NPS_EPI Form 3.24.2023

OMB Control Number: 1024-XXXX
Expiration Date: XX/XX/XXXX

National Park Service
Office of Public Health
Case Investigation and Outbreak Form

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction
Act (44 U.S.C. 3501) to provide park managers with the information needed to protect the health of the public. It is in
your best interest to complete the form as thoroughly as possible in order for the park manager to respond to urgent
outbreaks or events and prevent disease transmission and illnesses within or associated with National Parks. You are
not required to respond to this or any other Federal agency-sponsored information collection unless it displays a
currently valid OMB control number. OMB has approved this collection of information and assigned Control No.
1024-XXXX.

Estimated Burden Statement: Public Reporting burden for this form is approximately 20 minutes depending on
the nature of the disease outbreak or event., including the time it takes for reviewing instructions and completing the
form. Comments regarding this burden estimate or any aspect of this form should be sent to the Information
Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive Reston, VA 20192. Please do not
mail your completed form to this address.

Section I. Demographic/Contact information
What is your primary/preferred language?
1. Are you a:

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2
3
4.
5
6
7
8
9
10
11
12

NPS employee
Volunteer
Concessioner
Other NPS Partner
Visitor/public
Other

Last name
First name
Address
City
County
State
Zip
Country (if not U.S)
Phone 1
Phone 2
E-mail address

13. (If a surrogate is answering the questions), What is your relationship to the case?
 Parent
 Spouse or domestic partner
 Sibling
 Friend
 Other, specify:

Questions below are intended for the case of interest. If you are answering as a surrogate,
please state the response for the case and not yourself.
14. Gender:

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Male
Female
Transgender, non-binary, or another gender
Prefer not to disclose

15. Date of Birth:

/

/

Are you [they] Hispanic or Latino?

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

YES
NO

16. What is your [their] race? (Select one or more responses.)

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American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Multiracial or Biracial
A race/ethnicity not listed here

17. What is your [their] occupation?
18. Do you [they] live in NPS park or concession housing?




Yes
No

If Yes, specify:

Section II. Travel and National Park Visitation Information
1. Name of National Park(s)/Monument(s) visited:

2. Name of park/monument and date(s) of visit(s) at each park:
Name

Date
/
/
/

Date
/
/
/

/
/
/

/
/
/

3. Did you [they] travel from out of state or out of country to visit the National Park?
 Yes
 No
If Yes, specify your [their] state/country of residence:
4. Which modes of transportation did you [they] take to get to the park(s) (select all that apply):
 Car
 Plane
 Other, specify:
 N/A
5. Did you [they] participate in any park tours?
 Yes
 No
If Yes, specify:
6. Which of the following activities did you [they] participate in, or places did you [their] visit
during your trip? (select all that apply):

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Visitor’s center
Museum
Gallery
Native American village (if yes, did they enter any of the dugout structures?)
Nature Centers
Horseback riding
Rock climbing
Hiking
Biking
Other: specify

7. Did you [they] stay overnight at or near the park(s) visited?
 Yes
 No
If Yes, specify (hotel, lodge, cabin, tent, backcountry, other):

8. How many different locations did you [they] stay (please provide details)?
Name (Location)

Dates Stayed

Type of Lodging

9. Were there other people who stayed overnight with you (e. g. in the same room, same
campground, same party)?
 Yes
 No
9a. If Yes, for other attendees, please provide specific information:
Name

Relationship

Phone

9b. Were any of the other people you [they] stayed overnight with within the week before or after
you [they] spent time with them?
For other attendees, specify:
Name

Describe illness

10. Were there other people whom you had close contact with (e.g., tour group members, day
hiking partners, sexual partners, etc).
 Yes
 No
10a. If Yes, for other close contacts, please provide specific information:
Name

Relationship

Phone

10b. Were any of the other people who had close contact with you sick?
For other close contacts, specific
Name

Describe illness

11. Did you [they] travel to any other destinations in the two weeks prior to developing
symptoms?
 Yes
 No
If Yes, specify city, state, location:

12. Did you [they] travel outside the U.S. in the two weeks prior to developing symptoms?
 Yes
 No
If Yes, specify location:

Section III. Clinical and Medical Care Information
1. Did you see a healthcare provider for this illness?
 Yes
 No
 Not sure
If Yes, specify with admission and discharge date:
2. Were you hospitalized?
 Yes
 No
 Not sure
If Yes, specify:
3. Dates of medical care related to this illness:

/

/

–

4. Name of medical facility:

5. Name of medical provider:
6. Contact Information for medical facility or provider:

7. Address of medical facility:

8. Is the local/state health department aware of your illness?
 Yes
 No
 Not sure
If Yes, specify (points of contact, contact information):
9a. Date of illness onset:

9b. Date of diagnosis:

/

/

/

/

10. Duration of illness:

11. Date of suspected exposure:

/

/

/

/

12. Did you experience any of the following signs or symptoms during your illness (select all that
apply):

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Fever
Muscle aches
Vomiting
Nausea
Sore throat

Chills
Headache
Blood in stool
Coughing
Rash

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Fatigue
Diarrhea
Abdominal cramps
Congestion
Difficulty breathing

Other, specify:
13. Were any clinical samples collected and tested (select all that apply) or any diagnostic tests
done?:

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Blood
Sputum

Urine
Nasal swab

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Stool
Chest X-ray

Other, specify:
14. For any clinical testing done, indicate which test and whether the test results were: Positive,
Negative, Inconclusive, Not sure
Specimen

Date of
collection

Test 1:
Test 2
Test 3
15. Were you [they] given a diagnosis (or multiple)?
 Yes
 No
 Not sure
If Yes, specify:

16. Was treatment initiated?
 Yes
 No
 Not sure
If Yes, specify the type of treatment:

Test type

Results

17. Do any of the following apply to you or the person you are responding for?

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Pregnant
Diabetes
Adult >65 years old
Child <5 years old
High-dose corticosteroids
Otherwise immunosuppressed (e.g. HIV, transplant recipient

Other
18. Do you [they] smoke?
 Yes
 No
If Yes, specify how much per day:
19. Have you ever been vaccinated against (insert relevant disease of concern)?
 Yes
 No
 Not sure
If Yes, specify date(s) of vaccine(s):
IV. Additional Comments

Appendix
NOTE TO REVIEWER: Questions in the following sections below are examples of the questions
that may be asked based on the specific outbreak/event.. Examples of exposures include bat,
rodent, vector, foodborne illness, waterborne illness, bloodborne illness, and other person-toperson event.

SUSPECTED ZOONOTIC DISEASE
1. Did you [they] have contact with any animals in the park (bite, scratch, pet, other)
 Yes
 No
If Yes, specify which type of contact:
2. What type of animal did you [they] have contact with?
3. What parts of your [their] body came in contact with the animal?

4. Is the animal available for monitoring or testing?
 Yes
 No
 Not sure
If Yes, specify:
5. Have you been previously vaccinated against rabies?
 Yes
 No
 Not sure
If Yes, when:

/

/

BAT EXPOSURES
1. Did you have any potential exposures to a bat (bite, scratch, or otherwise close exposure to
your body)?
 Yes
 No
 Not sure

2. Was a bat seen in a building where you were?
 Yes
 No
 Not sure
3. How many bats were seen?



Not sure

4. Did the bat have access to sleeping or incapacitated people?
 Yes
 No
 Not sure
If Yes, specify:
5. Date of bat entry:



/

/

and time

:

Not sure

6. Is there evidence of long-term bat presence, including bat feces accumulations or urine
stains?
 Yes
 No
 Not sure

RODENT AND VECTOR EXPOSURES
1. Did you see any evidence of rodents while in the park (droppings, nests, holes, gnaw marks,
scattered food, etc.)
 Yes
 No
 Not sure
If Yes, indoors or outdoors and specify:
2. Did you attempt to clean up rodent droppings or other rodent evidence while in the park?
(exposure includes cleaning, sweeping, sleeping, or any other activity where you might inhale
dust or have close exposure to an area with rodent droppings)
 Yes
 No
 Not sure
If Yes, specify:

3. Did you experience any insect (flea, mosquito, kissing bug) or arachnid (spider, tick, scorpion)
bites in the park?
 Yes
 No
 Not sure
If Yes, specify:

FOR FOODBORNE OR WATERBORNE ILLNESS
1. Did you spend time with anyone or have any household members that experienced a similar
illness in the 3-days prior to your illness?
 Yes
 No
 Not sure
If Yes, specify:
2. Do you suspect a specific establishment or source of your illness?
 Yes
 No
 Not sure
If Yes, specify why:

3. Did you notify the suspected establishment or source?
 Yes
 No
 Not sure
4. Did you attend any special or organized group events while at the park?
 Yes
 No
 Not sure
If Yes, specify (including date):

5. Did you eat raw or undercooked meat, seafood, or shellfish?
 Yes
 No
 Not sure
If Yes, specify (including date):
6. Would you be willing to submit a stool sample for testing?
 Yes
 No
 Not sure
7. If foodborne illness is suspected or confirmed, please complete this four-day food history
using the following daily template:
Day 1

Meal Time

Location of Meal

Food

Drink

Meal Time

Location of Meal

Food

Drink

Meal Time

Location of Meal

Food

Drink

Meal Time

Location of Meal

Food

Drink

Breakfast
Lunch
Dinner
Other

Day 2
Breakfast
Lunch
Dinner
Other

Day 3
Breakfast
Lunch
Dinner
Other

Day 4
Breakfast
Lunch
Dinner
Other

8. Did you drink water from a well, non-municipal, or a potentially unsafe water source (e.g.,
stream, lake)?
 Yes
 No
 Not sure
If Yes, specify:

9. Did you bathe or swim outside or in a potentially unsafe water source (e.g., stream, lake)?

10. Did you have any exposure to aerosolized water (e.g. hot tubs, misters, spa, sauna)?
 Yes
 No
 Not sure
If Yes, specify:

FOR NPS FOOD SERVICE WORKERS ONLY
1. What are your job duties?

2. If you work with food, please describe which foods and what type of food handling you do:

3. Which food items served on

/

/

4. What days and times did you work since

did you handle or prepare?

/

5. Do you know of any other workers that are ill?
 Yes
 No
 Not sure
If Yes, specify:

/

?

SUSPECTED BLOODBORNE ILLNESS
1. Did you have exposure to human blood or other human fluids/waste at the park?
 Yes
 No
 Not sure
If Yes, specify (when and what):

PERSON-TO-PERSON ILLNESS
1. In the past 14 days, have you had contact with a person with a confirmed or suspected
illness?
 Yes
 No
 Not sure
If Yes, specify: