"General Enteric Diseases Interview Form - Cryptosporidium" - Connecticut

General Enteric Diseases Interview Form - Cryptosporidium is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on January 1, 2019;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "General Enteric Diseases Interview Form - Cryptosporidium" - Connecticut

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GENERAL ENTERIC DISEASES INTERVIEW FORM
CRYPTOSPORIDIUM
Version 01-2019
Reporting Health Department
Completed by:
LHD:
Phone:
Date of first interview attempt:
/
/
Date interview completed:
/
/
Case was interviewed
Case was not interviewed because:
Unreachable
Refused
No working phone
Other________________________
NOTE: Even if case could not be interviewed, please complete above information and enter into CTEDSS or fax this page to the DPH
Epidemiology Program at 860-509-7910.
Case Information
Last name:
First Name:
Street:
City:
Zip:
Phone: (
)
-
DOB:
/
/
Age:
Sex:
M
F
Other____________
Date specimen collected:
/
/
Source:
Stool
Blood
Urine
Other________________
Pathogen:
Laboratory:
Before we ask about your illness, we would like to get some information on your race and ethnicity.
What is your race?
White
Black
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Other____________________
Unknown
Are you of Hispanic background?
Yes
No
Unknown
Illness Information
Yes
No
Unk
If yes, additional details:
Did you have any symptoms associated with
Date/time of onset:
/
/
:
AM
PM
this illness?
Vomiting
Date/time of onset:
/
/
:
AM
PM
Diarrhea
Date/time of onset:
/
/
:
AM
PM
Number of days diarrhea lasted:
Bloody Diarrhea
Fever
Highest temperature:
Are you still experiencing symptoms?
If no, total number of days illness lasted:
Yes
No
Unk
If yes, additional details:
Were you hospitalized?
Hospital name:
(Inpatient only, not just ED visit)
Admit date:
/
/
Discharge date:
/
/
Do you have any underlying medical
Describe:
conditions or are you
immunocompromised?
Outcome:
Survived
Died
Occupation and Risk Factor Information
What is your occupation?
Yes
No
Unk
If yes, specify name and address of the facility
Do you work or volunteer in a facility that
prepares/serves/handles/sells food?
Provide direct patient care outside the home
Work in day care setting
Attend day care setting
Can you tell us about other household members, their ages, occupation, and whether they have been ill with a similar
illness:
Name
Relationship
Age
Occupation
Ill
If yes, onset date and symptoms
Yes
No
Yes
No
Yes
No
Yes
No
NOTE: If case or household contacts are involved in high risk occupations/activities, implement appropriate control
recommendations. Refer to the “Reportable Infectious Diseases Reference Manual”.
1
GENERAL ENTERIC DISEASES INTERVIEW FORM
CRYPTOSPORIDIUM
Version 01-2019
Reporting Health Department
Completed by:
LHD:
Phone:
Date of first interview attempt:
/
/
Date interview completed:
/
/
Case was interviewed
Case was not interviewed because:
Unreachable
Refused
No working phone
Other________________________
NOTE: Even if case could not be interviewed, please complete above information and enter into CTEDSS or fax this page to the DPH
Epidemiology Program at 860-509-7910.
Case Information
Last name:
First Name:
Street:
City:
Zip:
Phone: (
)
-
DOB:
/
/
Age:
Sex:
M
F
Other____________
Date specimen collected:
/
/
Source:
Stool
Blood
Urine
Other________________
Pathogen:
Laboratory:
Before we ask about your illness, we would like to get some information on your race and ethnicity.
What is your race?
White
Black
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Other____________________
Unknown
Are you of Hispanic background?
Yes
No
Unknown
Illness Information
Yes
No
Unk
If yes, additional details:
Did you have any symptoms associated with
Date/time of onset:
/
/
:
AM
PM
this illness?
Vomiting
Date/time of onset:
/
/
:
AM
PM
Diarrhea
Date/time of onset:
/
/
:
AM
PM
Number of days diarrhea lasted:
Bloody Diarrhea
Fever
Highest temperature:
Are you still experiencing symptoms?
If no, total number of days illness lasted:
Yes
No
Unk
If yes, additional details:
Were you hospitalized?
Hospital name:
(Inpatient only, not just ED visit)
Admit date:
/
/
Discharge date:
/
/
Do you have any underlying medical
Describe:
conditions or are you
immunocompromised?
Outcome:
Survived
Died
Occupation and Risk Factor Information
What is your occupation?
Yes
No
Unk
If yes, specify name and address of the facility
Do you work or volunteer in a facility that
prepares/serves/handles/sells food?
Provide direct patient care outside the home
Work in day care setting
Attend day care setting
Can you tell us about other household members, their ages, occupation, and whether they have been ill with a similar
illness:
Name
Relationship
Age
Occupation
Ill
If yes, onset date and symptoms
Yes
No
Yes
No
Yes
No
Yes
No
NOTE: If case or household contacts are involved in high risk occupations/activities, implement appropriate control
recommendations. Refer to the “Reportable Infectious Diseases Reference Manual”.
1
Did you travel to any other states in the 10 days before illness?
Yes
No
Unknown
City/State:
Depart CT:
/
/
City/State:
Depart CT:
/
/
Did you travel outside of the United States in the 10 days before illness?
Yes
No
Unknown
Country:
Depart CT:
/
/
Country:
Depart CT:
/
/
Did you attend any large parties or gatherings (parties, fairs, festivals) in the 10 days before illness?
Yes
No
Unknown
Event:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Did you eat out at any restaurants in the 10 days before illness?
Yes
No
Unknown
Name:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Name:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Name:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Where did you purchase groceries eaten in the 10 days before illness (including farmer’s markets, home delivery
service)
Store Name
City
Did you have any of the following exposures in the 10 days before your illness? (Note for interviewer: If yes, please ask any
listed follow-up questions)
Water-Related Exposure
Yes
No
Unk
If yes, where:
Live in a home with a septic system
Use water from a private well as drinking water
Drink untreated water (natural spring, pond, lake, river)
Swim, wade, or play in untreated water (ocean, lake,
pond, river, stream, or natural spring)
Swim, wade, or play in treated water (pool, hot tub/spa,
fountain, splash pad, or waterpark with treated or
chlorinated water)
Animal Contact
Yes
No
Unk
If yes, where/type of animal:
Visit, work, or live on farm/ranch/petting zoo
Cattle, goats, sheep
Pig
Live poultry (chicken, turkey)
Dog
Is dog a puppy (<1 year)?
Cat
Contact with a pet that had diarrhea
Foods
Yes
No
Unk
If yes, where
Unpasteurized or raw milk
Unpasteurized cider
Ill Contacts
Yes
No
Unk
If yes, who: If yes, where
Household or close contact with diarrhea
COMMENTS:_________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please enter interview data into CTEDSS or fax to DPH Epidemiology Program at 860-509-7910. Thank you.
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