General Comments about the 'System'
About the “Shotgun” Questionnaire
This template is adapted from a hypothesis-generating questionnaire developed in Oregon. It was designed for use when subtyping information (e.g., serotype or PFGE patterns) suggests a common-source outbreak caused by a widely distributed but unknown food item. It pretty much assumes that by the distribution of cases you have already ruled out attendance at a common event or location. Interviews will typically take 30–60 minutes depending on how chatty everyone is and how much detail you try to capture about foods that are named.
Food exposure frequencies for cases can be compared with specific controls or with known or estimated food consumption frequencies for comparable populations (e.g., FoodNet population survey information available at ).
Before deploying your questionnaire, decide on the time interval to be covered in the interview (e.g., 5 or 7 days before onset). The default is 7 days, which is reasonable for salmonellosis and E. coli O157 at least. Before you start, use a calendar to try and fix the starting and ending dates in the subject’s mind. Periodically remind the interviewee of the reference period. “Again, still just talking about those 7 days before you got sick, did you eat any....”
There is space left throughout the questionnaire to allow one to write in details about items of interest: brand names, whether eaten raw or cooked, purchase locations and dates, etc. Where an item lists several varieties (e.g., “clams, mussels, scallops”, check the 1 box and circle the specific choices if given (or write in). In the short term these details are rarely keypunched unless they are of special interest. How much detail is captured “up front” sort of depends on what stage of the investigation you are at and how likely you are to be able to easily re-contact the individual if necessary. Always notify interviewees that someone may need to contact them again to get additional details. Emphasize how much we appreciate their help in preventing other people from getting sick. One can of course attach additional pages of notes.
This questionnaire is inappropriate (or, at least, needs to be customized) for some kinds of outbreaks. Demographic clues (e.g., atypical distributions of age, sex, race, or ethnicity) may suggest a need to modify or abandon this very broad brush survey. Do not use it without thinking about what you are doing. Modify it as necessary—ideally in coordination with other users for a given outbreak! Familiarize yourself with the flow of the questionnaire before you use it. If you have time, it is a good idea to practice on a friend or family member that you don’t live with.
In a perfect world, a single person would do all interviews for a given cluster. This allows one to read between the lines and adapt a bit on the fly. Life is often not perfect, however; do the best you can.
Questionnaires should be faxed to a central location for keypunching; put the fax number in the footer.
Although it can be used as a stand-alone form, this template has been specifically formatted to facilitate rapid and accurate data entry into pre-existing FileMaker database templates and rapid analysis using customized EpiInfo 6 routines. For more information about these advanced features, refer to Oregon’s web site () or contact Bill Keene at the Oregon Public Health Division: 971.673.1111 or keene@). Do not delete the keypunch code letters (A B C D…) and numbers ( [1], [2], …).
We recommend that all finalized questionnaires be converted to PDFs before distribution; this is the best way to ensure consistent formatting between users with different systems, fonts, etc., and it keeps most people from messing with it (inadvertently, of course). It should be obvious that one should not change keypunching codes in the middle of the stream. Add additional pages and item blocks as needed at the end; do not insert new items into existing blocks.
As the investigtion progresses, you may be able to shorten the questionnaire. For example, you might drop items that none of the first 10 people mention; that may be 80% or more—a real time saver. There is a right way and a wrong way to do this. The easiest and best way to do this is not to delete the items per se, but rather change the color of the text to white. This makes the items “invisible” and preserves the order and consistency of the all-important keypunch codes. Once you color one item white, you can use the control-Y shortcut (command-Y on a Mac) to quickly repeat this action on subsequent selections. This does leave a bit of a Swiss cheese appearance to the questionnaire, but it is quick and allows one to easily go back if necessary.
This template revised 29 Jan 2008
Respondent was... ρ self ρ parent ρ spouse r ___________________ Interviewed by ___________ on ____/____
Age _____ Sex ρ M ρ F State of Residence ______ County __________________
First positive specimen collected ____/____/____ PHL Specimen ID ________ Source ρ stool ρ urine ρ blood ρ _____
Get precise answers for onset times if at all possible. Without a date and time, it’s hard to make a decent epi curve or to calculate incubation times. Estimates are OK. Prompt as needed: "What is your best guess of the time?" Don’t let them get away with vague stuff like “morning” or “some time after midnight.” Be careful with times such as "midnight" or early morning hours—which day do they mean? By “2 am Friday night,” for example, do they really mean Saturday morning? Keep probing until it is unambiguous.—and then write down what they mean—not just what they say. Midnight will be considered as the end of the day (e.g., 11:59 pm).
Onset of first symptoms (m/d/y) ____/____/____ Time of first onset ____ am ρ noon ____ pm ρ midnight
Onset of first vomiting or diarrhea (m/d/y) ____/____/____ Time of first V or D ____ am ρ noon ____ pm ρ midnight
|[[i]] Y ? N |LEAD-IN QUESTIONS |
|A r r r |Was anyone in your household sick with diarrhea or vomiting in the week before you got sick? ρ single person in HH |
| |If yes, when did they first get sick? ____/____/____ |
|B r r r |Did you spend any time out of your home state in the 7 days before you got sick? |
| |If yes, which other states or countries did you visit? |
|C r r r |Did you visit an emergency room because of your illness? |
|D r r r |Were you formally admitted to the hospital overnight? (Distinguish admission from short stay observation) _____ days |
|E r r r |Do you make a point to select mostly “organic” produce when you shop? |
|F r r r |Are you a vegetarian or vegan? |
|G r r r |Before you got sick, were you on any kind of special or restricted diet for medical, weight loss, religious, or other reasons? |
| |If yes, describe… |
First I'd like to ask about the kinds of places where you might have eaten something in the 7 days before you got sick. This may help jog your memory about remember specific food items, which I’ll ask you about in a few minutes. Did you eat anything at any....
|[[ii]] Y ? N |EATING AND SHOPPING VENUES |
|A r r r |fast-food restaurants |
|B r r r |sit-down restaurants |
|C r r r |grocery-store deli or other kind of deli |
|D r r r |bakery, dessert, or pastry shop |
|E r r r |coffee shops (e.g., Starbucks) |
|F r r r |street vendors/push carts/kiosks |
|G r r r |event concession stands (e.g., sports events, county fairs, or concerts) |
|H r r r |gas stations, truck stops, mini-marts |
|I r r r |shopping mall or airport food courts |
|J r r r |ice cream, candy, and dessert shops |
|K r r r |tavern or bar |
|L r r r |free sample giveaways (e.g., at Costco, Trader Joe’s, farmer’s market) |
|M r r r |cafeteria/dining room (e.g., worksite, hospital, school or college) |
|N r r r |nursing home/assisted living dining facility |
|O r r r |hotel room service or hotel/motel breakfast |
|P r r r |child-care facility |
|Q r r r |potluck meals with family or friends |
|R r r r |catered private gatherings (e.g., weddings, funerals, parties) |
|S r r r |any food at a church social or similar gathering |
|T r r r |food brought in to school classes, offices, or work place |
|U r r r |any food at a meeting or conference |
|V r r r |any mail-order or home-delivery foods or door-to-door sale items |
|W r r r |airplanes (specify airline) |
|X r r r |trains, buses, cruise ships, ferries |
|Z r r r | |
Now I’d like to ask about where the food came from that you ate at home in those 7 days. In other words, this isn’t necessarily where you shopped in those days, but where the food that you ate during that time came from. OK? Did any of it come from...
|[[iii]] Y ? N |SOURCES OF FOOD AT HOME [List store names and check if they use a “shopper card” or save itemized receipts] |
|A r r r |grocery stores/supermarkets (specify) ρ ________________ ρ ________________ ρ ________________ |
|B r r r |food warehouse stores (Costco, Sam's, etc.) ρ ________________ ρ ________________ ρ ________________ |
|C r r r |small markets and mini-marts |
|D r r r |ethnic specialty markets (e.g., Asian groceries |
|E r r r |health foods, “whole food” stores, coops |
|F r r r |other specialty markets (AJ’s, Trader Joe’s, gourmet foods, ...) |
|G r r r |delicatessens, including supermarket delis |
|H r r r |bakeries, bagel and doughnut shops |
|I r r r |farmer’s markets, roadside stands, open-air markets |
|J r r r |CSA produce (Community Supported Agriculture) |
|K r r r |fish or meat specialty shops |
|L r r r |take-out or home delivered ready-to-eat food (e.g., pizza, Chinese) |
|M r r r |home delivery grocery services (e.g., Schwan's, Meals-on-Wheels) |
|N r r r |home-grown produce |
|O r r r |private- or custom-slaughtered meat |
|P r r r |food at other households (friends, family, etc) |
|Q r r r |food banks or charity kitchens |
| |If we really needed it, what kinds of records might exist that would help us pin down specific food purchase dates? |
| |R r receipts S r ATM/credit card records T r check stubs U r shopper card records at store |
| |V r membership records (e.g., Costco, Sam’s Club W r _________ X r nothing; uses cash and tosses receipts |
[If applicable] You said that you ate at some restaurants [and fast food places]. Let me run through a list of some popular national chains to see if you remember eating there during that time.
|[[iv]] Y ? N |FAST FOOD CHAINS |[[v]] Y ? N |CHAIN RESTAURANTS |[[vi]] Y ? N |RESTAURANT GENRES |
|A r r r |A & W |A r r r |Applebee’s |A r r r |Chinese |
|B r r r |Arby’s |B r r r |Chili’s |B r r r |Vietnamese |
|C r r r |Baskin-Robbins |C r r r |Chuck E Cheese |C r r r |Thai |
|D r r r |Boston Market |D r r r |Country Kitchen |D r r r |Japanese |
|E r r r |Burger King |E r r r |Denny’s |E r r r |Indian/South Asian |
|F r r r |Carl’s Jr. |F r r r |Friendly’s |F r r r |other Asian |
|G r r r |Dairy Queen |G r r r |Hardee’s |G r r r |Mexican |
|H r r r |Del Taco |H r r r |HomeTown Buffet |H r r r |other Latin American |
|I r r r |Domino’s |I r r r |IHOP |I r r r |pizzeria |
|J r r r |Dunkin Donuts |J r r r |Olive Garden |J r r r |Italian |
|K r r r |Jack-in-the-Box |K r r r |Red Lobster |K r r r |French/Spanish/European |
|L r r r |KFC |L r r r |Ruby Tuesday’s |L r r r |Cuban/Caribbean |
|M r r r |Krystal |M r r r |Sbarro |M r r r |Greek |
|N r r r |McDonald’s |N r r r |Shari’s |N r r r |Middle Eastern/Arabic |
|O r r r |Panda Express |O r r r |Sizzler |O r r r |Other “international” |
|P r r r |Papa Murphy’s |P r r r |T.G.I. Fridays |P r r r |vegetarian or vegan |
|Q r r r |Pizza Hut |Q r r r |Waffle House |Q r r r |barbeque |
|R r r r |Quizno’s |R r r r |Starbucks |R r r r |steakhouse or grill |
|S r r r |Round Table |S r r r | |S r r r |"family" restaurant |
|T r r r |Sonic | | |T r r r |seafood |
|U r r r |Subway | | |U r r r |breakfast/brunch place |
|V r r r |Taco Bell |Z r r r | |V r r r |diner/neighborhood cafe |
|W r r r |Taco John | | |W r r r |all-you-can-eat buffet |
|X r r r |Wendy’s | | | | |
|Z r r r | | | |Z r r r | |
List by name any other restaurants that you can recall eating at that week; if possible what was eaten.
Now I’d like to ask you about a long list of food items, and for each one my question will be “Did you eat it in that same 7- day period before you got sick?” The lists are organized into categories, like eggs and dairy foods, vegetables and fruits, and so on. For each item, give me a “yes” or “no” if you remember eating or even tasting it in those 7 days before you got sick. Some of the questions might seem a little repetitive, but please try and answer each question individually, even if you think it was already covered. Unless I specify otherwise, I’m interested in whether you ate these items at home or away from home—either one, OK?
|[[vii]] Y ? N |EGGS AND DAIRY |
|A r r r |eggs (anything anywhere from whole eggs [i.e., not powdered or processed]) If yes, ... |
|B r r r |any eggs at home |
|C r r r |any eggs at restaurants or elsewhere away from home |
|D r r r |any eggs anywhere that were raw or runny |
|E r r r |anything uncooked made with raw eggs (e.g., cookie dough, sauces, mousse, homemade ice cream or mayo) |
|F r r r |any egg substitutes (Egg-Beaters, etc.) |
|G r r r |butter (real butter; not margarine) |
|H r r r |buttermilk (fluid, not powdered) |
|I r r r |sour cream |
|J r r r |whipped cream from a carton (i.e., fresh) |
|K r r r |whipped cream in spray cans |
|L r r r |other imitation dairy topping (e.g., Cool-Whip) |
|M r r r |frozen yogurt or yogurt drinks |
|N r r r |any other store-bought yogurt |
|O r r r |ice cream bars or frozen dairy dessert items from a store |
|P r r r |ice cream bars or dessert items from a vendor or truck |
|Q r r r |ice cream from a grocery store (e.g., carton or tub) |
|R r r r |ice cream at a dessert shop or ice cream store (e.g., Baskin-Robbins) |
|S r r r |any unpasteurized (raw) milk |
|T r r r |any pasteurized (“regular”) milk. If yes, specify: |
| |U r skim V r 1% W r 2% X r 4% (whole) Y r flavored (e.g., chocolate) Z r __________ |
|[[viii]] Y ? N |CHEESE |
|A r r r |cream cheese or Neufchatel |
|B r r r |cottage cheese |
|C r r r |Ricotta |
|D r r r |any “string” cheese |
|E r r r |any cheese sold as or cut from solid blocks (e.g., cheddar, Swiss, Colby, Jack, ...) |
|F r r r |any cheese on a deli-type sandwich |
|G r r r |any flavored cheese spread in a tub |
|H r r r |any cheese spread or topping in a can |
|I r r r |American (processed) cheese |
|J r r r |any soft cheese like Brie or Camembert |
|K r r r |uncooked mozzarella (e.g., not cooked on pizza) |
|L r r r |any fresh Parmesan, Romano, or similar dry cheese |
|M r r r |dried (powdered) cheese (Parmesan, Romano,...) |
|N r r r |any blue-veined cheese (Bleu, gorgonzola,...) |
|O r r r |any goat cheese |
|P r r r |any sheep cheese |
|Q r r r |homemade Mexican-style (queso fresco, q. blanco) |
|R r r r |Store-bought Mexican-style (queso fresco, q. blanco) |
|S r r r |any imported cheese (other than queso fresco) |
|T r r r |any gourmet or "artisanal" cheese (usually expensive, often sold at specialty shops, markets, whole foods stores...) |
|U r r r |any cheese made from unpasteurized milk (often homemade or sold off-the-farm or door-to-door) |
|V r r r |any cheese from a mail-order source |
|W r r r |any cheese from an ethnic market or specialty shop |
|X r r r |any other cheese (specify) |
|[[ix]] Y ? N |FRESH AND FROZEN MEAT & POULTRY |
|A r r r |anything from ground chicken (raw, not processed) |
|B r r r |anything prepared at home from pre-cut chicken parts |
|C r r r |if yes, was those parts already frozen when you got them? |
|D r r r |anything prepared at home from a “whole” chicken |
|E r r r |if yes, was that chicken already frozen when you got it? |
|F r r r |any other chicken (at home or away—NOT including fingers, tenders, or strips) |
|G r r r |anything from ground turkey (raw, not processed) |
|H r r r |anything prepared at home from a “whole” turkey |
|I r r r |if yes, was that turkey frozen when you got it? |
|J r r r |anything prepared at home from pre-cut turkey parts |
|K r r r |if yes, was that turkey frozen when you got it? |
|L r r r |any other turkey (at home or away) |
|M r r r |duck, game hen, goose, squab, or other poultry |
|N r r r |pre-frozen hamburger patties eaten at home |
|O r r r |fresh (not store-frozen) hamburger at home |
|P r r r |anything else made with ground beef at home |
|Q r r r |pre-frozen beef steaks or roasts |
|R r r r |any other fresh beef (steak, roasts, etc.) at home |
|S r r r |ground pork |
|T r r r |any other fresh pork (not ham) |
|U r r r |lamb or veal (circle which) |
|V r r r |wild venison or game (deer, elk, pheasant, duck, whale…) |
|W r r r |organ meats (liver, kidneys, brains....) |
|X r r r |chitterlings, scrapple, head cheese, “variety meats” |
|[[x]] Y ? N |COOKED OR PROCESSED MEATS (not canned) |
|A r r r |ham |
|B r r r |any pre-packaged deli meats |
|C r r r |any other sliced deli meats (e.g., cut-to-order) |
|D r r r |corn dogs |
|E r r r |hot dogs (all beef, chicken, turkey, pork, vegetarian, unknown) |
|F r r r |bologna, pastrami, corned beef, or other processed meat products |
|G r r r |bacon (regular, turkey, etc.) |
|H r r r |breakfast sausage (links, patties, ground) |
|I r r r |any other sausage/bratwurst/kielbasa... |
|J r r r |pepperoni, salami, prosciutto ... |
|K r r r |homemade dried meat products (jerky, strips, etc.) |
|L r r r |any commercial dried meat products (jerky, strips, etc.) |
|------------------|FISH & SEAFOOD (not canned) |
|- |smoked or dried fish (e.g., lox) |
|N r r r |any fresh fish from a store or other commercial source (not sport fishing) |
|O r r r |crab |
|P r r r |oysters |
|Q r r r |any oysters specifically eaten raw |
|R r r r |clams, mussels, scallops, cockles |
|S r r r |shrimp, prawns, crawfish, lobster |
|T r r r |seaweed or seaweed products |
|U r r r |squid or any other seafood |
|V r r r |any commercially prepared seafood salad |
|W r r r |any imitation Krab (surimi) or similar product |
|X r r r | |
Now let me ask you about fresh vegetables and other produce. I’ll ask about frozen stuff later.
|[[xi]] Y ? N |FRESH VEGETABLES 1 |
|A r r r |“mini” carrots (peeled; usually sold in sealed bag) |
|B r r r |loose or bagged carrots (full size) |
|C r r r |celery |
|D r r r |cucumbers |
|E r r r |broccoli |
|F r r r |cauliflower |
|G r r r |bell peppers (green, red, yellow, orange) |
|H r r r |other fresh peppers (chilis, jalapeños) |
|I r r r |asparagus |
|J r r r |fresh corn on the cob |
|K r r r |snow peas (eaten in pod) |
|L r r r |other fresh peas |
|M r r r |fresh beans |
|N r r r |brussel sprouts |
|O r r r |zucchini or other "soft" squash |
|P r r r |any "hard” squash (pumpkin, acorn, butternut, etc.) |
|Q r r r |fresh potatoes |
|R r r r |yams or sweet potatoes |
|S r r r |any homegrown fresh tomatoes (from your own garden or a friend/neighbor) |
|T r r r |any commercial fresh tomatoes eaten raw at home or away from home |
| |if yes, specify V ρ cherry W ρ grape X ρ Roma Y ρ other (e.g., beefsteak) |
|[[xii]] Y ? N |FRESH VEGETABLES 2 |
|A r r r |white or yellow onions |
|B r r r |green onions (scallions) |
|C r r r |leeks |
|D r r r |eggplant |
|E r r r |commercially made guacamole |
|F r r r |other avocado |
|G r r r |cabbage |
|H r r r |bean sprouts |
|I r r r |any stir-fry that might have included bean sprouts |
|J r r r |alfalfa sprouts |
|K r r r |any other sprouts (clover, mixed, broccoli, daikon radish, …) |
|L r r r |Did you handle any sprouts, event if you didn’t eat them? |
|M r r r |any bagged, pre-washed lettuce or salad mix |
|N r r r |any other iceberg lettuce |
|O r r r |any romaine lettuce |
|P r r r |any other leafy lettuce (red, green, butter, radicchio …) |
|Q r r r |any mesclun, “spring mix”, or “baby” salad items |
|R r r r |any lettuce on sandwiches or burgers |
|S r r r |any tomatoes on sandwiches or burgers |
|T r r r |bagged, pre-washed spinach or spinach mix |
|U r r r |fresh spinach (“loose”; not frozen) |
|V r r r |arugula, endive, chard, watercress, other salad greens |
|W r r r |other greens (kale, collard, mustard, etc) |
|X r r r |fresh basil or pesto (at home or away) |
|Y r r r |fresh parsley (regular or Italian) |
|Z r r r |fresh cilantro |
|[[xiii]] Y ? N |FRESH VEGETABLES 3 |
|A r r r |any other fresh herbs |
|B r r r |fresh ginger (root) |
|C r r r |fresh garlic |
|D r r r |dried mushrooms |
|E r r r |fresh mushrooms |
|F r r r |beets, turnips, or radishes |
|G r r r |okra, rhubarb |
|H r r r |any “organic” produce |
|I r r r |any fresh apple juice or cider |
|J r r r |orange juice from frozen concentrate |
|K r r r |any other juice from frozen concentrate |
|L r r r |fresh orange juice (not from concentrate) |
|M r r r |any raw or unpasteurized fruit juice (often from farms or fruit stands, but occasionally sold in stores) |
|N r r r |any fresh vegetable juice |
|------------------|FRESH FRUIT 1 (Not canned, frozen, dried, or cooked) |
|- |apples |
|O r r r |pears |
|P r r r |peaches |
|Q r r r |nectarines |
|R r r r |apricots |
|S r r r |plums |
|T r r r |oranges |
|U r r r |tangerines |
|V r r r |grapefruit |
|W r r r |fresh lemon or lime (including garnishes in drinks) |
|X r r r |other citrus fruit |
|Y r r r | |
|Z r r r | |
|[[xiv]] Y ? N |FRESH FRUIT 2 (Not canned, frozen, dried, or cooked) |
|A r r r |strawberries |
|B r r r |raspberries |
|C r r r |blueberries |
|D r r r |blackberries |
|E r r r |cranberries |
|F r r r |other fresh berries (specify) |
|G r r r |cherries |
|H r r r |grapes (green, red, ....) |
|I r r r |bananas |
|J r r r |plantains |
|K r r r |cantaloupe |
|L r r r |honeydew |
|M r r r |watermelon |
|N r r r |any other kind of melon (specify) |
|O r r r |any pre-mixed cut melon or melon salad |
|P r r r |kiwi |
|Q r r r |pineapple |
|R r r r |mango |
|S r r r |papaya, guava, or pomegranate |
|T r r r |other “exotic” fruits (specify) |
|Z r r r | |
|[[xv]] Y ? N |PREMIXED, DRIED FOODS, NUTS |
|A r r r |store-bought fruit salad |
|B r r r |store-bought pasta salad |
|C r r r |store-bought potato salad |
|D r r r |store-bought egg salad |
|E r r r |store-bought cole slaw |
|F r r r |dried buttermilk |
|G r r r |other powdered milk (not including baby formula) |
|H r r r |flavored milk powder (e.g., chocolate) |
|I r r r |dried beans (e.g., red, pinto, navy) or lentils |
|J r r r |coconut (whole, shredded, canned coconut milk) |
|K r r r |dried seaweed |
|L r r r |whole peanuts (specify shelled or in-shell) |
|M r r r |peanut butter (specify brands) |
|N r r r |whole almonds |
|O r r r |pre-chopped or sliced almonds, almond-dusted pastries or candies |
|P r r r |walnuts |
|Q r r r |cashews |
|R r r r |pistachios |
|S r r r |hazelnuts (filberts) |
|T r r r |and other whole nuts |
|U r r r |any other pre-chopped or sliced nuts |
|V r r r |any ground nut paste or spread other than peanut butter (e.g., almond butter) |
|W r r r |sunflower seeds |
|X r r r |sesame seeds |
|Y r r r |tahini, halva, or other sesame products |
|Z r r r |hummus or baba ghanuj |
|[[xvi]] Y ? N |MISCELLANY 1 |
|A r r r |raisins |
|B r r r |any other commercial dried fruit (specify) |
|C r r r |any pre-made pudding or custard (not a mix) |
|D r r r |applesauce |
|E r r r |chips (potato, corn, Fritos, etc); pretzels |
|F r r r |other packaged snack food or and treats (e.g., Pirate’s Booty) |
|G r r r |salsa |
|H r r r |commercial tomato sauce |
|I r r r |any other kind of store-bought, packaged sauce or dip |
|J r r r |flavored oils |
|K r r r |taco shells |
|L r r r |tortillas |
|M r r r |bulk chocolate (not commercially wrapped bars or candy) |
|N r r r |any other imported ethnic specialty foods |
|O r r r |any “personally imported” |
|P r r r |tofu |
|Q r r r |olives |
|R r r r |liquid baby formula |
|S r r r |powdered baby formula |
|T r r r |store-bought puréed baby food (e.g., Gerbers) |
|U r r r |any other foods specifically marketed for babies or popular with babies |
|V r r r |any spices bought in bulk or at ethnic specialty markets (e.g., from a bin or in a plastic pouch, Indian groceries, etc.) |
|W r r r |any spices at home first opened in the 2 weeks before illness onset |
|[[xvii]] Y ? N |MISCELLANY 2 |
|A r r r |any foods bought in bulk (e.g., where you fill a bag or container from a larger bin (specify) |
|B r r r |breakfast bars in sealed wrappers |
|C r r r |any “cold” breakfast cereals in boxes (e.g., Cheerios, Raisin Bran) |
|D r r r |any “cold” breakfast cereals sold in bagshot breakfast cereals (oatmeal, etc.) |
|E r r r |trail mix, gorp, or similar product |
|F r r r |granola (loose, cereal type) |
|G r r r |granola bars, power bars, Clif bar, Luna bar, ... |
|H r r r |polenta |
|I r r r |tabouleh |
|J r r r |garbanzos (chickpeas), falafel |
|K r r r |soybeans |
|L r r r |fruit roll-ups, fruit leather, or similar |
|M r r r |“smoothies” made at home |
|N r r r |any non-frozen special diet meals (e.g., Weight Watchers, etc.) |
|O r r r |commercial bottled water in large, multi-user tanks or carboys |
|P r r r |any other bottled water in personal size containers |
|[[xviii]] Y ? N |FROZEN FOODS |
|A r r r |frozen “TV” dinners or boxed entrees |
|B r r r |pot pies |
|C r r r |frozen pre-mixed meals in bag (e.g., stir-fry mix, etc.) |
|D r r r |frozen vegetables in a box (spinach, peas, corn, ....) |
|E r r r |frozen vegetables in a bag (spinach, peas, corn, ....) |
|F r r r |frozen snack foods (e.g., mozzarella sticks, jalapeño poppers, potato skins) |
|G r r r |frozen berries |
|H r r r |frozen fruit |
|I r r r |frozen vegetarian stuff (e.g., Gardenburgers, Morningstar stuff) |
|J r r r |frozen fish products (filets, fish sticks, nuggets) |
|K r r r |frozen chicken strips or nuggets (at home) |
|L r r r |any other frozen chicken products |
|M r r r |any cook-and-serve poultry products (chicken Kiev dinners, chicken cordon bleu etc.) |
|N r r r |frozen pizza |
|O r r r |frozen Mexican-style items (burritos, taquitos, etc.) |
|P r r r |frozen shrimp, frog legs, lobster, crab, other seafood |
|Q r r r |frozen diet meals of any kind |
|Z r r r | |
Let me ask you a few questions specifically about foods eaten away from home—like a restaurant or take-out food.
|[[xix]] Y ? N |SPECIFIC FOODS EATEN OUT These refer only to food eaten or prepared away from home. |
|A r r r |Any hamburger at a fast-food place (FF is defined as where you pay before you eat) |
|B r r r |hamburgers at other restaurant (not fast-food) |
|C r r r |any other beef (steak, etc.) away from home |
|D r r r |any deli-type sandwich |
|E r r r |any sandwich that might have had sprouts on it |
|F r r r |any sandwich or burger garnished with lettuce |
|G r r r |any sandwich or burger garnished with tomato |
|H r r r |anything from a salad bar |
|I r r r |if yes, were there sprouts on the salad bar? (Call restaurant to verify!!) |
|J r r r |any kind of salad made with lettuce or greens |
|K r r r |anything with raw tomatoes |
|L r r r |pizza from a pizzeria (not frozen or homemade) |
|M r r r |sushi, sashimi, or ceviche |
|N r r r |any kind of burrito or “wrap” |
|O r r r |“smoothies” (e.g., from a vendor or shop) |
| | |
|Z r r r | |
Finally, I’d like to ask a few questions about pets and animal contact. During the 7 days before you got sick, did you have any contact with…
|[[xx]] Y ? N |LIVE ANIMAL CONTACT, PETS, and PET FOOD |
|A r r r |dogs or puppies |
|B r r r |cats or kittens |
|C r r r |baby chicks or other baby poultry |
|D r r r |chickens, turkeys, other poultry |
|E r r r |other pet birds of any kind |
|F r r r |cows, cattle, calves |
|G r r r |goats, sheep, pigs, horses |
|H r r r |llamas, alpacas, … |
|I r r r |reptiles (snakes, lizards, turtles and tortoises) |
|J r r r |amphibians (frogs, toads, salamanders, …) |
|K r r r |goldfish or other aquarium fish |
|L r r r |rats, mice, gerbils |
|M r r r |any “exotic” pets or “pocket pets” (e.g., ferrets, pygmy hedgehogs; sugar gliders,...[specify]) |
|N r r r |any visits to a petting zoo or farm with livestock |
|O r r r |any visits to animal feed stores |
|P r r r |any visits to pet stores, swap meets, or other places where animals or birds were sold or shown |
|Q r r r |any county or state fair, 4-H event, or similar event where animals were present |
|R r r r |any contact with animals or pets at school, birthday parties, or similar events |
|S r r r |any exposure to dried animal droppings or pellets (e.g., owl pellets for science projects) |
|T r r r |any contact or household use of pet treats or chews (e.g., pig ears, pizzles, rawhide chews, package treats…) |
|U r r r |dry dog or cat food (e.g., kibble) |
|V r r r |any commercial type of fresh or frozen (i.e., not dry or canned) |
|Z r r r |frozen mice, rats, or similar pet food (typically used as food for snakes) |
Believe it or not, that’s the end of the questionnaire. Thank you very much for your time. These interviews are extremely valuable in helping us solve the mystery of why people are getting sick. Depending on what we find out when we put these interviews together, we may need to follow up about a few details. Are there any other numbers I should have in case I need to reach you quickly?
__________________________ __________________________
Do not delete the stuff on this page from the Word file, but do delete it from any PDF copies that you send out. The little box numbers show up as endnotes. They specify which section is which for keypunching purposes, and automatically update if boxes are moved around.
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