| ControlId |
ControlType |
ControlPrompt |
| CaseStatus |
CheckBox |
Classify case based on CDC case definition [Confirmed/Probable] |
| StateID |
TextBox |
State/NNDSS ID# |
| DateStoolCollected |
Date |
Date stool collected for Cyclospora testing |
| TestResult |
CheckBox |
Test results [Positive/Negative/Indeterminate/Pending] |
| LabType |
CheckBox |
Specify type of testing laboratories and testing method [table with test type (O&P, GI PCR Panel, PCR, Lab-developed test, Other) in columns and laboratory type (Clinical, Commercial, State, CDC) in rows] |
| Coinfection |
TextBox |
Specify name of lab-confirmed coinfection |
| StateLabID |
TextBox |
State Lab accession number |
| Interviewer |
TextBox |
Name |
| IntAgency |
TextBox |
Agency or Organization |
| IntPhone |
NumericTextBox |
Contact phone number |
| InterviewDate |
Date |
Date of Interview |
| TimesInt |
CheckBox |
Before this interview how many times has the case-patient been interviewed about his/her illness? |
| Respondent |
CheckBox |
Respondent for current interview was [Self/Parent/Spouse/Other (specify)] |
| ForCDCUseOnly |
GroupBox |
For CDC Use Only |
| EnteredatCDC |
CheckBox |
Entered at CDC |
| UserID |
TextBox |
UserID |
| State |
TextBox |
State |
| County |
TextBox |
County |
| ZipCode |
TextBox |
Zip Code |
| BirthMon |
NumericTextBox |
Birth month |
| BirthYr |
NumericTextBox |
Birth year |
| Age |
NumericTextBox |
Age |
| Sex |
CheckBox |
Sex |
| Ethnicity |
CheckBox |
Do you consider yourself of Hispanic or Latino origin [Yes/No/Unknown] |
| Race |
CheckBox |
How would you describe your race? [White, American Indian/Alaska Native, Black/African American, Asian, Native Hawaiian/Pacific Islander, Unknown, Other (Specify)] |
| OnsetDate |
Date |
What date did you (your child) first feel sick? |
| OnsetDateUnknown |
CheckBox |
Unknown |
| OnsetDateApproximate |
CheckBox |
Approximate date |
| Diarrhea |
CheckBox |
Did you (your child) have any diarrhea (defined as loose or watery stools that you do not normally have)? |
| DiarrheaDate |
Date |
Date diarrhea started |
| DiarrheaStopped |
Date |
Date diarrhea stopped? |
| DiarrheaOngoing |
CheckBox |
Ongoing |
| WeightLoss |
CheckBox |
Weight Loss |
| Fever |
CheckBox |
Fever |
| Fatigue |
CheckBox |
Fatigue |
| Anorexia |
CheckBox |
Anorexia |
| Nausea |
CheckBox |
Nausea |
| Vomiting |
CheckBox |
Vomiting |
| AbdominalCramps |
CheckBox |
Abdominal Cramps |
| Symptomsstopped |
CheckBox |
Have your (your child's) other symptoms stopped? |
| DateSymptomsStop |
Date |
If yes, date symptoms stopped [text/unknown] |
| Hospitalized |
CheckBox |
Were you (your child) hospitalized overnight? |
| NightsHosp |
NumericTextBox |
How many nights were you (your child) hospitalized? |
| DateHospitalized |
Date |
Admission date |
| HospName |
TextBox |
Hospital name: |
| WithinStateTravel |
TextBox |
List Counties in home state (outside county of residence) where you (your child) might have purchased or eaten foods during the 14 days before onset of illness. |
| UnkWithinStateTravel |
CheckBox |
Unknown |
| WithinStateDeparted1 |
Date |
Date Departed |
| WithinStateReturned1 |
Date |
Date Returned |
| WithinStateFood |
TextBox |
Foods Eaten |
| StateTravel |
TextBox |
List all US cities and states (outside of home state) where you (your child) might have purchased or eaten foods. This includes airports, bus or train stations. |
| UnknownStateTravel |
CheckBox |
Unknown |
| DateDepartedUS1 |
Date |
Date Departed |
| DateReturnedUS1 |
Date |
Date Returned |
| FoodsEatenUS1 |
TextBox |
Foods Eaten |
| TravelOutsideUS |
TextBox |
List all countries outside the US and dates or travel where you (your child) might have purchased or eaten foods. |
| UnkTravelOutsideUS |
CheckBox |
Unknown |
| NoIntlTravel |
CheckBox |
Did not travel Outside US |
| CountryTraveled1 |
TextBox |
Countries Traveled |
| CountryDateDeparted1 |
Date |
DateDeparted |
| CountryDateReturned1 |
Date |
Date Returned |
| CountryFoodsEaten1 |
TextBox |
Foods Eaten |
| Events |
CheckBox |
Did you (your child) attend any events where food was served (e.g., parties, fairs, concerts, tournaments, conventions)? |
| EventsInfo |
TextBox |
Please list the name of event, date, and location |
| OtherIll |
CheckBox |
Do you know of any other person(s) who has been sick recently with a similar illness? |
| OtherIllInfo |
TextBox |
If yes, please provide information for other ill person(s) including number of ill persons and
relationship to you (e.g. son, mother, neighbor, friend, etc.)*. |
| OtherIllComments |
TextBox |
Please provide information about the other ill persons and their relationship to you (include the STATE ID, do not enter names or other personally identifiable information) |
| lblFoodHome |
Literal |
Did you (your child) eat foods from: grocery stores or supermarkets, warehouse stores, small markets (such as gas stations), ethnic specialty markets, health food stores, co-ops, fish or meat specialty shops, farmer's markets or food directly from a farm, or any other sources?
|
| StoreName1 |
TextBox |
Store Name |
| StoreAddress1 |
TextBox |
Address |
| StoreCity1 |
TextBox |
City |
| StoreState1 |
TextBox |
State |
| DatesShopped1 |
Date |
Date shopped |
| ItemsPurchased1 |
TextBox |
Items purchased |
| ShopperCard |
TextBox |
Shopper card # |
| ShopperCardRefused |
CheckBox |
Refused to give shopper card # |
| lblFoodAway |
CheckBox |
Did you (your child) eat foods from: national fast food chains, Mexican-style, Italian, seafood, Jamaican/Cuban/Caribbean, Chinese/Indian/Japanese/Asian, vegetarian or vegan, barbeque or home-style, steakhouse or grill, diner, Middle Eastern/Arabic/Lebanese/African, all-you-can-eat buffet, sandwich shop or deli, salad bar, take-out, breakfast or brunch, school or institution, food truck, or other restaurants or commercial food establishments?
|
| RestaurantName1 |
TextBox |
Restaurant Name |
| RestaurantAddress1 |
TextBox |
Address |
| RestaurantCity1 |
TextBox |
City |
| RestaurantState1 |
TextBox |
State |
| DatesPatronized1 |
Date |
Meal date |
| FoodsEaten1 |
TextBox |
Foods eaten |
| FoodAwayComments1 |
TextBox |
Additional Comments |
| Cluster |
CheckBox |
Is this case associated with a cluster [Yes/No] |
| ClusterName |
TextBox |
What is the cluster name? |
| Basil |
CheckBox |
Did you (your child) eat any fresh basil? |
| Sweetbasil |
CheckBox |
Sweet |
| PurpleBasil |
CheckBox |
Purple (i.e., purple leaves and stems) |
| ThaiBasil |
CheckBox |
Thai (i.e., green leaves and purple stems) |
| OthUnkBasilType |
CheckBox |
Other/Unknown |
| BasilBrand |
TextBox |
If eaten at home, what was the: Brand(s) purchased: |
| BasilPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased: |
| BasilHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| grpBasil_Away |
GroupBox |
If eaten outside the home |
| BasilAwayName |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and locations: |
| BasilAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Cilantro |
CheckBox |
Did you (your child) eat any fresh cilantro? |
| CilantroBrand |
TextBox |
If eaten at home, what was the: Brand(s): |
| CilantroPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| CilantroHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| CilantroAwayName |
TextBox |
If eaten outside the home: List name(s) of establishments: |
| CilantroAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Parsley |
CheckBox |
Fresh parsley |
| Oregano |
CheckBox |
Fresh oregano |
| Thyme |
CheckBox |
fresh thyme |
| Mint |
CheckBox |
Fresh mint |
| Dill |
CheckBox |
Fresh dill |
| Sage |
CheckBox |
Fresh sage |
| Rosemary |
CheckBox |
Fresh rosemary |
| OtherHerb |
CheckBox |
Other fresh herbs? |
| OtherHerbDesc |
TextBox |
Type(s) |
| UnkOtherHerbType |
CheckBox |
Unknown |
| HerbComments |
TextBox |
Additional Comments |
| RedRasp |
CheckBox |
Did you (your child) eat any fresh red raspberries? |
| RedRaspBrand |
TextBox |
If eaten at home, what was the: Brand(s): |
| RedRaspPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) of purchase: |
| RedRaspHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| RedRaspAwayName |
TextBox |
If eaten outside the home: List name(s) of establishment(s): |
| RedRaspAwayLoc |
TextBox |
If eaten outside the home: List location(s): |
| RedRaspAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Blackberry |
CheckBox |
Did you (your child) eat any fresh blackberries? |
| BlackberryBrand |
TextBox |
If eaten at home, what was the: Brand(s): |
| BlackberryPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) of purchase: |
| BlackberryHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| BlackberryAwayName |
TextBox |
If eaten outside the home: List name(s) of establishment(s): |
| BlackberryAwayLoc |
TextBox |
If eaten outside the home: List location(s): |
| BlackberryAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| BlackRasp |
CheckBox |
Did you (your child) eat any black raspberries? |
| GoldRasp |
CheckBox |
Did you (your child) eat any golden raspberries? |
| Strawberry |
CheckBox |
Did you (your child) eat any strawberries? |
| Blueberry |
CheckBox |
Did you (your child) eat any blueberries? |
| Boysenberry |
CheckBox |
Did you (your child) eat any boysenberries? |
| OtherBerry |
CheckBox |
Did you (your child) eat any other fresh berries? |
| OtherSpecificBerries |
TextBox |
If yes, please specify: |
| BerryUnknown |
CheckBox |
Unknown |
| Apple |
CheckBox |
Did you (your child) eat any apples? |
| Grape |
CheckBox |
Did you (your child) eat any grapes? |
| Pear |
CheckBox |
Did you (your child) eat any pears? |
| Peach |
CheckBox |
Did you (your child) eat any peaches? |
| Nectarine |
CheckBox |
Did you (your child) eat any nectarines? |
| Plum |
CheckBox |
Did you (your child) eat any plums? |
| Orange |
CheckBox |
Did you (your child) eat any oranges? |
| Grapefruit |
CheckBox |
Did you (your child) eat any grapefruit? |
| Tangerine |
CheckBox |
Did you (your child) eat any tangerines? |
| LemonLime |
CheckBox |
Did you (your child) eat any fresh lemon or lime? This could include a garnish on a drink. |
| Cherry |
CheckBox |
Did you (your child) eat any cherries? |
| Cantaloupe |
CheckBox |
Did you (your child) eat any cantaloupe? |
| Honeydew |
CheckBox |
Did you (your child) eat any honeydew melon? |
| Watermelon |
CheckBox |
Did you (your child) eat any watermelon? |
| PreCutMelon |
CheckBox |
Did you (your child) eat any precut melon or melon salad? |
| OtherMelon |
CheckBox |
Did you (your child) eat any other melon? |
| Pineapple |
CheckBox |
Did you (your child) eat any pineapple? |
| Mango |
CheckBox |
Did you (your child) eat any mango? |
| Coconut |
CheckBox |
Did you (your child) eat any coconut (whole or shredded)? |
| OtherFruit |
CheckBox |
Did you (your child) eat any other fruit (e.g., kiwi, papaya, guava, pomegranate, other [specify])? |
| FreshFruitComments |
TextBox |
Additional Comments |
| PremadeSalad |
CheckBox |
Did you (your child) eat any pre-made, single serving salads (e.g., ready to eat salads with toppings, meats, dressing)? |
| PremadeSaladIngredients |
TextBox |
Ingredients (lettuce, cabbage, carrots, etc.) |
| PremadeSaladBrand |
TextBox |
Brand(s): |
| PremadeSaladPlacePurch |
TextBox |
Place(s) purchased (names, locations): |
| Iceberg |
CheckBox |
Did you (your child) eat any iceberg lettuce? |
| PrepackagedIceberg |
CheckBox |
Prepackaged |
| HeadLooseIceberg |
CheckBox |
Head/Loose |
| ToppinggarnishIceberg |
CheckBox |
Topping/garnish |
| UnkIcebergType |
CheckBox |
Unknown |
| IcebergBrand |
TextBox |
If eaten at home, what was the: Brand(s): |
| IcebergPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| IcebergHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| IcebergAway |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and locations: |
| IcebergAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Romaine |
CheckBox |
Did you (your child) eat any romaine lettuce? |
| RomaineTypeGroup |
CheckBox |
If eaten at home: What was the type? |
| PrepackagedRomaine |
CheckBox |
Prepackaged |
| HeadLooseRomaine |
CheckBox |
Head/Loose |
| ToppinggarnishRomaine |
CheckBox |
Topping/garnish |
| UnkRomaineType |
CheckBox |
Unknown |
| RomaineHomeBrand |
TextBox |
If eaten at home, what was the: Brand(s): |
| RomainePlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| RomaineHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| RomaineAway |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and locations: |
| RomaineAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Mesclun |
CheckBox |
Did you (your child) eat any mesclun lettuce (e.g., spring mix, field greens, baby greens)? |
| MesclunBrand |
TextBox |
If eaten at home, what was the: Brand(s) purchased: |
| MesclunPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| UnkMesclunPlacePurch |
CheckBox |
Not Applicable (did not eat at home) |
| MesclunAwayName |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and location(s): |
| MesclunAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Cabbage |
CheckBox |
Did you (your child) eat any fresh cabbage? |
| RedCabbage |
CheckBox |
Red |
| GreenCabbage |
CheckBox |
Green |
| SavoyCabbage |
CheckBox |
Savoy (aka, curly) |
| NapaCabbage |
CheckBox |
Napa |
| Bokchoy |
CheckBox |
Bok choy |
| BrusselsSprouts |
CheckBox |
Brussels sprouts |
| OthUnkCabbageType |
CheckBox |
Other/Unknown |
| CabbageBrand |
TextBox |
If eaten at home, what was the: Brand(s) purchased: |
| CabbagePlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| CabbageHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| CabbageAwayName |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and location(s): |
| CabbageAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Spinach |
CheckBox |
Did you (your child) eat any fresh spinach? |
| PrepackagedSpinach |
CheckBox |
Prepackaged |
| HeadLooseSpinach |
CheckBox |
Head/Loose |
| ToppinggarnishSpinach |
CheckBox |
Topping/garnish |
| UnkSpinachType |
CheckBox |
Unknown |
| SpinachHomeBrand |
TextBox |
If eaten at home, what was the: Brand(s): |
| SpinachHomePlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| SpinachHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| SpinachAwayPlaceName |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and locations: |
| SpinachAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| OtherGreens |
CheckBox |
53. Did you (your child) eat any other lettuce or leafy greens? |
| Arugula |
CheckBox |
Arugula |
| Kale |
CheckBox |
Kale |
| Endive |
CheckBox |
Endive |
| mustardgreens |
CheckBox |
Mustard greens |
| radicchio |
CheckBox |
Radicchio |
| UnkLeafyGreenType |
CheckBox |
Unknown |
| OtherLeafyGreens |
CheckBox |
Other |
| OtherLeafySpecify |
TextBox |
Please specify: |
| LettuceLeafyComments |
TextBox |
Additional Comments |
| Prepkgdsalad |
CheckBox |
Did you (your child) eat any other prepackaged salad mix (not previously identified above)? |
| Prepkgdsaladingredients |
TextBox |
Ingredients (lettuce, cabbage, carrots, etc.) |
| Prepkgdsaladbrand |
TextBox |
Brand(s): |
| PrepkgdsaladPlacePurch |
TextBox |
Place(s) purchased (names, locations): |
| LeafyGreensComments |
TextBox |
Additional Comments |
| Cucumber |
CheckBox |
Did you (your child) eat any cucumbers? |
| Zucchini |
CheckBox |
Did you (your child) eat any zucchini? |
| Squash |
CheckBox |
Did you (your child) eat any squash? |
| BellPepper |
CheckBox |
Did you (your child) eat any bell peppers? |
| RedBellPepper |
CheckBox |
Red |
| GreenBellPepper |
CheckBox |
Green |
| OrangeBellPepper |
CheckBox |
Orange |
| YellowBellPepper |
CheckBox |
Yellow |
| UnkBellPepper |
CheckBox |
Unknown |
| HotPepper |
CheckBox |
Did you (your child) eat any hot chili/chile peppers? |
| Celery |
CheckBox |
Did you (your child) eat any celery? |
| MiniCarrot |
CheckBox |
Did you (your child) eat any "mini" carrots? These are often peeled and sold in a sealed bag. |
| OtherCarrot |
CheckBox |
Did you (your child) eat any other fresh carrots? |
| RootVeg |
CheckBox |
Did you (your child) eat any other raw root vegetables? |
| Radish |
CheckBox |
Radish |
| Beets |
CheckBox |
Beets |
| Turnips |
CheckBox |
Turnips |
| RootVegUnk |
CheckBox |
Unknown |
| RootVegOther |
CheckBox |
Other [specify] |
| RootVegOtherSpecify |
TextBox |
Specify |
| Peas |
CheckBox |
Did you (your child) eat any fresh, raw peas? May be shelled or in the pod. |
| GardenPeas |
CheckBox |
Garden peas |
| SnowPeas |
CheckBox |
Snow peas (i.e., flat, shiny pods containing tiny peas) |
| SugarSnapPeas |
CheckBox |
Sugar snap peas (i.e, plump, crisp, edible pods) |
| OthUnkPeas |
CheckBox |
Other/Unknown |
| OthUnkPeasSpecify |
TextBox |
Specify |
| PeasBrand |
TextBox |
If eaten at home, what was the: Brand(s) purchased: |
| PeasPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| PeasHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| PeasAwayName |
TextBox |
If eaten outside the home: List name(s) of establishments and locations: |
| PeasAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Broccoli |
CheckBox |
Did you (your child) eat any broccoli? |
| Cauliflower |
CheckBox |
Did you (your child) eat any cauliflower? |
| Sprouts |
CheckBox |
Did you (your child) eat any sprouts? |
| Onion |
CheckBox |
Did you (your child) eat any raw onions? |
| WhiteOnion |
CheckBox |
White |
| YellowOnion |
CheckBox |
Yellow |
| RedPurpleOnion |
CheckBox |
Red/Purple |
| UnkOnion |
CheckBox |
Unknown |
| OtherOnion |
CheckBox |
Other |
| OtherOnionSpecify |
TextBox |
Other specify |
| Scallion |
CheckBox |
Did you (your child) eat any raw green onions/scallions? |
| Tomato |
CheckBox |
Did you (your child) eat any fresh tomatoes? |
| RedRoundTomato |
CheckBox |
Red round |
| RomaTomato |
CheckBox |
Roma (oval-shaped) |
| GrapeCherryTomato |
CheckBox |
Grape/Cherry (bite-sized) |
| UnkTomato |
CheckBox |
Unknown |
| OtherTomato |
CheckBox |
Other |
| OtherTomatoSpecify |
TextBox |
Other specify |
| Pico |
CheckBox |
Did you (your child) eat any fresh salsa or pico de gallo (not from a jar)? |
| PicoBrand |
TextBox |
If eaten at home what was the: Brand(s) purchased: |
| PicoPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| PicoHomeNotApplicable |
CheckBox |
Not Applicable (did not eat at home) |
| PicoAwayName |
TextBox |
If eaten outside the home: List name(s) of establishment(s) and locations: |
| PicoAwayNotApplicable |
CheckBox |
Not Applicable (did not eat outside the home) |
| Guacamole |
CheckBox |
Did you (your child) eat any fresh guacamole (not from a jar)? |
| GuacBrand |
TextBox |
If eaten at home what was the: Brand(s) purchased: |
| GuacPlacePurch |
TextBox |
If eaten at home, what was the: Place(s) purchased (names, locations): |
| GuacHomeNotApplicable |
TextBox |
Not Applicable (did not eat at home) |
| GuacAway |
CheckBox |
If eaten outside the home: List name(s) of establishment(s) and locations: |
| GuacAwayNotApplicable |
TextBox |
Not Applicable (did not eat outside the home) |
| FreshVegComments |
TextBox |
Additional Comments |