Salmonella Newport Focused Questionnaire

Section 1. Case Information:

Case Interviewed by:

v

Date of interview: d____ / m____ /  y______

Health Unit/Authority:

Date reported to Health Unit/Authority:   d____ / m____ /  y______

Province/Territory:

Respondent was: o Case   o Parent   o Spouse   o Caretaker   o Other, specify: ______________________________

Age: _______  

Sex:  o M    o F                                                                                                             

To be filed out by interviewer

Serotype:

WGS Cluster Code:

Positive specimen type(s):

o Stool   o Blood    o Urine   o Other, specify:  ______________     

                                                                                                                                                     Date of first positive specimen collection:  d_____ / m______ /  y______

Date of first symptom onset: d_______ / m_______ /  y______

Asymptomatic:   o Y   o N   o DK

Date of diarrhea onset: d_______ / m_______ /  y______

Admitted* to hospital because of the illness?  o Y   o N   o DK

*Do not include individuals who visit an emergency room or outpatient clinic

Date of admission: d______ / m______ /  y______

Date of discharge: d______ / m______ /  y______ o Still hospitalized

To be filed out by interviewer

Case deceased?     o Y    o N:       Date of Death: d______ / m______ /  y______

                                      If yes, was Salmonella infection the underlying/contributing cause of death?     o Y   o N   o DK

                                      If yes, was determination based on death certificate?                                         o Y   o N   o DK

Section 3. Travel Information

In the 7 days before onset of illness, that is from d____/m_____/y_____ through d____/m____/y____, did (you/case) travel within or outside of Canada?  

              o Y   o N   o DK

             If yes: o Within Province/Territory   o Other Province(s)/Territory(ies)   o Outside Canada

             Specify travel destination(s) (country/town/resort):

             Departure:   d____ / m____ /  y______                        Return:   d____ / m____ /  y______

Section 4: Food Exposures

INSTRUCTIONS TO READ TO CASE

I am interested in the food you ate during the 7 days before your illness onset date; that is from d____/m_____/y_____ through d____/m____/y____.  For each food item please give me your best guess as to whether you ate the food, you’re not sure but you probably ate the food, or you did not eat the food. Please include food eaten on their own, or as part of a salad, sandwich, or dish.

INSTRUCTIONS FOR INTERVIEWER

For each food item that the case consumed ask follow up questions regarding the brand, location of purchase. Please select an answer for each question or indicate if question not asked

Yes – indicates case ate the food                                               DK – indicates case doesn’t know if they ate the food

Prob. – indicates the case probably ate the food                       No – indicates case did not eat the food

Blueberries

oY

oP

oN

oDK

If Yes or Probably, please complete details in section 5

Almonds

oY

oP

oN

oDK

If Yes or Probably, please complete details in section 5

Walnuts

oY

oP

oN

oDK

If Yes or Probably, please complete details in section 5

Other nuts, including nuts in a nut mix (e.g. peanuts, hazelnuts, pecans, pistachios, pine nuts, macademia nuts or trail mix)

If yes, specify:___________________

oY

oP

oN

oDK

Sesame seeds

oY

oP

oN

oDK

If Yes or Probably, please complete details in section 5

Chia seeds

oY

oP

oN

oDK

If Yes or Probably, please complete details in section 5

Flax seeds

oY

oP

oN

oDK

If Yes or Probably, please complete details in section 5

Other seeds (e.g. hemp)

If yes, specify:___________________

oY

oP

oN

oDK

Section 5: Possible Sources

To interviewer: only complete this section if the case reported eating blueberries, almonds, walnuts, sesame seeds, chia seeds or flax seeds.

IMPORTANT. Please complete in as much detail as possible Type / Variety / Brand and dates.

Berries

Item

Description of brand or packaging

Purchase Information

Samples

Item 1 :

 Blueberries

Brand:

Product:

Description (fresh/frozen):

Packaging: Loose  plastic clamshell  cardboard box Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are receipts or purchase records available?

Y  N  DK

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N

Item 2 :

 Blueberries

Brand:

Product:

Description (fresh/frozen):

Packaging: Loose  plastic clamshell  cardboard box Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are receipts or purchase records available?

Y  N  DK

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N

Nuts

Item

Description of brand or packaging

Purchase Information

Samples

Item 1 :

 Almonds

 Walnuts

Brand:

Product:

Description (raw/roasted/whole/sliced):

Packaging: Loose  plastic clamshell  bag Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are receipts or purchase records available?

Y  N  DK

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N

Item 2 :

 Almonds

 Walnuts

Brand:

Product:

Description (raw/roasted/whole/sliced):

Packaging: Loose  plastic clamshell  bag Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are receipts or purchase records available?

Y  N  DK

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N

Seeds

Item

Description of brand or packaging

Purchase Information

Samples

Item 1 :

 Sesame seeds

 Chia seeds

  Flax seeds

Brand:

Product:

Description (raw/roasted/powder/sprouted):

Packaging: Loose  plastic clamshell  bag Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N

Item 2 :

 Sesame seeds

 Chia seeds

  Flax seeds

Brand:

Product:

Description (raw/roasted/powder/sprouted):

Packaging: Loose  plastic clamshell  bag Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N

Item 3 :

 Sesame seeds

 Chia seeds

  Flax seeds

Brand:

Product:

Description (raw/roasted/powder/sprouted):

Packaging: Loose  plastic clamshell  bag Other:

Description:

Size:

Best before date / Lot code #:

Store:

Address:

Date of purchase:

Are there leftovers available for sampling?

Y  N  DK

Have samples already been collected?

Y  N  DK

If no: May we collect samples?

Y  N