0920-21HN NORS Form 52.14

General

National Outbreak Reporting System

OMB No. XXXX-XXXX

This form is used to report investigations of foodborne and waterborne disease outbreaks; enteric disease outbreaks transmitted by contact with persons, animals, or environmental sources; or by
an unknown mode; and certain fungal disease outbreaks. This form has 16 sections, indicated by the dark purple headers. Please complete as much as possible of all applicable sections.
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA, 30333, ATTN: PRA (XXXX-XXXX) <---DO NOT MAIL CASE REPORTS TO THIS ADDRESS
Guidance document: https://www.cdc.gov/nors/forms.html

CDC ID CDC use only

State ID

Primary Mode of Transmission Select one
❍ Animal contact
❍ Environmental contamination other than food/water
❍ Food

❍ Person-to-person
❍ Water
❍ Indeterminate/Unknown

Dates mm/dd/yyyy
Date first case became ill (required):
Date of last exposure:

Date last case became ill:

Date of initial exposure:

Date of notification to State/Territory or Local/Tribal Health Authorities:

Date outbreak investigation began:

Geographic Location
Exposure state:
❍ Exposures occurred in multiple states
❍ Exposures occurred in a single state, but some or all case(s) resided in a different state(s)
Other states:

(For multistate exposure or multistate residency outbreaks, enter the case count for each state)

Exposure county:
❍ Exposures occurred in multiple counties in exposure state
❍ Exposures occurred in a single county, but some or all case(s) resided in a different county or multiple counties
Other counties:
Exposures occurred on any of the following:
❑ Not applicable (N/A)
❑ Tribal land (within census bureau boundaries)

❑ National park
❑ Other federal land (e.g., national forest, military base; specify below)

City/Town/Place of exposure (e.g., facility name):

Primary Cases
Primary Case Counts
Primary Case Counts

Number

Sex Number or percent of the primary cases

Lab-confirmed primary cases

#

Probable primary cases
Estimated total primary cases (required)

Number

Percent

Male

#

%

#

Female

#

%

#

Unknown sex

#

%

For food and animal contact outbreaks, if outbreak occurred during >1 calendar year, # cases per year (by illness onset)
Case Type

Year:

Year:

Year:

Year:

Lab-confirmed primary cases
Probable primary cases
Estimated total primary cases

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General
Age Number or percent of primary cases
Age

Number

Percent

Age

Number

Percent

Age

Number

Percent

<1 year

#

%

10-17 years

#

%

65-74 years

#

%

1-4 years

#

%

18-49 years

#

%

≥75 years

#

%

5-9 years

#

%

50-64 years

#

%

Unknown

#

%

Signs or Symptoms Among primary cases
Commonly reported signs
or symptoms

# cases

# cases with
info available

Other signs or symptoms

# cases

# cases with
info available

Select all that apply from list in Appendix E

Vomiting

#

#

Fever

#

#

Diarrhea

#

#

Other (specify):

#

#

Bloody stools

#

#

Other (specify):

#

#

Abdominal cramps

#

#

Other (specify):

#

#

Incubation Period Among primary cases; select appropriate units

Duration of Illness Among recovered primary cases; select appropriate units

❑ Unknown incubation period
Incubation Period

❑ Unknown duration of illness

Number

Illness Duration

Increment

Shortest

#

Median

#

Longest

#

Mins

Mins

Mins

Hours

Hours

Hours

Number

Increment

Days

Shortest

#

Mins

Hours

Days

Days

Median

#

Mins

Hours

Days

Days

Longest

#

Mins

Hours

Days

# of cases with info available:

# of cases with info available:

Healthcare-Seeking Behaviors Among primary cases
Behavior

# cases

# cases with info available

Visited health care provider

#

#

Visited emergency department

#

#

Visited Indian Health Service or tribal facility

#

#

Case Outcomes Among primary cases
Outcome

# cases

# cases with info available

Died

#

#

Hospitalized

#

#

Hemolytic uremic syndrome (HUS)

#

#

#

#

#

#

Disseminated infection

(e.g., pathogen detected in blood, central nervous system, bone/joint)

Pregnancy loss (For # cases with info available, enter number of known
pregnant women)

Case Characteristics Among primary cases
Characteristic
During the exposure period of interest (or the 7 days before illness began for
unknown etiologies), indicate how many primary case-patients:

# cases

# cases with info available

Attended or worked in a child daycare

#

#

Were experiencing homelessness

#

#

Were exposed in the workplace

#

#

Were immunocompromised
(e.g., HIV/AIDS, solid organ or stem cell transplant, cancer)

#

#

#

#

Were men who reported sexual contact with another man (MSM)

Complete only for person-to-person and indeterminate/unknown outbreaks.
For # cases with info available, enter number of known men
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General

Lab/Environmental

Travel During the exposure period of interest (or 7 days before illness began for unknown etiologies)
1. For environmental contamination, person-to-person, water, and indeterminate/unknown outbreaks, did any primary case-patient travel for at
least one night away from the primary residence:
Domestically?*

Yes

No

Unknown

N/A
Internationally?†

Yes

No

Unknown

N/A
2. For food outbreaks, was the outbreak associated with the source case-patient (e.g., food worker) traveling internationally†?

Yes

No

Unknown

N/A
*This includes travel to a different city, state, or territory in the United States
†
Case-patients with implicated exposure outside the United States should not be included in case counts for this report. Only outbreaks with domestic exposures should be
reported through NORS.

Case characteristics remarks

Secondary Cases
Mode of Secondary Transmission Select all that apply
❑ Food
❑ Water
❑ Animal contact
❑ Person-to-Person
❑ Environmental contamination other than food/water
❑ Indeterminate/unknown

Secondary Case Counts
Secondary Case type

Number

Lab-confirmed secondary cases

#

Probable secondary cases

#

Estimated total secondary cases

#

Estimated total cases (Primary + Secondary)

#

Secondary Case Outcomes Complete for food and animal contact outbreaks only
Outcome

# secondary cases

# secondary cases with info available

Died

#

#

Hospitalized

#

#

Hemolytic uremic syndrome (HUS)

#

#

Laboratory and Environmental Investigation
Sample Collection and Testing For human samples, only include primary cases
1. Were any samples tested?

Yes

No

Unknown

2. What types of samples were tested?
a. Human

Yes
i. Food worker

Yes
b. Animal

Yes
c. Food

Yes
d. Water

Yes
e. Other environmental

Yes

No

No

No

No

No

No

Unknown
From how many persons (including food workers)?

Unknown

Unknown

Unknown

Unknown

Unknown  
Specify other type(s):

3. What were they tested for? (Select all that apply)
Human samples
❑ Bacterium/bacteria or bacterial toxin(s)
❑ Virus(es)
❑ Parasite(s)
❑ Chemical(s) or non-bacterial toxin(s)
❑ Fungus/fungi
❑ Other
❑ Unknown

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Animal, food, water, other environmental samples
❑ Bacterium/bacteria or bacterial toxin(s)
❑ Virus(es)
❑ Parasite(s)
❑ Chemical(s) or non-bacterial toxin(s)
❑ Fungus/fungi
❑ Other
❑ Unknown

National Outbreak Reporting System

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Lab/Environmental
4. What test types were used? (Select all that apply)
Human samples
❑ Test for chemical
❑ Culture
❑ DNA or RNA amplification/detection (e.g., PCR, RT-PCR,

Animal, food, water, other environmental samples
❑ Test for chemical
❑ Culture
❑ DNA or RNA amplification/detection (e.g., PCR, RT-PCR,

❑ Mass spectroscopy (e.g., MALDI-TOF)
❑ Metagenomics (e.g., DNAse SISPA, amplicon sequencing,

❑ Mass spectroscopy (e.g., MALDI-TOF)
❑ Metagenomics (e.g., DNAse SISPA, amplicon sequencing,

❑ Microscopy (e.g., Fluorescent, electron microscope)
❑ Serological or immunological test (e.g., EIA, ELISA, UAT)
❑ Antigen
❑ Antibody
❑ Tissue culture infectivity assay

❑ Microscopy (e.g., Fluorescent, electron microscope)
❑ Serological or immunological test (e.g., EIA, ELISA, UAT)

multiplex PCR panels)

multiplex PCR panels)

shotgun metagenomics)

shotgun metagenomics)

❑ Antigen
❑ Antibody

❑ Tissue culture infectivity assay
❑ Other (specify):
❑ Unknown

❑ Other (specify):
❑ Unknown

5. Did CDC NARMS perform antimicrobial susceptibility testing?

Yes

No

Unknown

Waterborne Disease Outbreak Environmental Investigation Complete only for waterborne disease outbreaks
1. Which of the following sampling locations were tested? Select all that apply from list in Appendix E.

2. Did environmental sampling results implicate water as the primary mode of transmission?
❍ Yes
❍ No (skip to b)
❍ Unknown (skip to b)
a. Did the results implicate the vehicle(s) of transmission? (e.g., pool, community water system, cooling tower)

Yes

No

Unknown
Please summarize the environmental sampling results that implicated water in support of the epidemiologic findings. (Select all that apply)

Environmental sampling results

Are there supporting
environmental
sampling results?

Fecal indicators

Yes

No

pH

Yes

No

Temperature

Yes

No

Turbidity

Yes

No

Residual/free disinfectant

Yes

No

Combined disinfectant

Yes

No

Etiologic agent(s)

Yes

No

Other (specify):

Yes

No

Please describe relevant environmental sampling results
(e.g., fecal indicators identified in well water on [insert date].)

b. Did historical or other environmental health evidence implicate water as the primary mode of transmission?

Yes

No

Unknown

If yes, please describe:
3. Would you like to attach environmental sampling results to this report?

CDC 52.13 CS317494 07/29/2021

Yes

National Outbreak Reporting System

No

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Etiology

Settings

Etiology and Isolates
Is there at least one confirmed* or suspected outbreak etiology(s)?

 Yes

 No (unknown etiology)

(If no, skip to next section)

*See the guidance document for guidelines on confirming the etiology of the outbreak.

Etiology If available, include the subtype and other characteristics such as virulence factors and metabolic profile.
Genus

Species

Subtype
(e.g., serotype,
genotype)

Other
characteristics

Total # positive primary cases

Detected
in*

Outbreak etiology
confirmed or
suspected

Total #:
# culture-confirmed:
# CIDT-positive only:
Total #:
# culture-confirmed:
# CIDT-positive only:
*Detected in (select all that apply): 1 – patient specimen; 2 – food sample; 3 – environmental sample; 4 – food worker specimen; 5 – water sample; 6 – animal specimen

Isolates or Strains For PulseNet isolates, complete only the first four columns. For all other isolates/strains, enter all available information.
CDC system

(PulseNet,
CaliciNet,
CryptoNet, Other,
Unknown, None)

State lab:
sample ID

CDC lab:
sample ID

(e.g., PulseNet
key, CaliciNet key,
CryptoNet key)

CDC lab:
outbreak ID

PFGE
pattern

(e.g., PulseNet
outbreak code,
CaliciNet outbreak
number, CryptoNet
outbreak number)

Sequencing
information
(e.g., allele code,
sequenced region)

Subtype
information

(e.g., serotype,
genotype)

Source/
sample type
(e.g.,
environmental
sample; refer to
list in Appendix E)

Enzyme 1:

Enzyme 2:

Enzyme 1:

Enzyme 2:

Settings
Setting(s) of Exposure: Animal Contact, Environmental Contamination, Food, Person-to-Person, and Indeterminate/Unknown
Enter all settings of exposure using list in Appendix E. Select a single setting unless exposures occurred in multiple settings. If multiple options
could describe a single outbreak setting, choose the option that best applies and provide details in the remarks box below. For foodborne disease
outbreaks, this is the location where food was eaten. Setting(s) where food was prepared is captured in the next section.
Setting 1/Major Setting*

Setting 2

Setting 3

Setting 4

Other (specify):

*Major setting for person-to-person, environmental, and indeterminate/unknown outbreaks should be entered in Setting 1

Setting of exposure remarks:

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Settings
Setting(s) of Preparation: Food Complete only for food outbreaks
Enter all settings where food was prepared using the list in Appendix E. Select a single setting unless preparation occurred in multiple settings.

Setting 1

Setting 2

Setting 3

Setting 4

Other (specify):

Setting of preparation remarks:

Setting(s) of Exposure and Implicated Vehicle Description: Water Complete only for water outbreaks
Implicated type(s) of water exposure Select all that apply and complete appropriate water exposure sections
❑ Treated recreational water (e.g., in manufactured venues such as pools, spas/whirlpools, hot tubs, spray pads, at-home kiddie pools)
❑ Untreated recreational water (e.g., natural venues such as freshwater lakes, hot springs, marine beaches/oceans)
❑ Drinking water in public or individual water systems (e.g., municipal system, private well, commercially-bottled water, water kiosk), regardless of the
exposure pathway (i.e., not limited to ingestion)
❑ Other exposures to water, including other environmental exposures to water (e.g., cooling/industrial, water reuse, irrigation, occupational, decorative/
display; includes water consumed from sources such as back-country streams)

❑ Undetermined exposures to water (i.e., the intended purpose or use of the water is unknown or the water exposure category could not be determined)
Implicated water — recreational water venue description
(TREATED WATER
OUTBREAKS ONLY)

Water venue

(e.g., spa/whirlpool/
hot tub; refer to list in
Appendix E)

Water venue subtype
(Refer to list in
Appendix E)

Setting of exposure

(e.g., hotel/motel; refer
to list in Appendix E)

(TREATED WATER
OUTBREAKS ONLY)

(TREATED WATER
OUTBREAKS ONLY)

How was the water in Treatment description What were chlorine
(e.g., chlorine)
the venue treated?
stabilizer levels at the
Select all that apply from time of the outbreak?
(e.g., disinfection,
filtration)

list in Appendix E

Implicated water — drinking water system description
Water system*

(e.g., community
water system; refer
to list in Appendix E)

Public water
system EPA ID
number†

Water source

(e.g., ground water,
surface water; refer
to list in Appendix E)

Water source
description

((e.g., spring, well,
lake; refer to list in
Appendix E)

How was the
water in the
system treated?
(e.g., disinfection,
filtration)

Treatment
description

( e.g., chlorine)
Select all that apply
from list in
Appendix E

Setting
of exposure

(e.g., hotel/motel;
refer to list in
Appendix E)

* Water system definitions: Community and non-community water systems are public water systems that have ≥15 service connections or serve an average of ≥25 residents
for ≥60 days/year. A community water system serves year-round residents of a community, subdivision, or mobile home park. A non-community water system serves an
institution, industry, camp, park, hotel, or business and can be non-transient or transient. Non-transient systems serve ≥25 of the same persons for >6 months of the year but
not year-round (e.g., factories and schools), whereas transient systems provide waterto places in which persons do not remain for long periods (e.g., restaurants, highway rest
stations, and parks). Individual water systems are small systems not owned or operated by a water utility that have<15 connections or serve <25 persons.
†
Number used for EPA reporting that uniquely identifies the public water system within a specific state. The water system ID number can be found by searching the Safe
Drinking Water Information System (SDWIS) online at https://ofmpub.epa.gov/apex/sfdw/f?p=108:200.

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Settings
Implicated water — other and undetermined exposure to water description

System or source of the water
(e.g., cooling tower; refer to list
in Appendix E)

Setting of exposure

(e.g., hotel/motel; refer to
list in Appendix E)

(OTHER AND ENVIRONMENTAL EXPOSURES
TO WATER OUTBREAKS ONLY)

(OTHER AND ENVIRONMENTAL EXPOSURES
TO WATER OUTBREAKS ONLY)

Was the water system/source
treated to reduce or prevent the
risk of disease transmission?

If yes, how was the water in the
system/source treated?

Water setting of exposure remarks

Associated Events Refer to list in Appendix E
Was exposure associated with a specific event(s) or gathering(s)?

Yes (specify):

No

Unknown

Long-term Care Outbreaks Complete this section only if “Long-term care/nursing home/assisted living facility,” “Long term care facility,”
or “Assisted Living/rehab” is selected as a setting above

Types of care affected (Select all that apply)
❑ Nursing home/skilled nursing
❑ Assisted living
❑ Independent living (in continuous care community)
❑ Intermediate care
❑ Memory care
❑ Other (specify):

School Outbreaks Complete this section only if “School/College/University” is selected as a setting above
1. Did the outbreak involve one or more schools?
 One
 More than one (number of schools:

)

Unknown

2. Grades affected (Select all that apply)
❑ K

1

2

3

4

5

6

7

8

9

10
❑ College/university/technical school
❑ Unknown or undetermined grade level(s)
3. Number of schools with public or private funding (If a single school was involved, write “1” next to the funding type):
Public:
Private:

Unknown or undetermined:

11

12

Correctional or Detention Facility Outbreaks Complete this section only if “Correctional/Detention Facility” is selected as a setting above
1. What was the name of the correctional/detention facility?
2. Is the facility run by the government or by a privately contracted business?

Government

Private

Unknown
3. What was the type of facility?
❍ Federal prison
❍ Juvenile detention center
❍ State prison
❍ Immigration detention center
❍ State/local jail
❍ Unknown

❍ Other (specify):

Complete for foodborne disease outbreaks only:
4. Who is involved in food preparation at this facility?
Inmate food workers

Yes

No

Unknown
Other food workers

Yes

No

Unknown
5. If contamination from a food worker was a contributing factor (also answer yes in the Food Contributing Factors section), were any of the
following types of food workers implicated? (cite C9, C10, or C11 within the food contributing factors section)
Inmate food workers

Yes

No

Unknown
Other food workers

Yes

No

Unknown
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Animal Contact

Settings

Attack Rates Complete for person-to-person, environmental contamination, and indeterminate/unknown outbreaks that occurred in a single setting only
Group

Estimated # exposed*

Estimated # ill

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

Residents, guests, attendees, patients, etc.

#

#

%

Staff, crew, etc.

#

#

%

*e.g., number of persons who attended, or were residents in nursing home, or were on affected ward

Animal Contact Section Complete for animal contact outbreaks
Animal vehicle undetermined?

Yes

No

If animal vehicle undetermined, reason(s) supporting animal contact as the mode of transmission (Select all that apply)
❑ Other (specify):
❑ Epidemiologic evidence
❑ Environmental evidence
❑ Laboratory evidence
❑ Traceback investigation
Question

Animal Vehicle 1

Animal Vehicle 2

Animal Vehicle 3

Animal type
Vehicle confirmed or suspected
Reason(s) confirmed or suspected
Enter all from list in Appendix E

Animal(s) experienced diarrhea
or illness that could be related to
outbreak illnesses?
Animal(s) imported to US?

Did the animal(s) implicated in
the outbreak meet any of the
following criteria?
(Select all that apply)

Yes

No

Unknown

Yes

No

Unknown

Yes

No

Unknown

❍ Yes, country:
❍ Yes, country unknown
❍ No
❍ Unknown

❍ Yes, country:
❍ Yes, country unknown
❍ No
❍ Unknown

❍ Yes, country:
❍ Yes, country unknown
❍ No
❍ Unknown

❑ Backyard/residential livestock
or poultry
❑ Commercial livestock or poultry
❑ Pet/companion animal
❑ Interactive exhibit animal
❑ Wild animal/wild game
❑ Other (specify):

❑ Backyard/residential livestock
or poultry
❑ Commercial livestock or poultry
❑ Pet/companion animal
❑ Interactive exhibit animal
❑ Wild animal/wild game
❑ Other (specify):

❑ Backyard/residential livestock
or poultry
❑ Commercial livestock or poultry
❑ Pet/companion animal
❑ Interactive exhibit animal
❑ Wild animal/wild game
❑ Other (specify):

❑ Unknown

❑ Unknown

❑ Unknown

1. How many animals were involved in the outbreak?

#

or

Unknown

a. How many animals died during the outbreak period of interest?
# or  
Unknown
b. How many animal deaths were presumed to be the result of outbreak-associated illness?
2. Was the animal’s living environment implicated as a source of the outbreak?

Yes

# or

No

Unknown

Unknown

3. If any outbreak-associated case-patients were exposed in the workplace, specify the occupation(s) of primary cases exposed in the workplace
(Select all that apply)

❑ Farm/dairy worker
❑ Pet store worker
❑ Agricultural store worker (e.g., farm/rural supply store)
❑ Processing plant/slaughterhouse worker
❑ Other (specify):

4. Was pet food or animal feed implicated as a source?

Yes

No

Unknown
If yes, specify:
❑ Prepackaged pet food
❑ Commercially prepared “raw” pet food
❑ Homemade pet food
❑ Feed (e.g., livestock feed, poultry feed, fish feed)
❑ Frozen or fresh feeder rodents or chicks
❑ Pet treats or chews

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National Outbreak Reporting System

❑ Other (specify):
❑ Unknown

8

Fungal

Animal Contact

5. Was the “Compendium of Measures to Prevent Disease Associated with Animals in Public Settings” used during the investigation?

Yes

No

Unknown
Animal Contact Remarks

Fungal Disease Outbreaks Complete for blastomycosis, coccidioidomycosis, histoplasmosis, and sporotrichosis outbreaks
Treatments
Treatment

# Cases

# Cases with info available

Treated with systemic antibacterial medication before fungal infection was diagnosed (e.g., oral, IV)

#

#

Treated with systemic antifungal medication (e.g., oral, IV)

#

#

Environmental Sampling
Environmental samples collected?

Yes

No

Unknown

Results:

Contributing Factors Select all that apply
❑ Demolition, construction, or renovation
❑ Disruption of bat droppings
❑ Disruption of bird droppings

❑ Natural disaster or phenomenon

(e.g., earthquake, dust storm) (specify):

❑ Bats (specify):
❑ Birds (specify):

❑ Disruption of plant matter

❑ Other (specify):

❑ Disruption of soil

❑ Unknown

Occupational Exposures
Specify major industry/industries* (employer’s type of business,
e.g., hospital, elementary school, clothing manufacturing, restaurant):

Specify major occupation(s)* (type of work, e.g., registered nurse,
janitor, cashier, auto mechanic):

*Resources for industry and occupation coding are available at: https://www.cdc.gov/niosh/topics/coding/collecting.html

Personal Protective Equipment (PPE)
PPE use

# Cases

Wore PPE at any time during the suspected exposure

# Cases with info available
#

#

Specify type(s) of PPE:

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Food

Food Section Complete for food outbreaks
Food vehicle undetermined?

Yes

No
If food vehicle undetermined, reason(s) supporting foodborne as the mode of transmission (Select all that apply)
❑ Epidemiologic evidence
❑ Traceback investigation
❑ Laboratory evidence
❑ Other (specify):
❑ Environmental evidence
Question

Food Vehicle 1

Food Vehicle 2

Food Vehicle 3

❍ Yes, country:
❍ Yes, country unknown
❍ No
❍ Unknown

❍ Yes, country:
❍ Yes, country unknown
❍ No
❍ Unknown

❍ Yes, country:
❍ Yes, country unknown
❍ No
❍ Unknown

Was product produced under U.S.
domestic regulatory oversight?

❍ Yes, federal
❍ Yes, state only
❍ No
❍ Unknown

❍ Yes, federal
❍ Yes, state only
❍ No
❍ Unknown

❍ Yes, federal
❍ Yes, state only
❍ No
❍ Unknown

Was product sold under U.S.
domestic regulatory oversight?

❍ Yes, federal
❍ Yes, state only
❍ No
❍ Unknown

❍ Yes, federal
❍ Yes, state only
❍ No
❍ Unknown

❍ Yes, federal
❍ Yes, state only
❍ No
❍ Unknown

Name of food
Vehicle confirmed or suspected
Reason(s) confirmed or suspected
Enter all from list in Appendix E

Ingredient(s)
Enter all

Contaminated ingredient(s)
Enter all

Method of processing

Enter all from list in Appendix E

Level of preparation

Select one from list in Appendix E

Method of preparation & service
Enter all from list in Appendix E

Type of packaging

Enter all from list in Appendix E

Contaminated food imported to US?

Does the location of preparation have a certified food protection manager?
If yes, is the certified manager on-site during all hours of operation for the location of preparation?

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Yes

Yes

No

No

Unknown

Unknown

10

Food
Was an infectious food worker implicated as the source of contamination?
If yes, select C9, C10, or C11 below

Yes

No

Unknown

Food Contributing Factors Select all that contributed to this outbreak
❑ Select if Contributing factors unknown
Point of final preparation/sale (POS): restaurant, grocery store, private home/residence.
Before point of final preparation/sale:
• Pre-Harvest: farm or dairy, harvest area, growing field
• Post-Harvest: processing or pasteurization plant, distribution or storage facility, during transit
• Unknown if pre or post-harvest: occurred before point of final prep/sale, but point unknown
Contamination Factors:
If no contamination factor available to enter, please select reason:

N/A (does not apply to etiologic agent)

Unknown
Factor
code
C1

C2

C3

C4

C5

C6

None identified

Factor

Source(s)

T
oxin or chemical agent naturally part of tissue in food

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

P
oisonous substance or infectious agent intentionally added to

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

P
oisonous substance accidentally/inadvertently added to food

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
ngredients toxic in large amounts accidentally added to food

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

C

ontainer or equipment used to hold or convey food was made

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

F
ood contaminated by animal or environmental source at point of

Point of Final Prep/Sale

(e.g., ciguatera, scombroid, mushroom poisoning)

food to cause illness (does not include injury)

(e.g., cleaning compound or metallic ingredients accidentally added
to food)
(e.g., niacin poisoning in bread, nitrites in cured meat)

with toxic substances (e.g., galvanized container used to store
acidic food/beverage, flour stored in container that previously held
toxic materials)
final preparation/sale (restaurant, private home, grocery store,
etc.) (e.g., mouse feces in pantry, leaking roof in restaurant)

F
ood contaminated by animal or environmental source before
C7

arriving at point of final preparation (pre or post-harvest) (e.g.,
shellfish from polluted waters, crops contaminated by irrigation
water, Salmonella in eggs, peanut butter in processing plant)

C

ross-contamination of foods, excluding infectious food workers/
C8

C9

C10

C11

C12

Before POS Pre-Harvest

Before POS Post-Harvest

Before POS Unknown Pre or Post Harvest

handlers (e.g., contamination of vehicle via contaminated surface,
food, or fomites including, but not limited to, worker’s hand, cutting
board, preparation table, utensils, processing line)

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

C

ontamination from infectious food worker/handler through

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

C

ontamination from infectious food worker/handler through

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

C

ontamination from infectious food worker/handler through

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

C

ontamination from infectious non-food worker/handler through

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

Other source of contamination (specify):

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

bare-hand contact with food

gloved-hand contact with food

unknown type of hand contact with food or indirect contact
with food (e.g., contact with utensils in food)
direct or indirect contact with food (e.g., contact with utensils in
food)

C13

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Food
Proliferation Factors: Bacterial and fungal outbreaks only
If no proliferation factor available to enter, select reason:

N/A (does not apply to etiologic agent)

Unknown
Factor
code
P1

P2

P3

P4

P5

P6

P7

P8

P9

P10

P11

None identified

Factor

Source(s)

A
llowing foods to remain out of temperature control for a prolonged

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

A
llowing foods to remain out of temperature control for a prolonged

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
nadequate cold holding temperature due to malfunctioning

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
nadequate cold holding temperature due to an improper

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
nadequate hot holding temperature due to malfunctioning

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
nadequate hot holding temperature due to an improper practice

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
mproper cooling of food (e.g., food refrigerated in large quantities

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

E
xtended refrigeration of food for an unsafe amount of time,

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
nadequate Reduced Oxygen Packaging (ROP) of food (e.g.,

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

I
nadequate non-temperature dependent processes (e.g.,

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

O
ther situations that promoted or allowed microbial growth or toxic

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

period of time during preparation (e.g., lengthy preparation time,
allowing frozen foods to thaw at room temperature)

period of time during food service or display
(e.g., during buffet line)
refrigeration equipment

practice (e.g., overloaded refrigerator/cooler, storing food above
fill line)
equipment

(e.g., steam table not turned on, overloaded hot holder/crockpot
used to heat or reheat food)
during cooling process)

relative to the food product and pathogen (e.g., Listeria growth
after refrigeration of deli meat for more than 7 days)
vacuum-packed fish, salad in gas-flushed bag, garlic packaged
in oil)

acidification, water activity, fermentation) applied to a food to
prevent pathogens from multiplying
production (specify):

Survival Factors: Bacterial, viral, parasitic, and fungal outbreaks only
If no survival factor available to enter, select reason:

N/A (does not apply to etiologic agent)

Unknown

None identified
Factor
code

Factor

Source(s)

S1

I
nadequate time and temperature control during initial cooking/

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

S2

I
nadequate time and temperature control during reheating of

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

S3

I
nadequate time and temperature control during freezing of

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

S4

I
nadequate non-temperature dependent processes

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

thermal processing of food (e.g., inadequate pasteurization of
milk, inadequate cooking of meats/poultry prior to service)
food (e.g., insufficient reheating of sauces)

food designed for pathogen destruction

(e.g., acidification, water activity, fermentation) applied to
food to prevent pathogen from surviving

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Water

Food
Factor
code

Factor

Source(s)

S5

N
o attempt was made to inactivate the contaminant through initial

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

S6

O
ther process failures that permit pathogen survival (specify):

Point of Final Prep/Sale

Before POS Post-Harvest

Unknown location

Before POS Pre-Harvest

Before POS Unknown Pre or Post Harvest

cooking/thermal processing, freezing, or chemical processes

Food Contributing Factors Remarks:

Traceback & Recall Complete only for food and animal contact outbreaks
Traceback Investigation Include all traceback points that played a role in the contamination of the implicated vehicle or helped amplify or spread
the contaminant, and any details regarding the implicated point of service/sale
Traceback point(s)

1

2

3

Company name
Company type Description of implicated company
(e.g., restaurant, retailer, farm, breeder, supplier/
distributor, manufacturer, processor, producer, etc.)

Country
State
Traceback findings

Select all that apply from list in Appendix E

What federal agencies were involved in the traceback investigation? (Select all that apply)

CDC

FDA

USDA/APHIS

USDA/FSIS

Other (specify):

None

Recall
❑ Food product was recalled
Exact item(s) recalled:
Link to official recall announcement(s):
Comments:

Water Section Complete for water outbreaks
Supporting evidence
1. Estimated total number of persons with primary water exposure:

#

2. What evidence implicated the water exposure(s)? (Select all that apply)

Epidemiologic data
 Clinical laboratory data

Environmental health data
3. Were data collected to estimate association (e.g., odds ratio) ?

Yes

No

a. If no or unknown, was water the common source shared by persons who were ill?
b. If yes, please provide the epidemiologic data that implicates the water exposure:
Exposure description

CDC 52.13 CS317494 07/29/2021

Attack rate

Effect measure

(number ill/number
exposed as n/N)

(numeric)

Type of effect
measure

Prior experience makes this a likely source

Unknown

Yes

No
p-Value

Unknown
95% confidence
interval

(e.g., odds ratio,
relative risk)

National Outbreak Reporting System

13

Rec Water

Legionella
Water Remarks

Legionella and Other Biofilm-Associated Pathogens
Additional questions for biofilm-associated pathogens

1. Did the outbreak occur in a facility with any of the following characteristics? (Select all that apply)
❑ >10 stories
❑ “Green” components (e.g., low-flow engineering)
❑ Construction in building within the last six months
❑ Construction nearby within the last six months
❑ Associated cooling towers
❑ Other associated aerosolizing devices (e.g., hot tub,

❑ Supplemental building disinfection system
❑ Centralized hot water system
❑ Other (specify in facility characteristic remarks)
❑ Unknown
❑ None

decorative fountains, misters)

Facility characteristic remarks:
2. Did the facility have a water management program in place at the time of the outbreak?

Yes

No

Unknown

a. If yes, which of these elements did the plan include: (Select all that apply)
❑ Multi-disciplinary water management program team
❑ Diagram of the building’s water system
❑ Identification of control points/locations

❑ Method of plan verification

(e.g., pathogen testing, clinical surveillance)

❑ Documentation of water management program
performance and activities
❑ Unknown
❑ None

(e.g., areas of potential Legionella growth and spread)

❑ Established control limits
❑ Regular water parameter testing (e.g., disinfectant, temperature, pH)
❑ Plan for implementing corrective action (tasks taken when monitoring
values are outside of control limits)

b. If yes, who designed the water management program: (Select all that apply)
❑ Facility
❑ Outside contractor
❑ Public health department

❑ Other (specify):
❑ Unknown

3. After the outbreak, were recommendations provided to the facility to decrease the risk of Legionella or other biofilm-associated
pathogen exposure?

Yes

No

Unknown

Not applicable
a. If yes, please select all that apply:
❑ Flushing potable water system
❑ Superheat potable water system
❑ Implement secondary potable water disinfection system
❑ Implement point of use filter(s)
❑ Hyperchlorination of potable water system
❑ Hyperchlorination of recreational water system
❑ Low level chlorination of potable water system

❑ Water restrictions

(e.g., discontinuing use of showers, faucets, or other water uses)

❑ Closure of an associated device (e.g., shutdown of a fountain,
hot tub)

❑ Other (specify):

4. Were samples tested for Legionella at a laboratory participating in a national proficiency program (e.g., ELITE, ELAP, AIHA)?

Yes

No
 Unknown

Not applicable

Biofilm-associated pathogen remarks

Recreational Water — Treated Venue
Water quality management — treated recreational water
1. Was water venue(s) inspected in the 6 months before the outbreak?

Yes

No

Unknown

Not applicable

[NOTE: If yes, attach inspection report(s)]

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Treated recreational water remarks

Factors contributing to recreational water contamination or increased exposure in treated venues
Factor

Recreational water (treated venue) contributing factors Select all that apply*

Documented/observed or Suspected†

Unknown

Contributing factors are unknown

People

Maximum bather load exceeded

Documented/observed

Suspected

Water venue(s) primarily used by children ages <5 years

Documented/observed

Suspected

Fecal/vomit incident in water

Documented/observed

Suspected

Patrons or staff entered the water when ill with diarrhea

Documented/observed

Suspected

H
ygiene facilities (e.g., toilets, diaper-changing stations) inadequate or distant
from water venue(s)

Documented/observed

Suspected

C
ross connection with other water venue(s) or with wastewater/
non-potable water

Documented/observed

Suspected

Ventilation insufficient in indoor aquatic facility

Documented/observed

Suspected

New construction or alteration of water venue or indoor facility

Documented/observed

Suspected

Chemical feed continues when no or low water in recirculation system

Documented/observed

Suspected

Disinfection (e.g., chlorine, bromine) inadequate or absent

Documented/observed

Suspected

Disinfection (e.g., chlorine, bromine) excessive

Documented/observed

Suspected

Chloramine concentration >0.4 ppm

Documented/observed

Suspected

Filtration system malfunctioning or inadequate

Documented/observed

Suspected

Recirculation pump off or restarted with swimmers in water

Documented/observed

Suspected

No regular scrubbing to remove slime/biofilm

Documented/observed

Suspected

No regular hot tub/spa draining

Documented/observed

Suspected

Stagnant water in hot tub/spa piping

Documented/observed

Suspected

No qualified operator§ on payroll or under contract

Documented/observed

Suspected

No qualified operator§ or responsible supervisor¶ on duty during outbreak

Documented/observed

Suspected

Water quality monitoring (e.g., test kit, testing frequency) inadequate or absent

Documented/observed

Suspected

R
ecord keeping (e.g., water quality testing results, fecal incident response)
inadequate or absent

Documented/observed

Suspected

Employee illness policies not enforced or absent

Documented/observed

Suspected

Documented/observed

Suspected

Facility Design

Maintenance

Policy and
management

N/A

W
ater venue(s) not regulated as recreational water venue(s) (e.g., does not
meet state/local definition)

*Only select what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred
but for which no documentation (as defined previously) is available.
§
A qualified operator is defined as someone who has completed training approved by appropriate state/local officials.
¶
A responsible supervisor is defined as someone who conducts and records results of water quality testing, properly maintains water quality, performs general maintenance
procedures, and identifies when to close venues to protect public health without a full-time onsite qualified operator.

Other contributing factors

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Rec Water
Recreational Water — Untreated Venue
Water quality management — untreated recreational water
1. Did the venue meet recreational water quality standards (e.g., applicable local, state, or Environmental Protection Agency [EPA] criteria)
at the time of the outbreak?

Yes

No

Unknown

Not Applicable
2. Do you have microbiological water quality testing results collected in the 3 months before the outbreak?

Yes

No

Unknown
[NOTE: If yes, please attach results]
Untreated recreational water remarks

Factors contributing to recreational water contamination and/or increased exposure in untreated venues
Factor

Recreational water (untreated venue) contributing factors Select all that apply*

Documented/observed or Suspected†

Unknown

Contributing factors are unknown

People

Maximum bather load exceeded

Documented/observed

Suspected

Water venue(s) primarily used by children ages <5 years

Documented/observed

Suspected

Fecal/vomit incident in water

Documented/observed

Suspected

Patrons or staff entered the water when ill with diarrhea

Documented/observed

Suspected

Stagnant or poorly circulating shallow water in swim area

Documented/observed

Suspected

Heavy rainfall and runoff

Documented/observed

Suspected

Algal bloom

Documented/observed

Suspected

Seasonal variation in water quality

Documented/observed

Suspected

Animal contamination: Domestic: pet (e.g., dog)

Documented/observed

Suspected

Animal contamination: Domestic: livestock (e.g., cow, pig)

Documented/observed

Suspected

Animal contamination: Wildlife: birds (e.g., goose)

Documented/observed

Suspected

Animal contamination: Wildlife: Other (specify): (e.g., deer)

Documented/observed

Suspected

Animal contamination: Other (specify):

Documented/observed

Suspected

Sewage contamination: Wastewater treatment plant, sewer system

Documented/observed

Suspected

Sewage contamination: Septic tanks

Documented/observed

Suspected

Improper dumping of sewage (e.g., from boat, RV)

Documented/observed

Suspected

Application or release of chemical

Documented/observed

Suspected

No trained beach manager§ on payroll or under contract

Documented/observed

Suspected

No trained beach manager§ on duty when initial outbreak exposure

Documented/observed

Suspected

M
onitoring of microbiological water quality (e.g., frequency, site of water sample
collection) inadequate or absent

Documented/observed

Suspected

I
nadequate communication (e.g., signage, website posting) to patrons of poor
recreational water quality or closures

Documented/observed

Suspected

H
ygiene facilities (e.g., toilets, diaper-changing stations) inadequate or distant
from water venue(s)

Documented/observed

Suspected

W
ater venue(s) not designated and managed by state/local jurisdiction(s) as
recreational water venue(s)

Documented/observed

Suspected

Environment

Policy and
management

N/A

*Only select what was found during investigation.
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred
but for which no documentation (as defined previously) is available.
§
A trained beach manager is defined as someone who has successfully completed training approved by appropriate state/local officials.
†

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Rec Water-Untreated

Drinking Water System

Other contributing factors

Drinking Water Systems
Water quality management — drinking water system(s)
1. Did the drinking water system(s) have any monitoring violations in the 1 month before the outbreak?

Yes

No

Unknown

Not Applicable
a. If yes, explain:

2. Did the drinking water system(s) have any maximum contaminant level (MCL) violations in the 1 month before the outbreak?

Yes

No

Unknown

Not Applicable
a. If yes, explain:

3. Did the drinking water system(s) have any violations in the 12 months before the outbreak?§

Yes

No

Unknown

Not Applicable
a. If yes, explain:

§

Sources of information about past violations can be obtained from utility records, consumer confidence reports (water quality reports), or violation records from state or local
health departments

Drinking water remarks

Factors contributing to drinking water contamination or increased exposure to contaminated drinking water

Location in system contributing to drinking water contamination
1. Was there a problem with the quality of the source water?

Yes (See contributing factor section 1 below)

No

Unknown

2. Was water quality affected by a problem occurring with the water treatment or within the distribution system before entry into a building
or house?

Yes (See contributing factor section 2 below)

No

Unknown
(NOTE: For a community water system, distribution refers to the system of pipes and storage infrastructure under the jurisdiction of the water utility prior to the
water meter or property line if the system is not metered. For non-community and non-public water systems, distribution refers to the system of pipes and
storage infrastructure prior to entry into a building or house)

3. Was water quality affected by a problem occurring after the water meter or outside the jurisdiction of a water utility?

(e.g., in a service line leading to a house/building, in the plumbing inside a house/building, during shipping/hauling, during storage other than in the distribution
system, at the point of use, involving commercially-bottled water)

Yes (See contributing factor section 3 below)

CDC 52.13 CS317494 07/29/2021

No

Unknown

National Outbreak Reporting System

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Drinking Water System
Drinking Water Contributing Factors
Factor

Drinking water contributing factors Select all that apply*

Documented/observed or Suspected†

Unknown

Contributing factors are unknown

N/A

Source water

Groundwater under direct influence of surface water (e.g., shallow well)

Documented/observed

Suspected

Contamination through limestone or fissured rock (e.g., karst)

Documented/observed

Suspected

Use of alternative source of water by a water utility

Documented/observed

Suspected

Algal bloom

Documented/observed

Suspected

Domestic animal contamination (e.g., livestock, concentrated feeding operation, pets)

Documented/observed

Suspected

Wildlife contamination

Documented/observed

Suspected

Improper construction, location, or maintenance of a well or spring

Documented/observed

Suspected

Extreme weather in area (e.g., flooding/heavy rains, drought)

Documented/observed

Suspected

Contamination from agricultural chemical application (e.g., fertilizer, pesticides)

Documented/observed

Suspected

Contamination from chemical pollution not related to agricultural application

Documented/observed

Suspected

Documented/observed

Suspected

Filtration inadequate or absent in drinking water system

Documented/observed

Suspected

D
isinfection (e.g., chlorine, monochloramine) inadequate or absent in drinking
water system

Documented/observed

Suspected

Aging or corroded water distribution components (e.g., pipes, tanks, valves)

Documented/observed

Suspected

Low water pressure event in the distribution system

Documented/observed

Suspected

Documented/observed

Suspected

Temperatures in optimal range for opportunistic plumbing pathogen growth

Documented/observed

Suspected

D
isinfectant (e.g., chlorine, monochloramine) inadequate or absent in building
water system

Documented/observed

Suspected

Documented/observed

Suspected

Construction in or around building

Documented/observed

Suspected

W
ater system components (e.g., pipe, tanks, disinfectant system, thermostat,
valves) not functioning as designed

Documented/observed

Suspected

from device’s water line, manufacturer maintenance recommendations not followed,
design flaw)

Documented/observed

Suspected

M
issing or poor adherence to industry compliant water management
programs

Documented/observed

Suspected

Contamination of commercially-bottled water at point of use

Documented/observed

Suspected

W
astewater contamination of drinking water source (e.g., septic system

contaminating groundwater, community sewer system malfunction or overflow)

Water treatment/
distribution system

§

W
astewater contamination after water treatment (e.g., cross connection or
malfunctioning back-flow preventer in distribution system)

Outside water
utility jurisdiction
or at point
of use

S
tagnation of water in building water system (e.g., sporadic occupancy, poorly
designed water system, interruption in water supply)

E
quipment/device (e.g., soda machine) contamination or failure (e.g., leaching

*Only select what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but
for which no documentation (as defined previously) is available.
§
Low water pressure is relative to what is normally observed in the distribution system. Sources of low pressure could include events such as main breaks, maintenance activities,
issues with back-flow or cross-connections, pump station activity, service interruptions (e.g., due to power outages), hydrant flushing, and heightened water demand.

Other contributing factors

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Other Water Exposures

Other Exposures to Water, Including Other Environmental Exposures to Water
Implicated water — water exposure description
1. How did the exposure(s) to the water system/source occur? Refer to list in Appendix E
Other exposures to water remarks

Factors contributing to contamination and/or increased exposure to contaminated water
Factor

Contributing factors Select all that apply*

Documented/observed or Suspected†

Unknown

Contributing factors are unknown

Cross cutting

M
issing or poor adherence to industry compliant water management
programs

Documented/observed

Suspected

Presence of dirt, organic matter, or other debris in the basin or fill

Documented/observed

Suspected

Construction in or around the building

Documented/observed

Suspected

Missing or inadequate disinfectant

Documented/observed

Suspected

Lack of a written cleaning and maintenance plan/program

Documented/observed

Suspected

Temperatures in optimal range for opportunistic plumbing pathogen growth

Documented/observed

Suspected

Broken/damaged sewer pipe

Documented/observed

Suspected

Recycling of water

Documented/observed

Suspected

Improper start-up or shutdown procedures

Documented/observed

Suspected

Presence of scale or corrosion

Documented/observed

Suspected

Damaged or missing drift eliminators

Documented/observed

Suspected

Missing or inadequate scale and corrosion inhibitors

Documented/observed

Suspected

History of recent repairs to the device

Documented/observed

Suspected

can be opened)

Documented/observed

Suspected

Intended as an ornamental fountain but utilized as an interactive fountain

Documented/observed

Suspected

Inadequate disinfection for recreational use

Documented/observed

Suspected

Inadequate filtration for recreational use

Documented/observed

Suspected

Presence of submerged lighting

Documented/observed

Suspected

Other

N/A

L
ocation of device near high risk area (e.g., building air intake, windows that

*Only select what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred
but for which no documentation (as defined previously) is available.

Other contributing factors

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Outbreak Detection

Und. Water Exposures

Undetermined Exposures to Water
Implicated water — water description
1. Which water exposure(s) were suspected in the outbreak? (Select all that apply)
❑ Treated recreational water
❑ Untreated recreational water
❑ Drinking water in public or individual water systems
❑ Other exposures to water including environmental exposure to water
❑ Specific water exposure(s) could not be identified
Undetermined exposure to water remarks

Factors contributing to contamination and/or increased exposure to contaminated water
1. Were any contributing factors documented or suspected† in this outbreak investigation?
†

Yes

No

Unknown

“Documented” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but
for which no documentation (as defined previously) is available.

If yes, please describe the contributing factors below.
Contributing factors

Outbreak Detection & Investigation Methods
Outbreak Detection — How was the outbreak initially detected? Select all that apply
❑ Public complaint to health department
❑ Routine public health surveillance interview
❑ Notification from facility

❑ Notification from other CDC group
❑ Notification from other public health lab
❑ Website or social media (e.g., Twitter, Yelp, Facebook)
❑ Media report from news outlet
❑ Other (specify):

(e.g., long-term care facility, school, prison, restaurant)

❑ Healthcare provider report
❑ Notification from CDC lab system (e.g., PulseNet)

Investigation Methods Select all that apply
Epidemiologic
❑ Binomial probability assessment
❑ Case-control study
❑ Case-case study
❑ Cohort study
❑ Interviews only of ill persons
❑ Other (specify):

Environmental
❑ Food preparation review
❑ Water system assessment:
drinking water
❑ Water system assessment:
non-potable water
❑ Treated or untreated recreational
water venue assessment
❑ Environmental, food, water, animal,
or sample testing
❑ Other (specify):

Traceback
❑ Food, animal, or water investigation
❑ Consumer purchase records
(e.g., shopper card)

❑ Investigation at distributor, supplier, or
production facilities (e.g., factory,
treatment plant)

❑ Investigation at original source
(e.g., farm, water source)

❑ Other (specify):

Investigation methods comments

Other Linked CDC Systems
NEARS
NEARS Evaluation ID

1.

OHHABS
OHHABS ID

1.

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Interventions

Interventions
1. Were any interventions recommended or implemented to help stop the outbreak?

Yes

No

Unknown

a. If no, explain why none were recommended or implemented.

b. If yes, what type(s) of interventions were recommended or implemented to help stop the outbreak? Select all that apply in the table below
using list in Appendix E.

Directions:
Intervention Type
Any intervention type can be selected for any mode of transmission regardless of the header listed for each table below.
Any Point of Intervention OR Point of Exposure
Complete for all modes of transmission. For animal contact, foodborne, and indeterminate/unknown outbreaks, enter interventions at the point
of exposure in the “Any Point of Intervention OR Point of Exposure” column.
Recommended or implemented at other points of intervention
Complete only for animal contact, foodborne, and indeterminate/unknown outbreaks for columns:
• Point of distribution
• Point of processing
• Source

Facility/site/venue and equipment – Recommended and Implemented Interventions
Any Point of
Intervention OR Point
of Exposure

Intervention type

(Complete for all modes of
transmission. For animal
contact, foodborne, and
indeterminate/unknown
outbreaks, enter interventions
at the point of exposure)

Point of
distribution*

(e.g., shipping facility,
transportation equipment)

Point of
processing*

(e.g., pasteurization plant)

Source*

(e.g., farm)

Facility/site/venue closed
(for at least 1 day)

Facility/site/venue closed <1 day or
partially closed
Cleaning protocol modified
Facility/site/venue deep cleaned
Equipment deep cleaned
Equipment acquired, adjusted, repaired,
replaced, or discarded
Facility/site/venue physically or
structurally modified
Health promotion signage posted
Personal protective equipment provided
by facility
*Complete for animal contact, foodborne, and indeterminate/unknown outbreaks

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Interventions
People – Recommended and Implemented Interventions
Any Point of
Intervention OR Point
of Exposure

Intervention type

(Complete for all modes of
transmission. For animal
contact, foodborne, and
indeterminate/unknown
outbreaks, enter interventions
at the point of exposure)

Point of
distribution*

(e.g., shipping facility,
transportation equipment)

Point of
processing*

(e.g., pasteurization plant)

Source*

(e.g., farm)

Ill workers excluded
Ill workers restricted
Ill children or persons excluded
Ward(s) closed to new admissions
Visitors excluded
Asymptomatic persons’ stools screened
(e.g., for exclusion)

Ill persons’ stools screened
(e.g., for exclusion)

Vaccination or prophylaxis
Isolation/quarantine/cohorting
Education/training

(e.g., hand washing, certification)
*Complete for animal contact, foodborne, and indeterminate/unknown outbreaks

Animals– Recommended and Implemented Interventions
Any Point of
Intervention OR Point
of Exposure

Intervention type

(Complete for all modes of
transmission. For animal
contact, foodborne, and
indeterminate/unknown
outbreaks, enter interventions
at the point of exposure)

Point of
distribution*

(e.g., shipping facility,
transportation equipment)

Point of
processing*

(e.g., pasteurization plant)

Source*

(e.g., farm)

Animal(s) quarantined or movement
stopped
Animal(s) relocated
Herd culled
Vaccination or prophylaxis
*Complete for animal contact, foodborne, and indeterminate/unknown outbreaks

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Interventions
Food – Recommended and Implemented Interventions
Any Point of
Intervention OR Point
of Exposure

Intervention type

(Complete for all modes of
transmission. For animal
contact, foodborne, and
indeterminate/unknown
outbreaks, enter interventions
at the point of exposure)

Point of
distribution*

(e.g., shipping facility,
transportation equipment)

Point of
processing*

(e.g., pasteurization plant)

Source*

(e.g., farm)

Menu modified
Food preparation processes modified
Self-service discontinued
Food withdrawn (before recall)
Food discarded
Food embargoed
Food source modified (e.g., vendor)
*Complete for animal contact, foodborne, and indeterminate/unknown outbreaks

Water – Recommended and Implemented Interventions
Any Point of
Intervention OR Point
of Exposure

Intervention type

(Complete for all modes of
transmission. For animal
contact, foodborne, and
indeterminate/unknown
outbreaks, enter interventions
at the point of exposure)

Point of
distribution*

(e.g., shipping facility,
transportation equipment)

Point of
processing*

(e.g., pasteurization plant)

Source*

(e.g., farm)

Water restrictions issued
Water advisory issued

(e.g., drinking, swimming)

Water chemically treated (e.g.,

hyperchlorination, secondary disinfection)

Water filtered
Water system superheated
Water system flushed
*Complete for animal contact, foodborne, and indeterminate/unknown outbreaks

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Interventions
Other – Recommended and Implemented Interventions
Any Point of
Intervention OR Point
of Exposure

Intervention type

(Complete for all modes of
transmission. For animal
contact, foodborne, and
indeterminate/unknown
outbreaks, enter interventions
at the point of exposure)

Point of
distribution*

(e.g., shipping facility,
transportation equipment)

Point of
processing*

(e.g., pasteurization plant)

Source*

(e.g., farm)

Other (specify):
Other (specify):
Other (specify):
*Complete for animal contact, foodborne, and indeterminate/unknown outbreaks

2. Were any public communications released for this outbreak? (e.g., press release or outbreak notice)
If yes, by what group(s)? (Select all that apply)
❑ State/local/territorial health department
❑ Other state/local/territorial government agency (specify):
❑ Federal government
❑ Industry
❑ Facility
❑ Other (specify):

Yes

No

Unknown

Remarks about interventions

Remarks
General Remarks Briefly describe any important aspects of the outbreak not covered above, including links to communications or publications.

Please attach summaries or add links to relevant publications.
Thank you for completing this form. These data will help us prevent illnesses.

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