals were present?
				Did you (your child) have any contact with:
				Animals/pets in school or daycare?
				Dogs or puppies?
				Cats or kittens?
				Cow/Bull/Steer?
				Pig/piglet?
				Live adult or baby chicks, ducklings or other poultry?
				Turtles or tortoises?
				a. Was the shell <4 inches in diameter? Yes No Unknown b. Location of purchase: __________________________________ Date of purchase: ____________
				Frozen mice, rats, or similar pet food for reptiles?
				Reptiles, such as snakes, lizards, geckos, bearded dragons, etc.?
				a. What was the: Type:__________________________________________ Unknown
				Amphibians, such as frogs, toads, or salamanders?
				a. What was the: Type:__________________________________________ Unknown
				Water pets in an aquarium (goldfish, aquatic frogs, snails, etc.)?
				a. What was the: Type:__________________________________________ Unknown
				Other small mammalian household pet other than dog or cat, such as hamster, rat, mouse, guinea pig, or hedgehog (excluding feeder rodents)?
				a. What was the: Type:__________________________________________ Unknown
				Prepackaged pet food (canned or dry)?
				a. What was the: Type, variety:________________________________ Unknown
				Raw pet food, like fresh or frozen chubs sold in stores or homemade?
				a. What was the: Type, variety:________________________________ Unknown
				Pet treats or chews (pig ears, pizzles, rawhide, hooves, etc.)?
Section 15 Comments. Please fill in any comments/notes from this section in the space provided below:

Section 16: Race/Ethnicity/Origin Information: I’d like to end by asking a few questions about yourself (your child) and your household.

1. Hispanic or Latino origin? Yes No Unknown Declined to answer

2. How would you describe your race?

African American/Black	White Middle Eastern/North African Not Middle Eastern/North African	Unknown
Native American Indian or Alaska Native	Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (specify)______________	Other (specify) ______________
Native Hawaiian or other Pacific Islander		Declined to answer

3. What is your country/culture of origin (regardless of country of birth) (specify): _____________________________________ Declined to answer

4. What is your occupation? (specify): ________________________________________________________________________ Declined to answer

5. Do you reside in any of the following settings:

Private home/residence	Homeless	Non-medical ward
Long term care facility	Incarcerated	Other: _________________________
Long term acute care facility	College dormitory	Declined to answer

Section 17: Hospitalization & Treatment Information: Now I have a few additional questions about your (your child’s) illness and course of treatment.
Yes	Maybe	No	Don’t Know
				Were {you/your child} admitted overnight to a hospital for this illness? Refused
				a. If yes, how many nights did {you/your child} spend in the hospital?_______________ b. If yes, during part of the hospitalization, did {you/your child} stay in an Intensive Care Unit (ICU) or a Critical Care Unit (CCU)? Yes No Don’t know Refused
				Did {you/your child} develop other serious problems or complications as a results of this illness, such as a blood stream infection, sepsis, infection of the joints or bones, or meningitis? Refused
				a. If yes, please explain: __________________________________________________________________
				Did {you/your child} take any antibiotics for this illness? Refused
				If yes, please specify: ________________________________________________________________ If yes, for how many days did you take them? ______________ days
				In the 30 days before your illness began, did {you/your child} take antibiotics?
				If yes, please specify: ________________________________________________________________
Now I have a few other questions for you that ask about exposures you may have had 30 days before your illness began.
Yes	Maybe	No	Don’t Know	Did you (your child)
				In the 30 days before {your/your child’s} illness began, did {you/your child} travel outside the U.S.? Refused
				a. If yes, which countries did {you/your child} visit?__________________________________________
				In the 30 days before {your/your child’s} illness began, did {you/your child} take a probiotic? Probiotics are live microorganisms (such as certain types of bacteria) that may benefit your health. These can take the form of pills, powders, yogurts, and other fermented dairy products, as well as anything labeled as containing “live and active cultures” or “probiotics”. Refused

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 0920-0997

National Hypothesis Generating Questionnaire, OMB No. 0920-0997, Page 25 of 25