General Comments about the 'System'
Outbreak name (2003-xxx) Interviewed by ______ on _____
Age _____ Sex ρ M ρ F Phone ____________________________
Home Address ____________________________ City ________________ State _______________ Zip ________
Race (Circle) Caucasian /African American / Asian / Other Occupation ________________________________
Name and Address of Employer, Daycare, or School_____________________________________________________________
Did you....
|[[i]] Y ? N |Lead-In QUESTIONS |
|A ρ ρ ρ |attend the rehearsal dinner on Friday night? |
|B ρ ρ ρ |go to the wedding? |
|C ρ ρ ρ |pet the iguana? |
|D ρ ρ ρ |go swimming in the pond? |
|E ρ ρ ρ |xxxxxxxxx |
|F ρ ρ ρ |xxxxxxxxx |
|Consider this format for multiple choice-type questions, for example: On which days did you attend the fair? |
|J ρSun, 20 K ρMon, 21 L ρTues, 22 M ρWed, 23 N ρThur, 24 O ρFri, 25 |
Food Exposures
Let me ask you about the items that were available at the xxxxxxxxxxxxxxxx OR
Let me walk you through the meals served over the last few days.
About what time did you eat? meal 1 ______ meal 2 ______ meal 3 ______ meal 4 ______ meal 5______
For each item, give me a “yes” or “no” answer if you remember eating or even tasting it.
Typical set-up for 3-across blocks
|[[ii]] Y ? N |BLOCK |[[iii]] Y ? N |BLOCK |[[iv]] Y ? N |BLOCK |
|A ρ ρ ρ |item |A ρ ρ ρ |item |A ρ ρ ρ |item |
|B ρ ρ ρ |item |B ρ ρ ρ |item |B ρ ρ ρ |item |
|C ρ ρ ρ |xxxx |C ρ ρ ρ |xxxx |C ρ ρ ρ |xxxx |
|D ρ ρ ρ |xxxx |D ρ ρ ρ |xxxx |D ρ ρ ρ |xxxx |
|E ρ ρ ρ |xxxx |E ρ ρ ρ |xxxx |E ρ ρ ρ |xxxx |
|F ρ ρ ρ |xxxx |F ρ ρ ρ |xxxx |F ρ ρ ρ |xxxx |
|G ρ ρ ρ |xxxx |G ρ ρ ρ |xxxx |G ρ ρ ρ |xxxx |
|H ρ ρ ρ |xxxx |H ρ ρ ρ |xxxx |H ρ ρ ρ |xxxx |
|I ρ ρ ρ |xxxx |I ρ ρ ρ |xxxx |I ρ ρ ρ |xxxx |
|J ρ ρ ρ |xxxx |J ρ ρ ρ |xxxx |J ρ ρ ρ |xxxx |
|K ρ ρ ρ |xxxx |K ρ ρ ρ |xxxx |K ρ ρ ρ |xxxx |
|L ρ ρ ρ |xxxx |L ρ ρ ρ |xxxx |L ρ ρ ρ |xxxx |
|M ρ ρ ρ |xxxx |M ρ ρ ρ |xxxx |M ρ ρ ρ |xxxx |
|N ρ ρ ρ |xxxx |N ρ ρ ρ |xxxx |N ρ ρ ρ |xxxx |
|O ρ ρ ρ |xxxx |O ρ ρ ρ |xxxx |O ρ ρ ρ |xxxx |
|P ρ ρ ρ |xxxx |P ρ ρ ρ |xxxx |P ρ ρ ρ |xxxx |
|Q ρ ρ ρ |xxxx |Q ρ ρ ρ |xxxx |Q ρ ρ ρ |xxxx |
|R ρ ρ ρ |xxxx |R ρ ρ ρ |xxxx |R ρ ρ ρ |xxxx |
|S ρ ρ ρ |xxxx |S ρ ρ ρ |xxxx |S ρ ρ ρ |xxxx |
|T ρ ρ ρ |xxxx |T ρ ρ ρ |xxxx |T ρ ρ ρ |xxxx |
|U ρ ρ ρ |xxxx |U ρ ρ ρ |xxxx |U ρ ρ ρ |xxxx |
|V ρ ρ ρ |xxxx |V ρ ρ ρ |xxxx |V ρ ρ ρ |xxxx |
|W ρ ρ ρ |xxxx |W ρ ρ ρ |xxxx |W ρ ρ ρ |xxxx |
|X ρ ρ ρ |xxxx |X ρ ρ ρ |xxxx |X ρ ρ ρ |xxxx |
|Y ρ ρ ρ |xxxx |Y ρ ρ ρ |xxxx |Y ρ ρ ρ |xxxx |
|(number) ___ |How many drinks with ice? |(number) ___ |How many drinks with ice? |(number) ___ |How many drinks with ice? |
Typical set-up for 2-across blocks
|[[v]] Y ? N |BLOCK |[[vi]] Y ? N |BLOCK |
|A ρ ρ ρ |item |A ρ ρ ρ |item |
|B ρ ρ ρ |item |B ρ ρ ρ |item |
|C ρ ρ ρ |xxxx |C ρ ρ ρ |xxxx |
|D ρ ρ ρ |xxxx |D ρ ρ ρ |xxxx |
|E ρ ρ ρ |xxxx |E ρ ρ ρ |xxxx |
|F ρ ρ ρ |xxxx |F ρ ρ ρ |xxxx |
|G ρ ρ ρ |xxxx |G ρ ρ ρ |xxxx |
|H ρ ρ ρ |xxxx |H ρ ρ ρ |xxxx |
|I ρ ρ ρ |xxxx |I ρ ρ ρ |xxxx |
|J ρ ρ ρ |xxxx |J ρ ρ ρ |xxxx |
|K ρ ρ ρ |xxxx |K ρ ρ ρ |xxxx |
|L ρ ρ ρ |xxxx |L ρ ρ ρ |xxxx |
|M ρ ρ ρ |xxxx |M ρ ρ ρ |xxxx |
|N ρ ρ ρ |xxxx |N ρ ρ ρ |xxxx |
|O ρ ρ ρ |xxxx |O ρ ρ ρ |xxxx |
|P ρ ρ ρ |xxxx |P ρ ρ ρ |xxxx |
|Q ρ ρ ρ |xxxx |Q ρ ρ ρ |xxxx |
|R ρ ρ ρ |xxxx |R ρ ρ ρ |xxxx |
|S ρ ρ ρ |xxxx |S ρ ρ ρ |xxxx |
|T ρ ρ ρ |xxxx |T ρ ρ ρ |xxxx |
|U ρ ρ ρ |xxxx |U ρ ρ ρ |xxxx |
|V ρ ρ ρ |xxxx |V ρ ρ ρ |xxxx |
|W ρ ρ ρ |xxxx |W ρ ρ ρ |xxxx |
|X ρ ρ ρ |xxxx |X ρ ρ ρ |xxxx |
|Y ρ ρ ρ |xxxx |Y ρ ρ ρ |xxxx |
|(number) ___ |How many drinks with ice? |(number) ___ |How many drinks with ice? |
Typical set-up for a 1-across block
|[[vii]] Y ? N |OTHER QUESTIONS FOR EVERYBODY |
|A ρ ρ ρ |Did you travel anywhere in the week prior to your illness? |
| |If yes, give place(s) that you traveled to: ________________ |
| |When: __/__/____ thru __/__/____ |
| |If airline travel, what airline? _________________________ Flight no. ____________ |
|B ρ ρ ρ |Did you come into contact with any animals, or did you visit a farm with animals during the week before you became ill? |
| |If yes, when? ___________________ Where?________________ |
| |What kind of animal? __________________________________ |
| |Did you go swimming in the week before you became ill? |
|C ρ ρ ρ |If yes, where? __________________________ When? ___________________ |
| |Did you participate in group gatherings, parties, field trips or other group activites, any local sporting events (eg basketball) in the |
|D ρ ρ ρ |week before you illness? |
| |If yes, list activities: __________________________________________________ |
| |Where? ________________________________ When? _____________________ |
| |Do you know anyone else who has been ill with diarrhea or vomiting during the past week? |
|E ρ ρ ρ |If yes, who (relationship and name)? _______________________________________ |
| |Did you have contact with young children in a daycare setting during the past week? |
|F ρ ρ ρ |If yes, when: __/__/___ thru __/__/____ and where: _______________________________ |
| |Phone: _______________________ |
| |Xxxxxxx |
|G ρ ρ ρ | |
| | |
| Y ? N |were you SICK? |
|ρ ρ ρ |Have you yourself been sick at all with xxxxx since xxxxxxxxxx? |
if this person has not been sick, STOP HERE. If they have had symptoms, CONTINUE to the last page.
This page is only for people who got sick. Discard for those who did not become ill.
Let me read you a list of symptoms. For each one, give me a “yes” or “no.” Did you have any...
| Y ? N |SIGNS AND SYMPTOMS | Y ? N | |
|H ρ ρ ρ |headache |D ρ ρ ρ |any diarrhea or loose stools |
|N ρ ρ ρ |nausea |3 ρ ρ ρ |if yes to diarrhea, did you have 3 or more loose stools in |
|V ρ ρ ρ |vomiting | |any 24-hour period? |
|M ρ ρ ρ |myalgia (muscle aches) |B ρ ρ ρ |any blood in stools |
|C ρ ρ ρ |abdominal (stomach, belly) cramps |X ρ ρ ρ |constipation |
|T ρ ρ ρ |unusual fatigue (feeling tired) |Z ρ ρ ρ |backache |
|F ρ ρ ρ |fever (if yes, ρ subjective or _______˚ (max.) | |Other _______________________________ |
|L ρ ρ ρ |shaking chills | | |
|ONSET AND DURATION |October 2003 |
|Get precise answers for onset time. If you don't get a date and time, it can’t be placed on an epi curve. Estimates are OK. |S M Tu W Th F S |
|Prompt as needed: "What is your best guess of the time?"Don’t let them get away with vague stuff like “morning” or “after |1 2 3 4 |
|midnight.” Be careful with times such as "midnight" or early morning hours—which day do they mean?By “2am Friday night,” for |5 6 7 8 9 10 11 |
|example, do they mean Saturday morning? Keep probing until it is unambiguous. Midnight exactly will be graphed as 11:59 pm. |12 13 14 15 16 17 18 |
| |19 20 21 22 23 24 25 |
| |26 27 28 29 30 31 |
|On what date did you first feel sick? |
|ρ Fri, May 1 ρ Sat, May 2 ρ Sun, May 3 ρ Mon, May 4 ρ Tue, May 5 ρ ________ |
|At what time did you first feel sick? [ENTER A SPECIFIC HOUR IF POSSIBLE!!!] |
|ρ _______ am ρ noon ρ _______ pm ρ midnight (very end of day) |
|What was your first symptom? __________________________________________________ |
|[If applicable] On what day did you start having the vomiting or diarrhea (whichever came first)? |
|Note: the point here is to capture the onset time of some “hard” symptom, in case they had a “soft” prodrome. |
|ρ Fri, May 1 ρ Sat, May 2 ρ Sun, May 3 ρ Mon, May 4 ρ Tue, May 5 ρ ________ |
|[If applicable] At what time did the vomiting/diarrhea begin? [BE SPECIFIC!!!] |
|ρ _______ am ρ noon ρ _______ pm ρ midnight (end of day) |
|Are you still having any vomiting/diarrhea now? ρ yes ρ no |
|If no, how long did the vomiting/diarrhea last? ___ minutes ___ hours ___ days |
|Date of recovery? ___/___/______ Time of recovery?_______________ |
|Overall, how long did you feel ill? ___ minutes ___ hours ___ days |
Did you/Are you... (check all that apply; provide details [names, dates, phone numbers, etc.] at right.)
| Y ? N |Miscellany |
|W ρ ρ ρ |miss work or school? if yes, how many days? _____ |
|P ρ ρ ρ |see any clinician? if yes, whom? _________________ Phone _________________ |
|E ρ ρ ρ |visit an ER? if yes, specify _________________ |
|S ρ ρ ρ |give a stool specimen? if yes, when ___/___/_____ to whom ____________________________ |
|C ρ ρ ρ |If yes, was culture-positive? if yes, specify pathogen ________________________________ |
|F ρ ρ ρ |[if not] willing to provide specimen? |
|H ρ ρ ρ |get admitted to hospital overnight? if yes, how many nights? _____ |
| |Name of hospital: ________________________ Date of Admission ___/___/_____ |
SAMPLE Caller spielS
(YOU DON’T HAVE TO READ THESE WORD-FOR-WORD. THESE ARE SUGGESTIONS FOR THOSE WHO LIKE TO HAVE A WRITTEN TEXT. FEEL FREE TO MODIFY THEM SO THAT IT SOUNDS NATURAL FOR YOU.)
For cohort controls from groups
HELLO, THIS IS ___________ FROM THE _________. YOU MAY HAVE HEARD THAT A NUMBER OF PEOPLE BECAME SICK AFTER THE _____________. WE ARE WORKING WITH THE ______ COUNTY HEALTH DEPARTMENT TO TRY AND FIND OUT WHAT CAUSED THE OUTBREAK. ONE OF THE WAYS WE DO THAT IS BY COMPARING THE KINDS OF FOODS EATEN BY THE PEOPLE WHO GOT SICK WITH THOSE EATEN BY PEOPLE WHO DID NOT GET SICK. COULD I ASK YOU A FEW QUESTIONS ABOUT YOUR EXPERIENCE AT THE ___________?
FOR SHOTGUN QUESTIONNAIRE CONTROLS
Hello, this is ___________ from the _________. We are investigating an outbreak of disease that is affecting people in Oregon and several other states. A number of people have gotten sick and we are trying to find out what the source of the problem is so that we can prevent further illnesses. One of the ways we do that is by comparing the kinds of foods eaten by the people who got sick with those eaten by other people in the community. Right now we need the help of people between the ages of ______ and ______. Is there anyone in the household in that age range who could take a few minutes to answer some questions about food items that they have eaten over the past few days?
Reference CALENDARs
(USE TO HELP SORT OUT ONSET DATES, ETC.; WE SUGGEST PASTING IN ON SYMPTOM PAGE)
|SEPTEMBER 2003 |October 2003 |November 2003 |December 2003 |
|S M Tu W Th F S |S M Tu W Th F S |S M Tu W Th F S |S M Tu W Th F S |
|1 2 3 4 5 6 |1 2 3 4 |1 |1 2 3 4 5 6 |
|7 8 9 10 11 12 13 |5 6 7 8 9 10 11 |2 3 4 5 6 7 8 |7 8 9 10 11 12 13 |
|14 15 16 17 18 19 20 |12 13 14 15 16 17 18 |9 10 11 12 13 14 15 |14 15 16 17 18 19 20 |
|21 22 23 24 25 26 27 |19 20 21 22 23 24 25 |16 17 18 19 20 21 22 |21 22 23 24 25 26 27 |
|28 29 30 |26 27 28 29 30 31 |23 24 25 26 27 28 29 |28 29 30 31 |
| | |30 | |
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