Form 3 Form 3 Animal Contact Focus Questionnaire

Animal Contact Focus Questionnaire for Pathogen X
Notes to Interviewer: Instructions in italics are for interviewer only. Please do not read italicized words to person being interviewed. Where the questionnaire says [ANIMAL SPECIES], insert the name of the suspected animal vehicle for this investigation. The suspected animal vehicle will also determine which sections and questions are asked. Clear instructions including the suspected vehicle species and which sections to complete will be provided with the request to complete this questionnaire. Where the questionnaire says [PATHOGEN], insert the pathogen involved in this investigation. Please administer this questionnaire to the patient (or patient’s caregiver or parent). Please complete this questionnaire via the fillable PDF to have access to drop down menus as applicable. Please fill out one form for every patient and complete as much of the information as possible.
Section 1: Interview information (To be completed by interviewer prior to questionnaire administration)
PulseNet ID # (e.g., XX___12345678):  _________________		State/Local/Other ID #:  _____________________________
PulseNet cluster code (e.g., 2107MLJJP-1): ________________ 4.  WGS ID (e.g., PNUSAE12345): ___________________ 5. Serotype (e.g., Enteritidis): _________________
6.Date of Interview:  __ __ / __ __ / __ __ __ __   (MM/DD/YYYY)
Interviewer information	7.Name:                      8. Contact phone number: (____) ______-_______
	9.Agency:
10.Did the patient die?    ☐Yes     ☐No  10a: If the patient died, was it attributed to [PATHOGEN]?       ☐ Yes       ☐No
Hello. My name is _______________________and I’m calling from the _________________Department of Health. We are investigating an outbreak of [PATHOGEN] infections. We are calling everyone who became sick to ask more detailed questions about contact with [ANIMAL SPECIES of INTEREST]. This should take around 30 minutes. You do not have to respond to any question that you do not want to, but your answers will be useful for understanding the cause of people’s illness and preventing other people from getting sick. Any information you provide will remain confidential, to the extent allowed by law. Are you willing to participate? If Yes: Is now a good time? (If yes, skip to Section 2) If no, is there a better time to call back? __ __ / __ __ / __ __ __ __ (___:____ am/pm) Are you the patient or are you responding on behalf patient? (If responding on behalf to the patient, confirm age and preferred pronouns of patient to use during the interview) If No: Thank you for your time. (End Interview)
11. Respondent was:          ☐Patient    ☐Parent      ☐Other (specify)___________

Form Approved

OMB No: 0XXX-XXXX

Expires: XX/XX/20XX

Section 2: Demographic Data I’d like to ask a few questions about [your/the patient’s] demographics.
1. What is [your/the patient’s] state, county, and zip code? State abbr. _____ County ______________________ Zip Code ____________________
2. What is [your/the patient’s] date of birth? _____________________
3. What is [your/the patient’s] occupation or job?______________________________________________________________________________________
4. What is your race and/or ethnicity? (Select all that apply and enter additional details in the spaces below)	American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc. _______________________________	Asian Chinese Asian Indian Filipino Vietnamese Korean Japanese Enter, for example, Pakistani, Hmong, Afghan, etc. _______________________________	Black or African American African American Jamaican Haitian Nigerian Ethiopian Somali Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congalese, etc. _______________________________
	Hispanic or Latino Mexican Puerto Rican Salvadoran Cuban Dominican Guatemalan Enter, for example, Colombian, Honduran, Spaniard, etc. _______________________________	Middle Eastern or North African Lebanese Iranian Egyptian Syrian Iraqi Israeli Enter, for example, Moroccan, Yemeni, Kurdish, etc. _______________________________	Native Hawaiian or Pacific Islander Native Hawaiian Samoan Chamorro Tongan Fijian Marshallese Enter, for example, Chuukese, Palauan, Tahitian, etc. _______________________________
	White English German Irish Italian Polish Scottish Enter, for example, French, Swedish, Norwegian, etc. _______________________________
5. What languages are spoken at home? ________________________________________________________________________ Declined to answer
6. Sex: Male Female

Section 3: Clinical Information I have a few questions about [your/the patient’s] illness.
		1. What date did [you/the patient] first feel sick? __ __/ __ __/ __ __ __ __ (MM/DD/YYYY) ☐Don’t Know
☐Yes	☐No	2. Were/Was [you/the patient] hospitalized overnight? (If “Yes”, ask question 2a)
		a: For how many nights? ______ (whole number 1 - >180)
☐Yes	☐No	3. Before becoming ill, did [you/the patient] have any close contact with anyone with diarrhea or vomiting?
		a. When was this person ill? ☐less than 24 hours before [you/the patient] ☐ ≥ 24 hours before [you/the patient] ☐Don't know
		4. How many days total did [your/the patient’s] illness last? _______ days (whole number 1 - >180) ☐Still ill ☐Don't know

Section 3: Clinical Information (continued) I have a few questions about [your/the patient’s] illness.
☐Yes	☐No	Did [you/the patient] develop severe illness resulting from this infection (e.g. blood stream infection, brain infection, etc)?
		If yes, please describe
☐Yes	☐No	Is this [your/the patient’s] first infection with [PATHOGEN]?
		If no, please note previous culture date, and serotype information for any previous infections, if known): _____________________________________________________________________________________
☐Yes	☐No	Did [you/the patient] take any antibiotics for this illness?
		Please specify antibiotic name: ________________________________________ For how many days was the antibiotic taken? ______________ days
☐Yes	☐No	In the 7 days before illness began, did you (the patient) travel outside the U.S.?
		a. Which countries did you (the patient) visit? _____________________________
☐Yes	☐No	Are there other people in the household ill with a diarrheal illness? If yes, what date did they first feel sick? __ __/ __ __/ __ __ __ __ (MM/DD/YYYY) ☐Don’t Know

Section 4: Animal Contact: Now I have some questions about contact with pets or other animals in the 7 days before your (the patient’s) illness began. Contact is defined as: you (the patient) or someone in the household handling, touching, petting, or otherwise interacting with an animal or the areas where the animal lives/roams. This could have been at your home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location. As I read each exposure, please answer as yes, no, may have had, or can't remember having contact in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	In the 7 days before this illness began, did you (the patient) or anyone in the household have contact with any of the following types of animals or the areas where the animal lives/roams?
☐	☐	☐	☐	Chickens/chicks, ducks/ducklings, turkeys, or other backyard poultry? ☐ Chickens/Chicks ☐ Ducks/Ducklings ☐ Turkeys ☐ Other, specify: ___________________ ☐ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ ☐ Unknown
☐	☐	☐	☐	Turtles or tortoises? If yes/maybe, was the shell <4 inches in diameter (smaller than the palm of an adult hand)? ☐ Yes ☐ No ☐ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ ☐ Unknown
☐	☐	☐	☐	Other reptiles (such as snakes, lizards, geckos, bearded dragons), amphibians (frogs, toads, salamanders), fish or other aquatic animals? If yes or maybe, please specify the type: ________________________________________ ☐ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: ___________________________________________________ ☐ Unknown Was it fed: ☐ Live mice/rat ☐ Frozen mice/rat ☐ Live chick ☐ Frozen chick ☐ Other feeder animal, specify: ___________________ ☐ Not fed feeder animal ☐ Unknown
☐	☐	☐	☐	Small mammalian household pet, such as hamster, rat, mouse, guinea pig, gerbil, ferret, sugar glider, chinchilla, rabbit, or hedgehog (excluding feeder rodents used as pet food for reptiles, see #3c)? If yes or maybe, please specify the type: ________________________________________ ☐ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ ☐ Unknown
☐	☐	☐	☐	Any other type of pets (dogs, cats, birds (not poultry) etc.) If yes or maybe, please specify the type: ________________________________________ ☐ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ ☐ Unknown
☐	☐	☐	☐	Any other animal (such as farm animals or wildlife)? If yes or maybe, please specify the type: ________________________________________ ☐ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ ☐ Unknown
				For the following section, input the name of the suspected animal vehicle anywhere it says [ANIMAL SPECIES]. If the suspected animal vehicle was included in the previous 6 questions you can use those responses to complete the initial questions in this section.
☐	☐	☐	☐	During the 7 days before becoming ill, did [you/the patient] have any type of contact with [ANIMAL SPECIES] or an environment (e.g., an aquarium or tank) where [ANIMAL SPECIES] live/roam?
				If yes, please specify type of contact: Direct Indirect (did not directly touch)
				If no, were [you/the patient] around anyone who has an [animal species] in the week before you were ill? Yes Maybe No Don’t Know
				If yes, where did [you/the patient] have contact with [ANIMAL SPECIES] or the environment where [ANIMAL SPECIES] live/roam? (Check all that apply) At patient’s home Someone else’s home Retail store (e.g., pet store or agricultural store) -> If yes, please provide the name and address of the store in the comments section Day care/Child Care School Petting zoo Outdoors Flea Market Street/ roadside vendor Farmer’s market Farm (other than home) Work -> If yes, please provide the name of the location and the address in the comments section Other location: ______________________________________ Specify Name and Address of Location:_________________
				If yes, What type of contact did [you/the patient] have with the [ANIMAL SPECIES] or the environment where they live/roam? (Check all that apply) Touched or held [ANIMAL SPECIES] Kissed [ANIMAL SPECIES] Snuggled with [ANIMAL SPECIES] Allowed [ANIMAL SPECIES] to sit/crawl on lap Fed or watered [ANIMAL SPECIES] Allowed [ANIMAL SPECIES] to sit/crawl on head/shoulder Touched cages/enclosures Cleaned cages/enclosures Gathered/handled eggs Other: ___________________________
☐	☐	☐	☐	Did other people in the household have any type of contact with [ANIMAL SPECIES] or an environment where [ANIMAL SPECIES] live/roam? If yes, what is their relationship to the patient? ______________________________________
☐	☐	☐	☐	Did [you/the patient] attend or work at a daycare during the 7 days prior to illness onset? If yes, Specify Name and Address of Location:________________________________________
☐	☐	☐	☐	Does [your/the patient’s] school or daycare keep animals in the classroom? (Leave blank if no school or daycare for patient) If yes, Specify animal species and breed:
☐	☐	☐	☐	Do [you/the patient] or anyone in the household own a [ANIMAL SPECIES]?a If no, move to Section 5. If yes, move to Question 14.
				How many [animal species] do you own? ______________
				Why did [you/the patient purchase or adopt the [ANIMAL SPECIES](s)? Household pet Hobby Educational purposes (school, daycares, etc.) Club or Organization Scientific research Display purposes Gift Other (please specify):_____________
			☐	Approximately how old is [your/the patient’s/household member’s] [ANIMAL SPECIES]? <6 months 6-12 months 1-2 years 2+ years Don’t Know
			☐	How long have [you/the patient/household member] owned [ANIMAL SPECIES] for? <6 months 6 months to 1 year 1-2 years 2-5 years >5 years
				Was the [animal species] ill prior to [your/the patient’s] illness onset? (e.g., diarrhea) Yes Maybe No Don’t know
			☐	What is the current disposition of the [ANIMAL SPECIES](s)? Still in Household Re-homed/returned to purchase location Died Other:__________________
☐	☐	☐	☐	If the [AMINAL SPECIES] died, did they die in the 7 days before [your/the patient’s/household member’s] illness began?
Section 4: Animal Contact Comments. Please fill in any comments/notes from this section in the space provided below:

Section 5: Animal Contact: Pets
Yes	Maybe	No	Don’t Know
				Section 5a. Dog/Cat Specific Questions Now, I have a few questions about any interaction you/the patient may have had with dogs/cat/puppies/kittens in the 7 days before illness began.
☐	☐	☐	☐	In the 7 days before this illness began, did [you/the patient] touch any dog/cat/puppy/kitten cages or other areas where dogs/cats/puppies/kittens were present?
			☐	If yes, where did you/the patient have contact with a dog/cat/puppy/kitten cage/area in the 7 days before you/the patient became ill? (check all that apply) My/the patient’s home Another person’s home Pet store Other location_________________________________ If at a pet store, please provide more information Store name and location: _________________________________
			☐	What was the age of the dog/cat/puppy/kitten at the time of your/the patient’s illness? ≤6 months >6 months–1 year >1 year–3 years >3 years
			☐	What is the breed of your/the patient’s dog/cat/puppy/kitten ? Breed 1 Breed 2 Breed 3 Other _________________________________
			☐	Where did you get the [dog/cat/puppy/kitten]? Please check all that apply. Breeder Breeder name: ____________________________________________ Breeder address: __________________________________________________ For interviewer: USDA licensed breeder? Yes (License #: __________________________________) No Unknown Pet Store Pet store name: ____________________________________________ Pet store address: ______________________________________________ Loyalty card (number and name of card holder): _____________________________ May we have permission to retrieve information on purchases based on the information provided? This information will be kept confidential and only be used by public health officials. Yes No For interviewer: USDA licensed pet store? Yes (License #: __________________________________) No Unknown Internet Web address: ____________________________________ Other Individual Was the individual a: Family member Friend Other __________________________ Was the [dog/cat/puppy/kitten]?] purchased or a gift? Purchased Gift
				When did you/the patient get your dog/cat/puppy/kitten? MM DD YY: ______________
☐	☐	☐	☐	Do you have the microchip number for your dog/cat/puppy/kitten, and would you be willing to provide us the number? We may use this number to help determine where the animal came from, such as breeder. Microchip number: _____________________________________________
☐	☐	☐	☐	In the 7 days before your/the patient’s illness began, did the dog/cat/puppy/kitten have diarrhea?
☐	☐	☐	☐	If your dog/cat/puppy/kitten experienced diarrhea, did you take it to a veterinarian?
☐	☐	☐	☐	Would you be willing to submit a fecal specimen from your dog/cat/puppy/kitten for [PATHOGEN] testing (if diarrhea was within 2 weeks of patient illness onset)?
☐	☐	☐	☐	In the 7 days before your/the patient’s illness began, did you/the patient have contact with dog/cat feces? (i.e. as picking up after a dog in the backyard or on walks, scooping the litter box.)
☐	☐	☐	☐	In the 7 days before your/the patient’s illness began, did you/the patient’s dog/cat/puppy/kitten die?

Section 5: Animal Contact: Pets (continued)
Yes	Maybe	No	Don’t Know
				Section 5b. Small Mammal Specific Questions Now, I have a few questions about any interaction you/the patient may have had with [SMALL MAMMAL pets] in the 7 days before illness began
☐	☐	☐	☐	How many [SMALL MAMMAL SPECIES] do you own? Small mammal species and number: _________________________________
☐	☐	☐	☐	How long have you owned them? _________________________________
				Was the [SMALL MAMMAL SPECIES] ill prior to your/the patient’s illness onset?
☐	☐	☐	☐	Where did you get the [SMALL MAMMAL]? Please check all that apply. Breeder Breeder name: ____________________________________________ Breeder address: _________________________________________________ For interviewer: USDA licensed breeder? Yes (License #: __________________________________) No Unknown Pet Store Pet store name: ____________________________________________ Pet store address: __________________________________________________ Loyalty card (number and name of card holder): _____________________________ May we have permission to retrieve information on purchases based on the information provided? This information will be kept confidential and only be used by public health officials. Yes No For interviewer: USDA licensed pet store? Yes (License #: __________________________________) No Unknown Internet Web address: ___________________________________________ Other Individual Was the individual a: Family member Friend Other __________________________ Was the [SMALL MAMMAL] purchased or a gift? Purchased Gift
				When did you/the patient get your [SMALL MAMMAL]? MM DD YY: ______________
☐	☐	☐	☐	During the 7 days before becoming ill, did you/the patient have any type of exposure to or contact with a [SMALL MAMMAL] cage/enclosure?
				If yes, please specify type of contact: Direct Indirect (did not directly touch) Location of contact (i.e., home, work, school, daycare, pet store, petting zoo)?
☐	☐	☐	☐	Were you around anyone who has a [SMALL MAMMAL] in the 7 days before you were ill?

Section 5: Animal Contact: Pets (Continued)
Yes	Maybe	No	Don’t Know
				Section 5c. Reptile Specific Questions Now, I have a few questions about any interaction you/the patient may have had with [REPTILE SPECIES] in the 7 days before illness began.
				Bearded dragon specific questions:
				What type(s) of bearded dragon do [you/the patient/household member] own or had contact with? Standard Fancy Both Standard and Fancy Don’t Know
				Approximately how long is [your/the patient’s] bearded dragon? <6 inches 6-12 inches 1-1.5 feet (12-18 inches) 1.5-2 feet (18-24 inches) 2+ feet (>24 inches) Don’t Know
				What color of bearded dragon do [you/the patient/household member] own or had contact with? (Check all that apply) Red Yellow/Citrus White/Silver Orange Standard Mix (combination of brown, tan, maybe hints of yellow/orange) Other color: _____________________________________
				Turtle specific questions:
				Did [you/the patient] have contact (direct or indirect) with baby turtles or adult turtles? (Check all that apply) Baby turtles Adult turtles Don’t know
				What type of contact did [you/the patient] have to the turtles or the environment where they live/roam? (Check all that apply) Touched or held turtles Kissed turtles Changed turtle water Touched cages/enclosures Fed turtles Other: ___________________________
				What is the length of the turtle shell of the turtles [you/the patient] were in contact with? 1-2 inches (size of half dollar) 2-3 inches (size of regular chicken egg) 3-4 inches (size of peach) >4 inches (fits comfortably in palm of adult hand) Unknown
				What type of turtle did [you/the patient] have contact with? Red-eared slider Painted turtle Box turtle Mississippi Map Snapping turtle Yellow-bellied or Cumberland slider Other type: _______________________ Unknown
				Snake specific question:
				What type of snake did [you/the patient] have contact with? Corn Snake Rat Snake Python Boa Constrictor Other type: _______________________ Unknown
				All reptiles:
				Where did [you/the patient/household member] purchase/obtain the [REPTILE](s)? (Please be as detailed as possible) PetSmart Petco Reptile expo or show Gift Flea Market Roadside Vendor Online (please specify website): ________________ Other Pet Store: _____________________________ Other location: ______________________________ For all, specify name and address of location: _________________________________
				For any [REPTILE] purchased at a pet store (PetSmart, Petco, etc.), do [you/the patient/household member] have a loyalty/rewards card and would be willing to provide us the number? Yes, store name_____________________ #______________________ cardholder’s name _____________________ Yes, they have one but will not provide No Store does not offer one Don’t Know
				For any [REPTILE] purchased at a pet store (PetSmart, Petco, etc.), do [you/the patient/household member] have a receipt that you could provide? Yes #______________________ Yes, they have one but will not provide No Store does not offer one Don’t Know
				When did you/the patient get your [REPTILE]? MM DD YY: ______________

Section 6: Animal Contact: Farm Animals
Yes	Maybe	No	Don’t Know
				Section 6a. Visited a Farm Now, I have a few questions about animal interaction on the farms, ranches, or petting zoos with [FARM ANIMAL/S] that [you/the patient] might have visited or been around in the 7 days before illness began. This could include places not labeled as farms or ranches but where cows are kept regularly.
				What date did [you/the patient] visit the farm/ranch/petting zoo? M_____/D_______/Y_______
☐	☐	☐	☐	Did [you/the patient] have any contact with [FARM ANIMAL]?
☐	☐	☐	☐	Did any [FARM ANIMAL] touch, lick, or chew on [you/the patient]?
☐	☐	☐	☐	Did [you/the patient] enter a pen with [FARM ANIMAL]?
☐	☐	☐	☐	Did [you/the patient] feed any [FARM ANIMAL]?
				What was the approximate age of the [FARM ANIMAL/S] you/the patient were in contact with? _____________________
				Section 6b. Live/Work on a Farm. Now, I have a few questions about animal interaction on the farms or ranches with [FARM ANIMAL/S] that [you/the patient] have lived on or worked at in the 7 days before illness began. This also includes small hobby farms or if the patient has [FARM ANIMAL/S] that live on/at their property/residence, even if you consider them to be pets.
				What kind of farming is done on the farm where [you/the patient] live or work? (dairy, veal heifer raiser, beef cattle, etc.) _____________________________________________________________________________________________
				What [FARM ANIMAL] breed/s do you keep? ___________________________________________________
☐	☐	☐	☐	Is anyone else who lives at, works on, or visited the farm ill with a diarrheal illness?
☐	☐	☐	☐	In the 7 days before your illness, were any of your [FARM ANIMAL/S] ill? If no, end of Section 6.
				If yes, what symptoms did ill animals have? ___________________________________________________
				How many [FARM ANIMAL/S] were ill? ___________________________________________________
				About when were the animals ill? MM/DD/YYYY – MM/DD/YYYY: _________________________________
☐	☐	☐	☐	Were sick animals seen by a veterinarian?
				Name of the veterinarian? ___________________________________________________
☐	☐	☐	☐	Were the sick [FARM ANIMAL/S] treated with antibiotics?
				Please specify antibiotic name: ____________________________________
☐	☐	☐	☐	Did any [FARM ANIMAL/S] die as a result of this illness?
				How many [FARM ANIMAL/S] died? __________________
☐	☐	☐	☐	Have the sick [FARM ANIMAL/S] been tested for [PATHOGEN]?
				Where were the samples submitted? _________________________________
				What were the test results? _________________________________
☐	☐	☐	☐	Were any of the ill [FARM ANIMAL/S] recently purchased (last few weeks or months)?
				Where/who did you purchase them from? ________________________________
☐	☐	☐	☐	Did you receive a receipt or documentation for the purchase?
				What date did you purchase them? ____/_____/_____
				How many were purchased? ____________________
				What breed (e.g., Holstein, Jersey)? ___________________________________
				Are they bull or heifer calves? ________________________________________
☐	☐	☐	☐	Were there any changes to management practices prior to illness/death in [FARM ANIMAL/S]?
				Please describe:
☐	☐	☐	☐	In the 7 days before your illness, did you/the patient care for the sick [FARM ANIMAL/S]?
Comments: Farm Animal Exposure Please fill in any comments/notes in the space provided below:

Section 7: Animal Contact: Backyard Poultry
Yes	Maybe	No	Don’t Know
				Section 7a. BYP Contact
				Which of these did [you/the patient] have contact with? (Select all that apply) Baby poultry Adult poultry Hatching eggs Environment
				What species of backyard poultry did [you/the patient] have contact with or the environment where they live/roam? (Select all that apply) Chicks/Chickens Ducklings/Ducks Goslings/Geese Turkeys Guineas Pheasants Quail Other: _________________________________
☐	☐	☐	☐	During the seven days before becoming ill, did [you/the patient] eat eggs produced by backyard poultry?
☐	☐	☐	☐	During the seven days before becoming ill, did [you/the patient] eat meat from butchered backyard poultry?
☐	☐	☐	☐	During the seven days before becoming ill did anyone else in the household have any type of contact with BYP or an environment where BYP live/roam?
				Section 7b: BYP Flock Management Practices  Now I will ask questions about owning backyard poultry since January 1 of this calendar year
☐	☐	☐	☐	Since January 1st of this calendar year did [you/the patient] or anyone else in the household own any backyard poultry? If no, skip to Section 7c.
				How many total birds are in [you/the patients] backyard flock? 1-5     6-10     11-20     21-49      ≥50
				Approximately how many days per month have the poultry been housed or allowed to roam inside where people live? Never (0 days/month) Rarely (1-7 days/month) Sometimes (8-14 days/month) Usually (15-21 days/month) Always (21-30+ days/month)
				How long have [you/the patient] owned and cared for backyard poultry?  <6 months     ≥6 months –1 year     ≥1 year –5 years     ≥5 years
☐	☐	☐	☐	Do [you/the patient] ever eat or drink near the backyard poultry or their environment?
☐	☐	☐	☐	Do [you/the patient] own specific supplies to care for backyard poultry that are always kept outside of [your/the patient’s] home?
				Which supplies used while caring for the backyard poultry are always kept outside of [your/the patient’s] home? (Select all that apply) ☐Shoes worn inside of the coop (Coop Shoes) ☐Chicken Feed/Water Containers ☐Coveralls/Jackets ☐Rakes/Brooms ☐Other: ___________________________________
☐	☐	☐	☐	Have [you/the patient] ever sought veterinary care for your backyard poultry?
☐	☐	☐	☐	Have [you/the patient] ever given antibiotics to your backyard poultry?
				What antibiotics have [you/the patient] given? ______________
				How many of [your/the patient’s] backyard poultry have had illness or died this year, excluding from predation? 0 1-5     6-10     11-20     21-49     ≥50
				Would you be willing to have your poultry tested for [PATHOGEN]? This involves a swab of their cloaca, poop, or the area where they live and roam. Sampling in this manner is considered non-invasive and does not involve euthanasia of the animal/s.
				Section 7c: Poultry Purchase and Purchase Location Now I will ask about backyard poultry purchased or obtained after January 1st of this calendar year.
☐	☐	☐	☐	Did [you/the patient] purchase any backyard poultry after January 1st of this calendar year? If no, end of Section 7.
				Did [you/the patient] buy backyard poultry from single or multiple locations since January 1st of this calendar year? (If “Multiple”, please fill out Section 5 contd. after completing Section 5) ☐Single ☐Multiple ☐Don’t know
				What is the name of the location where [you/the patient] purchased or obtained backyard poultry? Name of store/hatchery/farm: ________________________________________ If other, please specify the name: _____________________________________
				What type of place was this location? ☐Retail Store ☐Hatchery ☐Local farm ☐Individual or Relative ☐Other: ________________________________
				What is the street address or online store website for this purchase? Street Address: ___________________________________________________ City: ______________________ State: _____
				Do [you/the patient] remember when you purchased the backyard poultry? ☐Yes, Date of Purchase: __ __/ __ __/ __ __ __ __ (MM/DD/YYYY) ☐Approximate Date of Purchase _____ (month) ☐No
				Do [you/the patient] have a receipt from this purchase [you/the patient] could provide? (If “Yes”, forward receipt to [email protected]) ☐Yes ☐No
				How many from this first purchase location are new to [your/the patient’s] backyard flock this year? ☐<5     ☐5-10     ☐11-20     ☐21-49     ☐≥50
				How did [you/the patient] receive the backyard poultry purchased? ☐Pickup from purchase location ☐Delivery from local store/farm ☐Delivery from online store ☐Other: ___________________________________
				What species of poultry did [you/the patient] purchase? (Select all that apply) ☐Chicks ☐Chickens ☐Hatching Eggs ☐Ducklings ☐Ducks ☐Goslings ☐Geese ☐Turkeys ☐Guineas ☐Other: __________________________________
				If respondent specifically purchased chicks/chickens, please complete the following: What breeds of chicks/chickens did [you/the patient] purchase? (Read off list of common chicken breeds if respondent needs help remembering.) (Select all that apply) ☐Araucanas/Ameraucanas ☐Bantams ☐Black Australorps ☐Black or Red Star ☐Brown Egg Layers ☐Buff Orpingtons ☐Cornish Game Hens ☐Cornish Cross ☐Feather Footed Fancies ☐Isa Brown ☐Leghorn ☐Polish ☐Reds (New Hampshire/ Rhode Island) ☐Rocks (Cornish/White/Plymouth/Barred) ☐Sex-Links (Black/White/Red) ☐Silkies ☐Wyandottes ☐Unknown ☐Other: __________________________
				If respondent specifically purchased ducklings/ducks, please complete the following: What breeds of ducklings/ducks did [you/the patient] purchase? (Read off list of common duck breeds if respondent needs help remembering.) (Select all that apply) ☐Ancona ☐Blue Swedish ☐Buff ☐Cayuga ☐Khaki Campbell ☐Muscovey ☐Pekin ☐Rouens ☐Runner ☐Welsh Harlequin ☐Unknown ☐Other: ____________________
☐	☐	☐	☐	If you purchased poultry from a feedstore, did [you/the patient] see sign(s) about handwashing posted near the backyard poultry or their environment?
☐	☐	☐	☐	If you purchased poultry from a feedstore, did [you/the patient] see handwashing stations or hand sanitizer near the backyard poultry?
☐	☐	☐	☐	If [you/the patient] contacted poultry at a feedstore, was there food or drink served near the poultry or their environment?

Section 8: Food, Feed, Treats
Yes	Maybe	No	Don’t Know	Section 8a. Pet food exposure and general feeding practices
☐	☐	☐	☐	In the 7 days before the illness began, did you (the patient) have contact with animal food, animal treats, animal feeding bowls or equipment, or the area where animal food/treats are stored or where animals are fed? What type of animal food: ☐ Dry ☐ Canned ☐ Fresh ☐ Raw ☐ Other, specify: ____________ ☐ Unknown Animal food brand: ___________________________________________________________ ☐ Unknown Purchase location: ___________________________________________________________ ☐ Unknown Animal treat type: ☐ Pig ear ☐ Pizzle/bully stick ☐ Raw hide ☐ Hooves ☐ Jerky-style treat ☐ Biscuit-style treats ☐ Freeze-dried treats ☐ Other, specify: ______________________ ☐ Unknown Animal treat brand: ___________________________________________________________ ☐ Unknown Purchase location: ___________________________________________________________ ☐ Unknown
				In the 7 days before your illness, what did [you/the patient] feed the [ANIMAL SPECIES](s) to eat? Include vitamins/minerals/supplements. Include brand name and place of purchase if available. Food/Feed: _______________________________ Brand:____________________________ Location purchased: ___________________________________________________________ Vitamin/Mineral/Supplement/Treats Name: ______________________________________________________________________ Purchase Location:____________________________________________________________
				In the 7 days before your illness began, did you feed [ANIMAL SPECIES]: Commercial Reptile Diet Crickets Are the crickets ‘gut-loaded’? Yes No Don’t know If yes Purchased with ‘gut-loaded’ Owner gut loads Mealworms Owner breeds Pet store Internet Other If store, internet or other, please specify Other insects Owner breeds Pet store Internet Other If store, internet or other, please specify Feeder animals (e.g, rodents, chicks) Fresh Frozen Owner breeds Pet store Internet Other If store, internet or other, please specify Vegetables Owner grows Pet store Internet Grocery Other If store, internet or other, please specify Fruit Owner grows Pet store Internet Grocery Other If store, internet or other, please specify Supplements (e.g., calcium, vitamins) Pet store Internet Other If store, internet or other, please specify: Please specify how supplements are fed:
				In the 7 days before your illness began, did you feed any of the following to [ANIMAL SPECIES]? Please check all that apply: Medicated milk replacer Feeds with antibiotics Pellets Mix feed/blend (blood meal, bone meal, cottonseed, etc.) Other, please specify: Brand (if known):_____________________________ Lot:___________________________ (Encourage them to take a picture and send) Purchase name and location:__________________________________________
☐	☐	☐	☐	Was the food/feed tested for [PATHOGEN]?
☐	☐	☐	☐	If yes, was [PATHOGEN] isolated from the feed?
				Section 8b. Pet Food and Raw Pet Food Exposure: Now I have a few questions about any pet food products you may have used in the 7 days before your illness began.
☐	☐	☐	☐	In the 7 days before your illness began, did you (the patient) have contact with prepackaged pet food (canned or dry)? If yes, what was the brand of the pet food? Brand A Brand B Brand C Other:_______________________ What store (name and location) did you purchase the pet food? Store name __________________________________ Store location (address, city, state) __________________________________ Purchase date (or estimated date)_______________________ Lot #:__________________________________ Is product available for testing? Yes No
☐	☐	☐	☐	In the 7 days before your illness began, did you (the patient) have contact with raw prepackaged pet food (refrigerated or frozen)? If yes, what was the brand of the raw pet food? Brand D Brand E Brand F Other:__________ What store (name and location) did you purchase the pet food? Store name __________________________________ Store location (address, city, state) __________________________________ Purchase date (or estimated date)_______________________ Lot #: __________________________________ Is product available for testing? Yes No
☐	☐	☐	☐	Did you (your family) prepare your own raw pet food? If yes, what raw meats did you include in the food?___________________________________
☐	☐	☐	☐	In the 7 days before your illness began, did you (the patient) have contact with pet treats or chews (pig ears, puzzles, rawhide, hooves, etc.)? If yes, what was the brand of the pet treats (please take picture of packaging)? Brand G Brand H Brand I Other: _________________________ What store (name and location) did you purchase the pet food? Store name __________________________________ Store location (address, city, state) __________________________________ Purchase date (or estimated date) _______________________ Lot #: __________________________________ Is product available for testing? Yes No
☐	☐	☐	☐	May we have permission to retrieve purchases based on your member card information? This information will be kept confidential and only be used by public health officials to help with this outbreak investigation. If yes, put member card details in the comments section.

Section 9: Animal Housing and Cleaning
Yes	Maybe	No	Don’t Know
☐	☐	☐	☐	Does the [ANIMAL SPECIES](s) have an enclosure where they live, If Yes or Maybe, what type? (Mark all that apply) Wire Cage Open bowl Bowl with a cover/lid Aquarium (specify size ____ gallons) No enclosure, free roams Other (please describe):_________________________________________________________________
				If the [ANIMAL SPECIES](s) is/are kept in an enclosure, what kind of bedding do you use in their habitat? (Mark all that apply) Sand Wood Chips Commercial Reptile Substrate Reptile Carpet Newspaper/paper Paper Towel Gravel/Stones/Pebbles Dirt Other:______________________________________
☐	☐	☐	☐	Does the [ANIMAL SPECIES](s) ever roam freely outside of its cage or container?
				If yes, where does the [ANIMAL SPECIES](s) roam? On the floor On the countertops/tabletop On furniture (sofa, chairs, etc.) In the yard Other: ___________________________
☐	☐	☐	☐	Is the [ANIMAL SPECIES](s) habitat cleaned? If no, move to Section 10.
				Who is responsible for cleaning the [ANIMAL SPECIES](s) habitat? You/the patient Children of household (other than the patient if applicable) Parent/guardian Other:______________________
				Where is the [ANIMAL SPECIES] habitat cleaned? Toilet Kitchen sink Bathroom sink Garbage can Yard Other:________________________________
				Where is/are the [ANIMAL SPECIES](s) kept when the habitat is cleaned? Bathtub Kitchen sink Bathroom sink Plastic container Other:__________________________________

Section 10: Hygiene Around Animals and After Handling
Yes	Maybe	No	Don’t Know
☐	☐	☐	☐	Do [you/the patient] wash your hands or use hand sanitizer to perform hand hygiene after handling the [ANIMAL SPECIES](s) or touching the [ANIMAL SPECIES] (s) enclosure/habitat/items?
				What type of hand hygiene (i.e. handwashing with soap) do [you/the patient] typically perform after handling your [ANIMAL SPECIES] (s) or the [ANIMAL SPECIES] habitat? Wash hands with soap and water Alcohol-based hand sanitizer Both None Other:_________________________________
				Since purchasing/obtaining the [ANIMAL SPECIES] (s), how often did [you/the patient] perform hand hygiene directly after handling the [ANIMAL SPECIES] (s)? Always (95-100%) Almost Always (75-95%) Most of the time (50-75%) Some of the time (30-50%) Rarely (<30%) Don’t know
				Since purchasing/obtaining the [ANIMAL SPECIES] (s), how often did [you/the patient] perform hand hygiene directly after touching the [ANIMAL SPECIES](s) enclosure/habitat/items? Always (95-100%) Almost Always (75-95%) Most of the time (50-75%) Some of the time (30-50%) Rarely (<30%) Don’t know
				How often do [you/the patient] perform hand hygiene directly after handling pet food/treats? Always (95-100%) Almost Always (75-95%) Most of the time (50-75%) Some of the time (30-50%) Rarely (<30%) Don’t know
				What do [you/the patient] use to perform hand hygiene after handling pet food/treats? Soap and water Alcohol-based hand sanitizer Both Nothing/Do not wash hands Other: _________________________________
				(If there are children younger than 5 in the household) In the last month, how often did the children (younger than 5 years old) wash their hands with adult supervision after interacting with [ANIMAL SPECIES]? Always (95-100%) Almost Always (75-95%) Most of the time (50-75%) Some of the time (30-50%) Rarely (<30%) Don’t know N/A (no children <5 years)
				In the past month how often did [you/the patient] wash your hands after interacting with [ANIMAL SPECIES]? Always (95-100%) Almost Always (75-95%) Most of the time (50-75%) Some of the time (30-50%) Rarely (<30%) Don’t know

Section 11: Awareness and Education The final questions have to do with your awareness of the connection between [ANIMAL SPECIES] and [PATHOGEN] and how you might educate yourself in caring for [ANIMAL SPECIES].
Yes	Maybe		No		Don’t Know
							Before this illness, were [you/the patient] aware of a connection between [ANIMAL SPECIES] contact and [PATHOGEN]?
							a: If yes or maybe, how did [you/the patient] find this information? (Check all that apply) Magazine/newspaper Website/blog Social Media Sign/employee at retail store Friend/family Television Other:_______________________________
							b: If no, would you still have obtained a [ANIMAL SPECIES] if you had known about the connection between [ANIMAL SPECIES] contact and [PATHOGEN]? Yes No Don’t Know
							Are there any changes you plan to make or things you plan to do differently regarding your [ANIMAL SPECIES] now that you have experienced [PATHOGEN] illness in your household? (If “Yes” or “Maybe” answer question 2a.) a. Describe what changes/things [you/the patient/household member] will do differently.____________________________________________________________________
							Would [you/the patient/household member] be willing to have the public health department come to collect samples of your [ANIMAL SPECIES]?
							What information do you think would be helpful to prevent these types of illnesses in the future?
Comments. Is there any other information you would like to share about this illness or about contact with [ANIMAL SPECIES]?

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0XXX-XXXX