Form CDPH8567 "Foodborne Disease Outbreak Report" - California

What Is Form CDPH8567?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on February 1, 2013;
  • The latest edition provided by the California Department of Public Health;
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Download Form CDPH8567 "Foodborne Disease Outbreak Report" - California

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State of California—Health and Human Services Agency
Local ID Number
Report Status
(Please use the same ID number on preliminary and
final reports to allow linkage to the same outbreak.)
 Preliminary
California Department of Public Health
 Final
Center for Infectious Diseases
Division of Communicable Disease Control
State ID
CDC ID
Infectious Diseases Branch
STATE
Surveillance and Statistics Section
USE
SSS Rec
Entry Date
File Date
MS 7306, P.O. Box 997377
ONLY
Sacramento, CA 95899-7377
FOODBORNE DISEASE OUTBREAK REPORT
INSTRUCTIONS
Please use this form to report:
– Two or more cases of similar illness from separate households resulting from the ingestion of a common food, OR
– Two or more cases of illness resulting from ingestion of food confirmed or suspected to be contaminated with botulism, marine toxins, or other chemicals.
Detailed instructions for completing this form can be found on the California Department of Public Health website at: http://www.cdph.ca.gov/pubsforms/
forms/Documents/CDPH8567-Instructions.pdf.
1. FOODHANDLER
Was a foodhandler implicated as the source of contamination? (required)
If Yes, specify (check only one)
 Yes
 No
 Laboratory evidence
 Laboratory and epidemiologic evidence
 Epidemiologic evidence
 Prior experience makes this the likely source
Please note: The purpose of this report is to capture information about the actual outbreak itself. If a FOODHANDLER was implicated as the source of
contamination, do NOT include the foodhandler’s information in any section of this report that asks about case information; that is, do NOT include the food-
handler in the case count, demographic data, any date fields, etc. Additional information about an implicated foodhandler may be included in the “Remarks”
section at the end of this report. If any foodhandlers are involved in the outbreak as cases (not the source), they SHOULD be included in case information.
2. INVESTIGATION METHODS
Investigation Methods (check all that apply)
 Interviews only of ill persons
 Investigation at original source (e.g., farm, marine estuary, etc.)
 Case-control study (please attach report and / or tables)
 Food product traceback
 Cohort study (please attach report and / or tables)
 Environmental or food sample testing
 Food preparation review
 Other (describe):_____________________________________
 Investigation at factory or production plant
Comments
3. DATES (PRIMARY CASES ONLY)
Date First Case Became Ill
Date Last Case Became Ill
Date of Initial Exposure (mm/dd/yyyy)
Date of Last Exposure (mm/dd/yyyy)
(required, mm/dd/yyyy)
(mm/dd/yyyy)
Date LHD or State First Notified of This Outbreak (mm/dd/yyyy)
Time LHD or State First Notified of This Outbreak (hh:mm)
Specify AM / PM
 AM
 PM
Date Investigation Initiated (mm/dd/yyyy)
Time Investigation Initiated (hh:mm)
Specify AM / PM
 AM
 PM
4. GEOGRAPHIC LOCATION
Reporting State
If Multiple States Involved
 California
 Other: ___________________________
 Exposure occurred in multiple states
 Exposure occurred in a single state, but cases resided in multiple states
If Multiple States Involved, List Additional States
Reporting Local Health Jurisdiction
If Multiple Local Health Jurisdictions Involved
 Exposure occurred in multiple jurisdictions
 Exposure occurred in a single jurisdiction, but cases resided in multiple jurisdictions
If Multiple Local Health Jurisdictions Involved, List Additional Local Health Jurisdictions
Name of Facility Where Exposure Occurred (If publicly available)
City / Town of Exposure
Page 1 of 8
CDPH 8567 (revised 2/13)
State of California—Health and Human Services Agency
Local ID Number
Report Status
(Please use the same ID number on preliminary and
final reports to allow linkage to the same outbreak.)
 Preliminary
California Department of Public Health
 Final
Center for Infectious Diseases
Division of Communicable Disease Control
State ID
CDC ID
Infectious Diseases Branch
STATE
Surveillance and Statistics Section
USE
SSS Rec
Entry Date
File Date
MS 7306, P.O. Box 997377
ONLY
Sacramento, CA 95899-7377
FOODBORNE DISEASE OUTBREAK REPORT
INSTRUCTIONS
Please use this form to report:
– Two or more cases of similar illness from separate households resulting from the ingestion of a common food, OR
– Two or more cases of illness resulting from ingestion of food confirmed or suspected to be contaminated with botulism, marine toxins, or other chemicals.
Detailed instructions for completing this form can be found on the California Department of Public Health website at: http://www.cdph.ca.gov/pubsforms/
forms/Documents/CDPH8567-Instructions.pdf.
1. FOODHANDLER
Was a foodhandler implicated as the source of contamination? (required)
If Yes, specify (check only one)
 Yes
 No
 Laboratory evidence
 Laboratory and epidemiologic evidence
 Epidemiologic evidence
 Prior experience makes this the likely source
Please note: The purpose of this report is to capture information about the actual outbreak itself. If a FOODHANDLER was implicated as the source of
contamination, do NOT include the foodhandler’s information in any section of this report that asks about case information; that is, do NOT include the food-
handler in the case count, demographic data, any date fields, etc. Additional information about an implicated foodhandler may be included in the “Remarks”
section at the end of this report. If any foodhandlers are involved in the outbreak as cases (not the source), they SHOULD be included in case information.
2. INVESTIGATION METHODS
Investigation Methods (check all that apply)
 Interviews only of ill persons
 Investigation at original source (e.g., farm, marine estuary, etc.)
 Case-control study (please attach report and / or tables)
 Food product traceback
 Cohort study (please attach report and / or tables)
 Environmental or food sample testing
 Food preparation review
 Other (describe):_____________________________________
 Investigation at factory or production plant
Comments
3. DATES (PRIMARY CASES ONLY)
Date First Case Became Ill
Date Last Case Became Ill
Date of Initial Exposure (mm/dd/yyyy)
Date of Last Exposure (mm/dd/yyyy)
(required, mm/dd/yyyy)
(mm/dd/yyyy)
Date LHD or State First Notified of This Outbreak (mm/dd/yyyy)
Time LHD or State First Notified of This Outbreak (hh:mm)
Specify AM / PM
 AM
 PM
Date Investigation Initiated (mm/dd/yyyy)
Time Investigation Initiated (hh:mm)
Specify AM / PM
 AM
 PM
4. GEOGRAPHIC LOCATION
Reporting State
If Multiple States Involved
 California
 Other: ___________________________
 Exposure occurred in multiple states
 Exposure occurred in a single state, but cases resided in multiple states
If Multiple States Involved, List Additional States
Reporting Local Health Jurisdiction
If Multiple Local Health Jurisdictions Involved
 Exposure occurred in multiple jurisdictions
 Exposure occurred in a single jurisdiction, but cases resided in multiple jurisdictions
If Multiple Local Health Jurisdictions Involved, List Additional Local Health Jurisdictions
Name of Facility Where Exposure Occurred (If publicly available)
City / Town of Exposure
Page 1 of 8
CDPH 8567 (revised 2/13)
California Department of Public Health
FOODBORNE DISEASE OUTBREAK REPORT
Local ID Number: ___________________________
5. PRIMARY CASES (DO NOT INCLUDE IMPLICATED FOODHANDLERS IN CASE COUNTS)
Case Definition (e.g., person, place, time)
Characteristic
Specify as Noted
Characteristic
Specify as Noted
# Lab-confirmed Cases
% Male
Number of
# Probable Cases
Sex
% Female
Primary Cases
(round %s to total 100)
# Estimated Total Primary Ill (required)
% Unknown
Total # Cases for Whom
% < 1 Year
Characteristic
# Cases
Information is Available
% 1 - 4 Years
Death (required)
Hospitalized
% 5 - 9 Years
Overnight (required)
Age Group
Visited Emergency
% 10 - 19 Years
(round %s to total 100)
Room (required)
% 20 - 49 Years
Visited Health Care
Provider (including
% 50 - 74 Years
Urgent Care visits
but excluding ER
% ≥ 75 Years
% Unknown
visits, required)
6. INCUBATION PERIOD (PRIMARY CASES ONLY)
Is incubation period known?
Total # Cases for Whom Information is Available
Incubation Period
Specify Units
 Yes
 No
Shortest
 Min
 Hours
 Days
Median
 Min
 Hours
 Days
Longest
 Min
 Hours
 Days
7. DURATION OF ILLNESS (AMONG RECOVERED PRIMARY CASES ONLY)
Is duration of illness known?
Total # Cases for Whom Information is Available
Duration of Illness
Specify Units
 Yes
 No
Shortest
 Min
 Hours
 Days
Median
 Min
 Hours
 Days
Longest
 Min
 Hours
 Days
8. SIGNS OR SYMPTOMS (PRIMARY CASES ONLY)
# Cases with
Total # Cases for Whom
# Cases with
Total # Cases for Whom
Sign / Symptom
Sign / Symptom
Sign / Symptom
Information is Available
Sign / Symptom
Information is Available
Hemolytic uremic
Vomiting
syndrome (for STEC only)
Diarrhea
Asymptomatic
Bloody stools
Other*: _______________
Fever
Other*: _______________
Abdominal cramps
Other*: _______________
* Please list any additional symptoms that affected a significant proportion of cases. See list on page 8.
9. SECONDARY CASES
# Lab-confirmed Secondary Cases
# Probable Secondary Cases
# Estimated Total Secondary Cases
# Total Cases (primary + secondary)
Page 2 of 8
CDPH 8567 (revised 2/13)
California Department of Public Health
FOODBORNE DISEASE OUTBREAK REPORT
Local ID Number: ___________________________
10. TRACEBACK
Was traceback conducted?
If Yes, was a source identified?
If Yes, specify source(s) to which traceback led below.
 Yes
 In progress
 No
 Unk
 Yes
 No
 Unk
11. TRACEBACK − DETAILS
Source Name 1 (e.g., company or
Source Type (e.g. poultry farm, tomato processing plant)
facility name, if publicly available)
Location of Source - State
Location of Source - Country
 United States
 Mexico
 Other:______________________
Comments
Source Name 2 (e.g., company or
Source Type (e.g. poultry farm, tomato processing plant)
facility name, if publicly available)
Location of Source - State
Location of Source - Country
 United States
 Mexico
 Other:______________________
Comments
12. RECALL AND CONTROL MEASURES
Was any food product recalled?
If Yes, type of item recalled
 Yes
 No
 Unk
Recall Comments
Other Control Measures
 Food facility inspection
 Food preparation education
 Other (describe):________________________________________________________
13. ETIOLOGY (PRIMARY CASES ONLY)
Is etiology known
Skip to Etiology - Details sections 14.1 and 14.2. Specify details of all confirmed and suspected etiologies. Name the
or suspected?
If Yes:
bacterium, chemical / toxin, virus, or parasite. If available, include the species, serotype, and other characteristics such as
phage type, virulence factors, and metabolic profile.
 Yes
 No
Were patient specimens collected?
How many patients had specimens
What were they tested for? (check all that apply)
collected and tested?
If No:
 Yes
 No
 Unk
 Bacteria
 Chemicals / toxins
 Viruses
 Parasites
14.1 ETIOLOGY #1 − DETAILS (PRIMARY CASES ONLY)
Etiology 1
If E. coli / STEC, specify serotype
 Bacillus cereus toxin
 O157:H7
 O103
 O111:NM
 O121
 O26:H11
 O45:H2
 Ound
 Other:____________
 Campylobacter*
 O157:NM
 O103:H2
 O118
 O26
 O45
 O69:H11
 Unk
 Clostridium botulinum toxin
If Salmonella, specify serotype
 Clostridium perfringens toxin
 E. coli / STEC
 Agona
 Heidelberg
 Kottbus
 Newport
 Typhi
 Unk
 Norovirus
 Braenderup
 I 4,[5],12:i:-
 Mbandaka
 Oranienburg
 Typhimurium
 Salmonella
 Enteritidis
 Infantis
 Montevideo
 Saintpaul
 Typhimurium var Copenhagen
 Scombroid toxin
 Hadar
 Javiana
 Muenchen
 Thompson
 Other:___________________
 Shigella*
Other Characteristics (List distinguishing characteristics not already indicated on this form, e.g., species, genotype, etc.)
 Staphylococcus aureus toxin
 Suspected bacterial toxin,
type undetermined
 Vibrio*
Confirmed outbreak etiology**?
What was it detected in? (check all that apply)
# Lab-confirmed
 Other:_________________
Primary Cases
 Yes
 No
 Patient specimen
 Environmental specimen
 Unk
 Food specimen
 Clinical evidence only
*Please indicate species in
 Foodhandler specimen
“Other Characteristics”.
**For most etiologic agents, CDC considers an outbreak to have a confirmed etiology if there are two or more lab-confirmed cases. However, because
botulism, marine toxin, and other chemical outbreaks have such distinct clinical symptoms, a physician’s diagnosis is often sufficient and laboratory
confirmation is not necessary to classify an outbreak as having a confirmed etiology. Therefore, for such outbreaks, CDC would consider the etiology
confirmed if there are at least 2 cases (lab confirmed and / or probable) with signs and symptoms meeting the confirmation criteria. Please refer to CDC's
Guide to Confirming a Diagnosis in Foodborne Disease at: http://www.cdc.gov/outbreaknet/references_resources/guide_confirming_diagnosis.html.
Page 3 of 8
CDPH 8567 (revised 2/13)
California Department of Public Health
FOODBORNE DISEASE OUTBREAK REPORT
Local ID Number: ___________________________
14.2 ETIOLOGY #2 − DETAILS (PRIMARY CASES ONLY)
Etiology 2
If E. coli / STEC, specify serotype
 Bacillus cereus toxin
 O157:H7
 O103
 O111:NM
 O121
 O26:H11
 O45:H2
 Ound
 Other:____________
 Campylobacter*
 O157:NM
 O103:H2
 O118
 O26
 O45
 O69:H11
 Unk
 Clostridium botulinum toxin
If Salmonella, specify serotype
 Clostridium perfringens toxin
 E. coli / STEC
 Agona
 Heidelberg
 Kottbus
 Newport
 Typhi
 Unk
 Norovirus
 Braenderup
 I 4,[5],12:i:-
 Mbandaka
 Oranienburg
 Typhimurium
 Salmonella
 Enteritidis
 Infantis
 Montevideo
 Saintpaul
 Typhimurium var Copenhagen
 Scombroid toxin
 Hadar
 Javiana
 Muenchen
 Thompson
 Other:___________________
 Shigella*
Other Characteristics (List distinguishing characteristics not already indicated on this form, e.g., species, genotype, etc.)
 Staphylococcus aureus toxin
 Suspected bacterial toxin,
type undetermined
 Vibrio*
Confirmed outbreak etiology**?
What was it detected in? (check all that apply)
# Lab-confirmed
 Other:_________________
Primary Cases
 Yes
 No
 Patient specimen
 Environmental specimen
 Unk
 Food specimen
 Clinical evidence only
*Please indicate species in
 Foodhandler specimen
“Other Characteristics”.
**For most etiologic agents, CDC considers an outbreak to have a confirmed etiology if there are two or more lab-confirmed cases. However, because
botulism, marine toxin, and other chemical outbreaks have such distinct clinical symptoms, a physician’s diagnosis is often sufficient and laboratory
confirmation is not necessary to classify an outbreak as having a confirmed etiology. Therefore, for such outbreaks, CDC would consider the etiology
confirmed if there are at least 2 cases (lab confirmed and / or probable) with signs and symptoms meeting the confirmation criteria. Please refer to CDC's
Guide to Confirming a Diagnosis in Foodborne Disease at: http://www.cdc.gov/outbreaknet/references_resources/guide_confirming_diagnosis.html.
15. ISOLATES
For bacterial pathogens, provide representative laboratory data for each distinct PFGE pattern, if available. For viral pathogens (norovirus and sapovirus),
provide CaliciNet outbreak code, key, and genotype for each distinct strain identified in the outbreak, if available. If you do not have any isolates, enter “N/A”
or “Unavailable” under “State or Local Lab ID” for Isolate 1.
State or Local Lab ID
CDC PulseNet or CaliciNet Outbreak Code
CDC PulseNet Pattern Designation for Enzyme 1
CDC PulseNet Pattern Designation for Enzyme 2
Isolate 1
CaliciNet Key / Other Molecular Designation 1
CaliciNet Genotype / Other Molecular Designation 2
State or Local Lab ID
CDC PulseNet or CaliciNet Outbreak Code
CDC PulseNet Pattern Designation for Enzyme 1
CDC PulseNet Pattern Designation for Enzyme 2
Isolate 2
CaliciNet Key / Other Molecular Designation 1
CaliciNet Genotype / Other Molecular Designation 2
State or Local Lab ID
CDC PulseNet or CaliciNet Outbreak Code
CDC PulseNet Pattern Designation for Enzyme 1
CDC PulseNet Pattern Designation for Enzyme 2
Isolate 3
CaliciNet Key / Other Molecular Designation 1
CaliciNet Genotype / Other Molecular Designation 2
16. IMPLICATED FOODS
Was a food vehicle identified or suspected?
If No or Unk, skip to Section 18.
 Yes
 No
 Unk
17.1 IMPLICATED FOOD #1 − DETAILS
Name of Food (e.g., beef lasagna)
Ingredient(s) (e.g., ground beef, tomatoes, pasta, cheese, salt)
Contaminated Ingredient(s) (e.g., ground beef)
Total # Primary Cases Exposed to Implicated Food
 Unknown
(continued on page 5)
Page 4 of 8
CDPH 8567 (revised 2/13)
California Department of Public Health
FOODBORNE DISEASE OUTBREAK REPORT
Local ID Number: ___________________________
17.1 IMPLICATED FOOD #1 − DETAILS (continued)
Reason(s) Suspected (check all that apply)
 1 - Statistical evidence from epidemiological investigation
 4 - Other data (e.g., same phage type found on farm that supplied eggs)
 2 - Laboratory evidence (e.g., identification of agent in food)
 5 - Specific evidence lacking but previous experience makes it likely source
 3 - Compelling supportive information
Method of Processing (prior to point-of service: processor; check all that apply)
 1 - Pasteurized (e.g., liquid milk, cheese, juice, etc.)
 7 - Frozen
 2 - Unpasteurized (e.g., liquid milk, cheese, juice, etc.)
 8 - Canned
 3 - Shredded or diced
 9 - Acid treatment (e.g., commercial potato salad with vinegar, etc.)
 4 - Pre-packaged (e.g., bagged lettuce or other produce)
 10 - Pressure treated (e.g., oysters, etc.)
 5 - Irradiation
 11 - Other or unknown
 6 - Pre-washed
Method of Preparation (at point-of-service; retail: restaurant, grocery store; select only one)
 1 - Prepared in the home
 2 - Ready to eat food: no manual preparation, no cook step (e.g., sliced cheese, pre-packaged deli meats; whole raw fruits; pre-shucked raw oysters, etc.)
 3 - Ready to eat food: manual preparation, no cook step (e.g., cut fresh fruits and vegetables, chicken salad made from canned chicken, etc.)
 4 - Cook and serve foods: immediate service (e.g., soft-cooked eggs, hamburgers, etc.)
 5 - Cook and hot hold prior to service (e.g., soups, hot vegetables, mashed potatoes, etc.)
 6 - Advance preparation: cook, cool, serve (e.g., sliced roast beef from a whole cooked roast, etc.)
 7 - Advance preparation: cook, cool, reheat, serve (e.g., casseroles, soups, sauces, chili, etc.)
 8 - Advance preparation: cook, cool, reheat, hot hold, serve (e.g., chili, refried beans, etc.)
 9 - Advance preparation: cook-chill and reduced oxygen packaging (ROP) (e.g., sauces, gravies, cheeses, etc. packaged under ROP)
 10 - Other or unknown
Level of Preparation (check all that apply)
 1 - Foods eaten raw with minimal or no processing (e.g., washing, cooling)
 2 - Foods eaten raw with some processing (e.g., no cooking, fresh cut and / or packaged raw)
 3 - Foods eaten heat processed (e.g., cooked: a microbiological kill step was involved in processing)
Contaminated food imported to U.S.? (This includes food hand-carried into the U.S.)
 Yes, country known (specify):________________________
 Yes, country unknown
 No
 Unk
17.2 IMPLICATED FOOD #2 − DETAILS
Name of Food (e.g., beef lasagna)
Ingredient(s) (e.g., ground beef, tomatoes, pasta, cheese, salt)
Contaminated Ingredient(s) (e.g., ground beef)
Total # Primary Cases Exposed to Implicated Food
 Unknown
Reason(s) Suspected (check all that apply)
 1 - Statistical evidence from epidemiological investigation
 4 - Other data (e.g., same phage type found on farm that supplied eggs)
 2 - Laboratory evidence (e.g., identification of agent in food)
 5 - Specific evidence lacking but previous experience makes it likely source
 3 - Compelling supportive information
Method of Processing (prior to point-of service: processor; check all that apply)
 1 - Pasteurized (e.g., liquid milk, cheese, juice, etc.)
 7 - Frozen
 2 - Unpasteurized (e.g., liquid milk, cheese, juice, etc.)
 8 - Canned
 3 - Shredded or diced
 9 - Acid treatment (e.g., commercial potato salad with vinegar, etc.)
 4 - Pre-packaged (e.g., bagged lettuce or other produce)
 10 - Pressure treated (e.g., oysters, etc.)
 5 - Irradiation
 11 - Other or unknown
 6 - Pre-washed
Method of Preparation (at point-of-service; retail: restaurant, grocery store; select only one)
 1 - Prepared in the home
 2 - Ready to eat food: no manual preparation, no cook step (e.g., sliced cheese, pre-packaged deli meats; whole raw fruits; pre-shucked raw oysters, etc.)
 3 - Ready to eat food: manual preparation, no cook step (e.g., cut fresh fruits and vegetables, chicken salad made from canned chicken, etc.)
 4 - Cook and serve foods: immediate service (e.g., soft-cooked eggs, hamburgers, etc.)
 5 - Cook and hot hold prior to service (e.g., soups, hot vegetables, mashed potatoes, etc.)
 6 - Advance preparation: cook, cool, serve (e.g., sliced roast beef from a whole cooked roast, etc.)
 7 - Advance preparation: cook, cool, reheat, serve (e.g., casseroles, soups, sauces, chili, etc.)
 8 - Advance preparation: cook, cool, reheat, hot hold, serve (e.g., chili, refried beans, etc.)
 9 - Advance preparation: cook-chill and reduced oxygen packaging (ROP) (e.g., sauces, gravies, cheeses, etc. packaged under ROP)
 10 - Other or unknown
Level of Preparation (check all that apply)
 1 - Foods eaten raw with minimal or no processing (e.g., washing, cooling)
 2 - Foods eaten raw with some processing (e.g., no cooking, fresh cut and / or packaged raw)
 3 - Foods eaten heat processed (e.g., cooked: a microbiological kill step was involved in processing)
Contaminated food imported to U.S.? (This includes food hand-carried into the U.S.)
 Yes, country known (specify):________________________
 Yes, country unknown
 No
 Unk
Page 5 of 8
CDPH 8567 (revised 2/13)