"General Enteric Diseases Interview Form - Yersinia" - Connecticut

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

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

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GENERAL ENTERIC DISEASES INTERVIEW FORM
YERSINIA
January 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?
During the 14 days before illness:
If yes, provide date, donated/received, blood product
Did you receive a blood transfusion or
and location:
donate blood?
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
1
GENERAL ENTERIC DISEASES INTERVIEW FORM
YERSINIA
January 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?
During the 14 days before illness:
If yes, provide date, donated/received, blood product
Did you receive a blood transfusion or
and location:
donate blood?
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
1
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”.
Did you travel to any other states in the 14 days before illness?
Yes
No
Unknown
City/State:
Depart CT:
/
/
Return CT:
/
/
City/State:
Depart CT:
/
/
Return CT:
/
/
Did you travel outside of the United States in the 14 days before illness?
Yes
No
Unknown
Country:
Depart CT:
/
/
Return CT:
/
/
Country:
Depart CT:
/
/
Return CT:
/
/
Did you attend any large parties or gatherings (parties, fairs, festivals) in the 14 days before illness?
Yes
No
Unknown
Event:
City:
Date/Time:
/
/
:
AM PM
Foods eaten:
Did you eat out at any restaurants in the 14 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 14 days before illness (including farmer’s markets, home delivery
service)
Store Name
City
Special Diet
Yes
No
Unk
If yes, specify/describe, brand/type:
Food allergies that prevent you from eating certain foods
Vegetarian or vegan diet
Special or restricted diet (weight-loss, cultural, religious)
If infant, formula or baby food
Did you have any of the following exposures in the 14 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:
Dog
Cat
Other pet mammals (rodent, ferrets, rabbits)
Pet bird (not poultry)
Reptiles/Amphibians (turtles, frogs, lizards)
Other pets (fish, hermit crabs)
Live poultry (chicken, turkey)
Cattle, goats, sheep
Pigs
Contact with a pet that had diarrhea
Visit, work, or live on farm/ranch/petting zoo
Visit or work on slaughterhouse
Ill Contacts
Yes
No
Unk
If yes, who:
Household or close contact with diarrhea
2
The food exposure section below can be omitted if case traveled internationally during the entire 14-day period before onset. If case
was out of the country only for part of the 14-day period before onset, please collect information on foods eaten while in US.
Did you eat the following items in the 14 days before your illness?
(Note for interviewer: If yes, please ask any listed follow-up questions and specify brand/type, where purchased/eaten.)
Meats and Seafood
Yes
No
Unk
If yes, food details:
Chicken or foods containing chicken (deli, ground, jerky)
Was chicken undercooked?
Beef or foods containing beef (deli, ground, jerky)
Was beef ground?
Was ground beef undercooked or raw?
Pork or foods containing pork (deli, ground, jerky)
Was pork undercooked?
Chitlins (pork intestines - also known as chitterlings)
Lamb or mutton
Sausage
Hot dogs
Raw or undercooked liver
Liver pate
Game meat (bison, elk, rabbit/hare, venison)
Fish or fish products
Was fish undercooked or raw (sushi)?
Shellfish (crab, shrimp, oysters, clams)
Was shellfish undercooked or raw?
Anyone in household handle raw meat, including chitlins?
Anyone in household handle raw poultry?
Eggs and Dairy
Yes
No
Unk
If yes, food details:
Eggs
Were eggs undercooked or raw?
Foods made with raw eggs (mayonnaise, cookie dough)
Unpasteurized or raw milk
Other raw/unpasteurized dairy products (yogurt, ice cream)
Soft cheeses
Was soft cheese unpasteurized?
Pasteurized cow’s or goat’s milk
Powdered milk
Any dairy products
Fresh, Raw Produce
Yes
No
Unk
If yes, food details:
Lettuce, specify type:
Was lettuce prepackaged/bagged?
Was lettuce whole head or loose leaf?
Mushrooms
Cabbage
Celery
Carrots
Sprouts, specify type:
Other fresh vegetables
Tofu
That completes the interview. Thank you for taking the time to answer these questions. Your responses may be helpful
in preventing others from becoming sick.
COMMENTS:_________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please enter interview data into CTEDSS or fax to DPH Epidemiology Program at 860-509-7910. Thank you.
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