"Cyclosporiasis National Hypothesis Generating Questionnaire"

Cyclosporiasis National Hypothesis Generating Questionnaire is a 10-page legal document that was released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention on September 1, 2020 and used nation-wide.

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v. 3.3 (September 2020)
State/NNDSS ID# (Required)______________
Cyclosporiasis National Hypothesis Generating Questionnaire
Form Approved
OMB No. 0920-1198
Exp. Date 09/30/2023
General information (Questions to be completed by interviewer before the questionnaire is administered.)
1. Classify case based on CDC case definition (Required):  Confirmed  Probable
Laboratory information:
2. Date(s) stool collected for Cyclospora testing: ___________________ __________________
3. Test results:  Positive
 Negative
 Indeterminate
 Pending
4. Specify type of testing laboratories and testing method(s) (Check all that apply including confirmatory testing):
O&P
GI PCR Panel
PCR
Lab-developed
Other
(e.g. microscopy,
(e.g. BioFire
(not part of a
test
stained smears)
FilmArray®)
panel)
Clinical lab
Commercial lab
State lab
CDC lab
5. Specify name of lab-confirmed coinfection:
_________________________________________________________________________
 Not applicable
6. State Lab Accession Number:
___________________________________________________________________________________________
Interviewer information:
7. Name: ____________________________________________________________________________________
8. Agency or organization: ______________________________________________________________________
9. Contact phone number: ______________________________________________________________________
10. Date of interview: _____ / _____ / _____
MM
DD
YY
11. Before this interview, how many times has the case-patient been interviewed about his/her illness?
 None
 Once
 Twice
 Three or more times
 Unknown
12. Respondent for the current interview was:
 Self
 Parent
 Spouse
 Other, specify: _______________________________
Public reporting of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions and
completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA (0920-1198)
1
v. 3.3 (September 2020)
State/NNDSS ID# (Required)______________
Cyclosporiasis National Hypothesis Generating Questionnaire
Form Approved
OMB No. 0920-1198
Exp. Date 09/30/2023
General information (Questions to be completed by interviewer before the questionnaire is administered.)
1. Classify case based on CDC case definition (Required):  Confirmed  Probable
Laboratory information:
2. Date(s) stool collected for Cyclospora testing: ___________________ __________________
3. Test results:  Positive
 Negative
 Indeterminate
 Pending
4. Specify type of testing laboratories and testing method(s) (Check all that apply including confirmatory testing):
O&P
GI PCR Panel
PCR
Lab-developed
Other
(e.g. microscopy,
(e.g. BioFire
(not part of a
test
stained smears)
FilmArray®)
panel)
Clinical lab
Commercial lab
State lab
CDC lab
5. Specify name of lab-confirmed coinfection:
_________________________________________________________________________
 Not applicable
6. State Lab Accession Number:
___________________________________________________________________________________________
Interviewer information:
7. Name: ____________________________________________________________________________________
8. Agency or organization: ______________________________________________________________________
9. Contact phone number: ______________________________________________________________________
10. Date of interview: _____ / _____ / _____
MM
DD
YY
11. Before this interview, how many times has the case-patient been interviewed about his/her illness?
 None
 Once
 Twice
 Three or more times
 Unknown
12. Respondent for the current interview was:
 Self
 Parent
 Spouse
 Other, specify: _______________________________
Public reporting of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions and
completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA (0920-1198)
1
v. 3.2 (April 2020)
State/NNDSS ID#______________
Begin Interview:
Hello, my name is [state interviewer name]. I am from [INTERVIEWER HEALTH DEPARTMENT]. We are
contacting you because of your (your child’s) recent infection with Cyclospora, which is a parasite that
causes intestinal illness. We are trying to determine how people become infected with Cyclospora so we
can prevent others from getting sick.
You may have already been contacted by someone at the health department, but I would like to ask you
questions in a standard way about your (your child’s) illness, and about any travel you may have had or
foods you may have eaten before becoming ill. The interview will take about 21 minutes. Your help in
the investigation is very important. Your participation is voluntary, and you may refuse to answer any
question at any time. All information you give will be kept confidential to the extent permitted by law.
No individual names or other identifying information will be used in any official reports about the
results of the investigation.
Are you willing to participate in this investigation?
If yes: The questions relate to the 14-day period before you (your child) became ill. Therefore, it may
help to have a calendar, recent restaurant and grocery store receipts, or credit card statements nearby.
Do you need a few moments to get this information? [Then proceed to start of interview]
If no: Thank you for your time.
Section 1: Demographic Data
I’d like to begin by asking a few demographic questions.
1. State: _________
County: ___________________________
3. Zip Code: ________________
4. Date of birth: _____ / __________
5. Age: _____________
6. Sex:
 Male
 Female
7. Do you consider yourself of Hispanic or Latino origin?
 Yes
 No
 Unknown
8. How would you describe your race?
 White
 American Indian/Alaskan Native
 Black/African American
 Asian
 Native Hawaiian/Other Pacific Islander
 Unknown
 Other, specify:
2
v. 3.2 (April 2020)
State/NNDSS ID#______________
Section 2: Clinical Information
Now I have some questions about your (your child’s) illness.
9. What date did you (your child) first feel sick? _____ / _____ / _____
 Approximate Date  Unknown
Don’t
Yes
Maybe
No
10. Have you (your child) had any of the following symptoms?
know
a. Diarrhea (loose, watery stools you do not normally have)?
a. Date diarrhea started: _____________________
b. Date diarrhea stopped: ____________________  Ongoing
b. Weight loss?
c. Fever?
d. Fatigue?
e. Anorexia?
f. Nausea?
g. Vomiting?
h. Abdominal cramps?
11. Have your (your child’s) symptoms stopped?
a. If yes, date symptoms stopped: ______________________
 Unknown
12. Were you (your child) hospitalized overnight?
a. How many nights were you (your child) hospitalized? ______
b. Admission date: __________________
c. Hospital name (Optional): ____________________
Section 3: Travel, events, and ill contacts
Now I have some questions about any travel you (your child) might have had or events you (your child) might
have attended during the 14 days before onset of illness. The travel or events could have been part of your
work or for pleasure. I also have some questions about other persons you know who have been sick with a
similar illness.
13. *(Optional – for local analysis) List counties in your home state (outside your county of residence) where
you (your child) might have purchased or eaten fresh foods during the 14 days before onset of illness.
 Did not travel to other counties within home state
 Unknown
Counties within home state
Date departed
Date returned
Foods eaten
14. List all states and U.S. cities outside of your home state where you (your child) might have purchased or
eaten fresh foods during the 14 days before onset of illness. This includes airports and bus or train stations.
 Did not travel to other U.S. states
 Unknown
U.S. States
U.S. Cities
Date
Date
Foods eaten
departed
returned
3
v. 3.2 (April 2020)
State/NNDSS ID#______________
15. List all countries outside the U.S. where you (your child) might have purchased or eaten fresh foods during
the 14 days before onset of illness.
 Did not travel outside the U.S.
 Unknown
Countries outside the U.S.
Date departed
Date returned
Foods eaten
16. During the 14 days before onset of illness, did you (your child) attend any events where fresh food was
served (e.g. parties, fairs, concerts, tournaments, conventions)?
 Yes
 Maybe
 No
 Unknown
16a. Please list the name of the event(s), date(s), and location(s).
___________________________________________________________________________________________
17. Do you know of any other person(s) (e.g. a family member, friend, travel companion, co-worker, neighbor,
church/temple/mosque member, health club, or other club member) who has been sick recently with a similar
illness?
 Yes
 Maybe
 No
 Unknown
17a. If yes/maybe, please specify if you (your child) and the other ill person(s):
 Live in the same household
 Attended same event
 Traveled together
 Other, specify: ______________________________________________________________________
17b. If yes/maybe, please provide information about the other ill person(s), including number of ill persons and
relationship to you (e.g. son, mother, neighbor, friend, etc.). *Please include the STATE ID of the ill contact(s), if
available/applicable. Do not enter names or other personally identifiable information.
___________________________________________________________________________________________
*Note to Interviewer: To help determine if the interviewee meets the case definition, did the interviewee
report international travel outside the U.S. or Canada during the 14 days before onset of illness?
If yes, thank the interviewee for his/her time and end the interview.
If no, continue with interview on next page.
4
v. 3.2 (April 2020)
State/NNDSS ID#______________
Section 4: Sources of produce at home
Now I have some questions about where the fresh produce came from that you ate at home during the 14
days before your illness began. This isn't necessarily where you shopped during that 14-day period, but where
what you actually ate then came from. I'm going to list several types of stores; for each type, please tell me
the names of each store from which you would have eaten food from during the 14 days before you became
sick. Please refer to your grocery store receipts or credit card statements to provide a more detailed
description.
18. Did you (your child) eat foods from: grocery stores or supermarkets, warehouse stores, small markets (such
as gas stations), ethnic specialty markets, health food stores, co-ops, fish or meat specialty shops, farmer's
markets or food directly from a farm, home delivery grocery services (e.g. CSA, Amazon Fresh), meal delivery
services (e.g. Blue Apron, Meals on Wheels), or any other sources?
Store
Address
City
State
Zip
Date
Foods purchased
*Shopper
name
Code
shopped
card #
*By giving your shopper card number, you are permitting retrieval of information regarding your purchases. This
information may be shared with other public health officials to help with outbreak investigations.
 Refused to give shopper card #
Section 5: Sources of produce outside the home
Now I have some questions about where you ate produce outside your home, such as at restaurants or fast
food chains during the 14 days before your illness began. I'm going to list several types of restaurants and
commercial food establishments; for each type, please tell me the names of each place. Please refer to your
restaurant receipts or credit card statements to provide a more detailed description.
19. Did you (your child) eat foods from: national fast food chains, Mexican-style, Italian, seafood,
Jamaican/Cuban/Caribbean, Chinese/Indian/Japanese/Asian, Middle Eastern/Arabic/Lebanese/African
vegetarian or vegan, barbecue or home-style, steakhouse or grill, all-you-can-eat buffet, sandwich shop or deli,
diner, salad bar, take-out, breakfast or brunch, school or institution, food truck, or other restaurants or
commercial food establishments?
Restaurant
Address
City
State
Zip
Meal
Foods eaten
name
Code
date
Additional comments: _________________________________________________________________________
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