0920-1198 Cyclosporiasis National Hypothesis Generating Questionna

v. 3.43 (September 20201) State/NNDSS ID# (Required)______________

Cyclosporiasis National Hypothesis Generating Questionnaire

Form Approved
OMB No. 0920-1198
Exp. Date 09/30/2023

General information (Questions to be completed by interviewer before the questionnaire is administered.)

1. Classify case based on CDC case definition (Required):  Confirmed  Probable

Laboratory information:

2. Date(s) stool collected for Cyclospora testing (MM/DD/YYYY): ___________________ __________________

3. Test results:  Positive  Negative  Indeterminate  Pending

4. Specify type of testing laboratories and testing method(s) (Check all that apply including confirmatory testing):

	O&P (e.g. microscopy, stained smears)	GI PCR Panel (e.g. BioFire FilmArray®)	PCR (i.e. standalone PCR test, not part of a panel)		Other test type
Clinical lab					
Commercial lab					
State lab					
CDC lab					

5. Was the patient co-infected with another intestinal pathogen? No  Yes 

5a. If YES, please specify name of lab-confirmed coinfection:___________________________________

Interviewer information:

6. Name: ____________________________________________________________________________________

7. Agency or organization: ______________________________________________________________________

8. Contact phone number: ______________________________________________________________________

9. Date of interview: _____ / _____ / _____
MM DD YYYY

10. Before this interview, how many times has the case-patient been interviewed about his/her illness?

 None  Once  Twice  Three or more times  Unknown

11. Respondent for the current interview was:

 Self  Parent  Spouse  Other, specify: _______________________________

For HD use only: Check if case was lost to follow up 
If case was lost to follow up, was information extracted from the medical record?No  Yes 

Begin Interview:

Hello, my name is [state interviewer name]. I am from [INTERVIEWER HEALTH DEPARTMENT]. We are

contacting you because of your (your child’s) recent infection with Cyclospora, which is a parasite that

causes intestinal illness. We are trying to determine how people become infected with Cyclospora so we

can prevent others from getting sick.

You may have already been contacted by someone at the health department, but I would like to ask you

questions in a standard way about your (your child’s) illness, and about any travel you may have had or

foods you may have eaten before becoming ill. The interview could take between 25-45 minutes. Your help in

the investigation is very important. Your participation is voluntary, and you may refuse to answer any

question at any time. All information you give will be kept confidential to the extent permitted by law.

No individual names or other identifying information will be used in any official reports about the

results of the investigation.

Are you willing to participate in this investigation?

If yes: The questions relate to the 14-day period before you (your child) became ill. Therefore, it may

help to have a calendar, recent restaurant and grocery store receipts, or credit card statements nearby.

Do you need a few moments to get this information? [Then proceed to start of interview]

If no: Thank you for your time.

Section 1: Demographic Data

I’d like to begin by asking a few demographic questions.

1. State: _________ 2. County: ___________________________ 3. Zip Code: ________________

4. Date of birth (MM/YYYY): _____ / __________ 5. Age: __________( years)6. Sex:  Male  Female

7. Do you consider yourself of Hispanic or Latino origin?

 Yes

 No

 Unknown

8. How would you describe your race?

 White	 American Indian/Alaskan Native	 Black/African American
 Asian	 Native Hawaiian/Other Pacific Islander	 Unknown
 Other, specify:

Section 2: Clinical Information

Now I have some questions about your (your child’s) illness.

9. What date did you (your child) first feel sick? _____ / _____ / _____  Approximate Date  Unknown

YYYY DD MM

10. Have you (your child) had any of the following symptoms?

Yes	Maybe	No	Don’t know
				a. Diarrhea (loose, watery stools you do not normally have)?
				Date diarrhea started: _____________________ Date diarrhea stopped: ____________________  Ongoing
				b. Weight loss?
				c. Fever?
				d. Fatigue?
				e. Anorexia? ( loss of appetite)e.g.
				f. Nausea?
				g. Vomiting?
				h. Abdominal cramps?
				11. Have your (your child’s) symptoms stopped?
				If yes, date symptoms stopped: ______________________  Unknown

12. Were you (your child) hospitalized overnight? No Yes 
12a. How many nights were you (your child) hospitalized? _____________________
12b. Admission date (MM/DD/YYYY): ________________________
12c. Hospital name (optional): __________________________________

Section 3: Travel, events, and ill contacts

Now I have some questions about any travel you (your child) might have had or events you (your child) might have attended during the 14 days before onset of illness. The travel or events could have been part of your work or for pleasure. I also have some questions about other persons you know who have been sick with a similar illness.

13. Did you (your child) travel to another state or country during the 14 days before onset of illness?

 Yes, traveled (continue to Question 14) No, did not travel (skip to Question 17)

14. *(Optional – for local analysis) List counties in your home state (outside your county of residence) where you (your child) might have purchased or eaten fresh foods during the 14 days before onset of illness.

 Did not travel to other counties within home state  Unknown

Counties within home state	Date departed (MM/DD/YYYY)	Date returned (MM/DD/YYYY)	Foods eaten

15. List all states and U.S. cities outside of your home state where you (your child) might have purchased or eaten fresh foods during the 14 days before onset of illness. This includes airports and bus or train stations.

 Did not travel to other U.S. states  Unknown

U.S. States	U.S. Cities	Date departed (MM/DD/YYYY)	Date returned (MM/DD/YYYY)	Foods eaten

16. List all countries outside the U.S. where you (your child) might have purchased or eaten fresh foods during the 14 days before onset of illness.

 Did not travel outside the U.S.  Unknown

Countries outside the U.S.	Cities outside U.S.	Date departed (MM/DD/YYYY)	Date returned (MM/DD/YYYY)	Foods eaten

*Note to Interviewer: To help determine if the interviewee meets the case definition, did the interviewee report international travel outside the U.S. or Canada during the 14 days before onset of illness?

If yes, thank the interviewee for his/her time and end the interview.

If no, continue with interview at Question 17.

17. During the 14 days before onset of illness, did you (your child) attend any events where fresh food was served (e.g. parties, fairs, concerts, tournaments, conventions)?

 Yes  Maybe  No  Unknown

17a. Please list the name of the event(s), date(s), and location(s).

Event ( wedding, fairs, concertse.g., )etc	Date attended event (MM/DD/YYYY)	Location of event (City, State)	Foods eaten

18. Do you know of any other person(s) (e.g. a family member, friend, travel companion, co-worker, neighbor, church/temple/mosque member, health club, or other club member) who has been sick recently with a similar illness?

 Yes  Maybe  No  Unknown

18a. If yes/maybe, please specify if you (your child) and the other ill person(s):

 Live in the same household  Attended same event  Traveled together

 Other, specify: ______________________________________________________________________

18b. If yes/maybe, please provide information about the other ill person(s), including number of ill persons and relationship to you (e.g. son, mother, neighbor, friend, etc.). *Please include the STATE ID of the ill contact(s), if available/applicable. Do not enter names or other personally identifiable information.

___________________________________________________________________________________________

*Note to Interviewer: To help determine if the interviewee meets the case definition, did the interviewee report international travel outside the U.S. or Canada during the 14 days before onset of illness?

If yes, thank the interviewee for his/her time and end the interview.

If no, continue with interview on next page.

Section 4: Sources of produce at home

Now I have some questions about where the fresh produce came from that you ate at home during the 14 days before your illness began. This isn't necessarily where you shopped during that 14-day period, but where what you actually ate during that time came from. I'm going to list several types of stores; for each type, please tell me the names of each store from which you would have eaten food from during the 14 days before you became sick. Please refer to your grocery store receipts, grocery order invoices, or credit card statements to provide a more detailed description.

19. Did you (your child) eat fresh produce from: grocery stores or supermarkets, warehouse stores, small markets (such as gas stations), ethnic specialty markets, health food stores, co-ops, farmer's markets or food directly from a farm, home delivery grocery services (e.g. CSA, Amazon Fresh, Instacart), meal delivery services (e.g. Blue Apron, Meals on Wheels), or any other sources?

Store name	Address	City	State	Zip Code	Date shopped (MM/DD/YYYY) or range	Foods purchased	*Shopper card #

*Many stores use a customer’s phone number as their shopper card number. If your phone number is your shopper card number, may we use your phone number to look up purchase histories at the stores you’ve listed?No  Yes 

*By giving your shopper card number, you are permitting retrieval of information regarding your purchases. This information may be shared with other public health officials to help with outbreak investigations.

 Refused to give shopper card # or permission to use phone number to look up purchase history.

Additional comments about grocery store purchases: ___________________________________________________________________________________________

Section 5: Sources of produce outside the home

Now I have some questions about where you ate produce outside your home, such as at restaurants or fast-food chains during the 14 days before your illness began. I'm going to list several types of restaurants and commercial food establishments; for each type, please tell me the names of each place. Please refer to your restaurant receipts or credit card statements to provide a more detailed description.

20. Did you (your child) eat foods from: national fast-food chains, Mexican-style, Italian, Jamaican/Cuban/Caribbean, Chinese/Indian/Japanese/Asian, Middle Eastern/Arabic/Lebanese/African, vegetarian or vegan, barbecue or home-style, steakhouse or grill, seafood, all-you-can-eat buffet, sandwich shop or deli, diner, salad bar, take-out, breakfast or brunch, school or institution, food truck, restaurants at airports or other restaurants or commercial food establishments?

Restaurant name	Address	City	State	Zip Code	Meal date (MM/DD/YYYY) or range	Foods eaten

Additional comments about restaurant meals: ___________________________________________________________________________________________

Questions to be completed by interviewer:

Is the case associated with a cluster?  Yes  No Unknown 

If yes, what is the cluster name? _____________________________________________________

Section 6: Fresh herbs

Now I have some questions about fresh herbs (not canned, cooked, frozen, or dried) that you (your child) may have eaten during the 14 days before your illness began. You could have eaten these herbs either in your home or away from home. I am only interested in fresh herbs that were not grown at home. Please remember that fresh herbs are often served as garnishes on drinks, entrees, desserts, or as part of a dish such as pesto, salsa, or a sauce. As I mention each food item, please answer yes, maybe, no, or don’t know as to whether you remember having eaten the food during the 14 days before you became ill.

Yes	Maybe	No	Don’t know	Did you (your child) eat:
				21. Fresh basil?
				a. Type(s):  Sweet basil  Purple basil (i.e. purple leaves and stems)  Thai basil (i.e. green leaves and purple stems  Other, specify: _________________________________________
				b. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				c. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				22. Fresh cilantro?
				a. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				23. Fresh parsley?
				24. Fresh oregano?
				25. Fresh thyme?
				26. Fresh mint?
				27. Fresh dill?
				28. Fresh sage?
				29. Fresh rosemary?
				30. Other fresh herbs?
				a. Type(s):______________________________________  Unknown

Additional comments about fresh herbs: __________________________________________________________

Section 7: Fresh berries and fruit

Now I have some questions about fresh berries and other fruit (not canned, cooked, frozen, or dried) that you (your child) may have eaten during the 14 days before your illness began. You could have eaten this fruit either in your home or away from home. I am only interested in fresh fruits that were not grown at home. Please remember that fruit and berries are often used in smoothies or as garnishes on top of or on the sides of salads and in desserts.

Yes	Maybe	No	Don’t know	Did you (your child) eat:
				31. Fresh red raspberries?
				a. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				32. Fresh blackberries?
				a. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				33. Fresh strawberries?
				a. If eaten , what was the:at home Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________ Not applicable (did not eat at home)
				b. If eaten :outside the home List the name(s) of establishment(s) and location(s): _______________ Not applicable (did not eat outside the home)
				34. Fresh blueberries?
				a. If eaten , what was the:at home Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________ Not applicable (did not eat at home)
				b. If eaten :outside the home List the name(s) of establishment(s) and location(s): _______________ Not applicable (did not eat outside the home)
				35. Other fresh berries
				a. Types: Boysenberries  Golden raspberries  Black raspberries b. Other type(s): _______________________________________  Unknown
				36. Apples?
				37. Grapes?
				38. Pears?
				39. Peaches?
				40. Nectarines?
				41. Plums?
				42. Oranges?
				43. Tangerines or “Cuties”)e.g.? (clementines
				44. Grapefruit?
				45. Fresh lemon or lime? This could include a garnish on a drink.
				46. Cherries?
				47. Cantaloupe?
				48. Honeydew melon?
				49. Watermelon?
				50. Precut melon or melon salad? ( premade, in a container)E.g. This could also include melon in a fruit cup or fruit salad.
				51. Other melon?
				52. Pineapple?
				53. Mango?
				54. Other fruit?
				a. Types:  Bananas Kiwi  Papaya  Guava  Pomegranate Coconut (whole or shredded) Other, specify: _______________________________________________

Additional comments about fresh fruit: ___________________________________________________________

Section 8: Leafy greens (e.g. iceberg, romaine, mesclun, cabbage, spinach)

Now I have some questions about leafy greens (not canned, cooked, or frozen) that you (your child) may have eaten during the 14 days before your illness began. You could have eaten these leafy greens either in your home or away from home. I am only interested in leafy greens that were not grown at home. Please remember to include greens you might have eaten on sandwiches or burgers or as a garnish.

Yes	Maybe	No	Don’t know	Did you (your child) eat:
				55. Bagged salad kits ( bagged leafy greens with dre.g.essing or other toppings like nuts, seeds, , or cheese that need to be mixed in).courtons
				a. What were the: Ingredients (lettuce, cabbage, carrots, etc.): ______________________ Brand(s): __________________________________________________ Place(s) purchased (names, locations): __________________________ *If multiple types of bagged salad kits are reported, please enter the additional types in the “Additional comments” section below. about leafy greens
				56. Pre-made, single serving salads (e.g. ready to eat salads with toppings, meats, and dressing, in a hard plastic container)? *These are “grab-and-” type items that you might find in the deli section of a grocery storego.
				a. What were the: Ingredients (lettuce, cabbage, carrots, etc.): ______________________ Brand(s): __________________________________________________ Place(s) purchased (names, locations): __________________________ *If multiple types of pre-made single serving salads are reported, please enter the additional types in the “Additional comments about leafy greens” section below.
				57. Iceberg lettuce?
				a. If eaten at home, what was the: Type(s):  Prepackaged, precut/shredded in a bag  Head/Loose (not prepackaged)  Topping/Garnish  Part of a pre-made salad or bagged salad kit?  Unknown Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				58. Romaine lettuce?
				a. If eaten at home, what was the: Type(s):  Prepackaged, precut/shredded in a bag  Head (prepackaged, in a bag)  Head/Loose (not prepackaged)  Topping/Garnish  Part of a pre-made salad or bagged salad kit?  Unknown Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				59. Mesclun lettuce (e.g. spring mix, field greens, baby greens)?
				a. If eaten at home, what was the: Type(s):  Prepackaged in a hard plastic container  Prepackaged in a bag  Head/Loose (not prepackaged)  Topping/Garnish Part of a pre-made salad or bagged salad kit?  Unknown Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				60. Butter lettuce (also called Boston or Bibb lettuce)
				a. Type(s):  Mixed Green  Red b. Packaging:  Prepackaged in a bag  Prepackaged in a hard plastic container  Head/loose (not prepackaged)  Part of a pre-made salad or bagged salad kit?
				c. If eaten , what was the:at home Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________ Not applicable (did not eat at home)
				d. If eaten :outside the home List the name(s) of establishment(s) and location(s): _______________ Not applicable (did not eat outside the home)
				61. Fresh cabbage?
				a. Type(s):  Red, head/loose (not prepackaged)  Green, head/loose (not prepackaged)  Precut/shredded, prepackaged in a bag (e.g. coleslaw mix) Part of a pre-made salad or bagged salad kit?  Savoy (aka curly)  Napa  Bok choy  Brussel sprouts  Other, specify: _______________
				b. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				c. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				62. Fresh spinach?
				a. If eaten at home, what was the: Type(s):  Prepackaged, in a bag  Prepackaged, in a hard plastic container  Head/Loose (not prepackaged)  Topping/Garnish  Part of a pre-made salad or bagged salad kit?  Unknown Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				63. Other lettuce or leafy greens?
				a. Type(s):  Arugula  Endive  Mustard greens  Radicchio  Kale  Other, specify: ___________________________________
				64. Other prepackaged salad mix (not previously identified)?
				a. What were the: Ingredients (lettuce, cabbage, carrots, etc.): ______________________ Brand(s): __________________________________________________ Place(s) purchased (names, locations): __________________________

Additional comments about leafy greens: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 9: Other fresh vegetables

Now I have some questions about fresh vegetables (not canned, cooked, or frozen) that you (your child) may have eaten during the 14 days before your illness began. You could have eaten these vegetables either in your home or away from home. I am only interested in vegetables that were not grown at home. Please include vegetables that were eaten alone or as part of a dish.

Yes	Maybe	No	Don’t know	Did you (your child) eat:
				65. Cucumbers?
				66. Raw, uncooked zucchini?
				67. Raw, uncooked squash? ( yellow squash)e.g.
				68. Raw, uncooked bell peppers?
				a. Type(s):  Red  Green  Orange  Yellow  Unknown
				69. Hot peppers or chili peppers (e.g. jalapenos or serranos)?
				70. Celery?
				71. Raw carrots?
				a. Type(s): “Mini” or “baby” carrots   Other raw carrots, _______specify:_________________
				72. Other raw, uncooked root vegetables?
				a. Type(s):  Radishes  Beets  Turnips  Unknown  Other, specify: ___________________________________________
				73. Fresh, raw peas? (May be shelled or in the pod)
				a. Type(s):  Garden peas  Snow peas (i.e. flat, shiny pods containing peas)  Sugar snap peas (i.e. plump, crisp, edible pods)  Unknown  Other, specify: ___________________________________________
				a. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				74. Broccoli?
				75. Cauliflower?
				76. Sprouts?
				77. Raw, uncooked onions?
				a. Type(s):  White  Yellow  Red/Purple  Green onion/scallion  Unknown  Other, specify: ___________________________________________
				78. Fresh tomatoes?
				a. Type(s):  Red round  Roma (oval-shaped)  Grape/Cherry (bite-sized)  Unknown  Other, specify: ____________________________
				79. Fresh made salsa or pico de gallo (i.e. not from a vacuum-sealed jar)?
				a. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)
				80. Fresh made guacamole (i.e. not from a vacuum-sealed jar)?
				a. If eaten at home, what was the: Brand(s): ______________________________________________ Place(s) purchased (names, locations): ______________________  Not applicable (did not eat at home)
				b. If eaten outside the home: List the name(s) of establishment(s) and location(s): _______________  Not applicable (did not eat outside the home)

Additional comments, including other types of fresh vegetables: _______________________________________

This completes the interview. Thank you very much for your time. Depending on what we find when we put these interviews together, we may need to talk to you again about a few details. Would you like to provide any additional thoughts about anything we’ve discussed or about this outbreak investigation?

___________________________________________________________________________________________

Public reporting of this collection of information is estimated to average 21 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current 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 (0920-1198)

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