Escherichia coli O157:H7 Investigation July 2014 – Supplemental Questionnaire

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Section 1: Case information

National ID: Date of interview (dd/mm/yy):
Case Interviewed by: Date reported to Health Unit/Authority(dd/mm/yy):
Health Unit/Authority: Province/Territory:
Age: Sex:  o M   o F
Respondent was: o Case  o Parent  o Spouse  o Caretaker  o Other, specify:

 

Section 2: Clinical information

Serotype: Phage Type:
PFGE 1: PFGE 2:

Positive specimen type(s):

o Stool  o Blood   o Urine  o Other, specify:

Date of first symptom onset (dd/mm/yy):

Asymptomatic? o Y  o N  o DK

Date of first positive specimen collection (dd/mm/yy): Date of diarrhea onset (dd/mm/yy):

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 (dd/mm/yy):                    o Still hospitalized

Date of discharge (dd/mm/yy):

Case deceased?         o Y  o N        Date of Death (dd/mm/yy):

If yes, was E.coli 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: Risk factors in the 7 days prior to illness onset

*P (Probably Ate) = Case thinks he/she ate this food or case usually eats this food, but is unsure if eaten during time period in question  DK (Don’t Know)

Activity Exposed? Date(s) Specify(Name/Location)
Was anyone in your household sick? oY  oP  oN  oDK    
Travel oY  oP  oN  oDK    
Recreational water (e.g. swimming in a lake/river, visiting a beach) oY  oP  oN  oDK    
Animal contact (e.g. pets, farm animals, wildlife) oY  oP  oN  oDK    
Contact with daycare oY  oP  oN  oDK    
Contact with long-term care facility oY  oP  oN  oDK    

 

Section 4: Food Exposures

Did (you/case) eat any of the following foods in the 7 days prior to illness onset?

*P (Probably Ate) = Case thinks he/she ate this food or case usually eats this food, but is unsure if eaten during time period in question  DK (Don’t Know)

Food Item Exposed? Details (type, brand, purchase location)
Any hamburgers (including frozen, fresh, homemade, restaurant) oY  oP  oN  oDK If Yes or Probably, please complete details in section 5
Any ground beef other ground beef oY  oP  oN  oDK If Yes or Probably, please complete details in section 5

Other meat:

Specify:

oY  oP  oN  oDK  
Cheese oY  oP  oN  oDK  
Unpasteurized dairy (cheese, milk, yogurt) oY  oP  oN  oDK  
Lettuce and/or spinach oY  oP  oN  oDK If Yes or Probably, please complete details in section 5
Red bell peppers oY  oP  oN  oDK  
Cherry tomatoes oY  oP  oN  oDK  
Mushrooms oY  oP  oN  oDK  
Bacon oY  oP  oN  oDK  
Sprouts (alfalfa, bean, etc.) oY  oP  oN  oDK  
Strawberries oY  oP  oN  oDK  
Unpasteurized cider oY  oP  oN  oDK  

 

Section 5: Possible Sources

To interviewer: only complete this section if the case reported eating beef and/or lettuce in section 3.

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

 

Lettuce

Item Description of brand and packaging Purchase information Samples

Item 1 :

o Romaine Lettuce

o Other Lettuce

Specify:

Brand:

Product:

o Prepackaged o Loose

o Whole head o Whole leaf o Shredded/cut

Size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling? oY  oN  oDK

 

Have samples already been collected? oY  oN  oDK

 

If no: May we collect samples?

oY  oN

If yes, complete section 6

Item 2 :

o Romaine Lettuce

oOther Lettuce

Specify:

Brand:

Product:

o Prepackaged o Loose

o Whole head o Whole leaf o Shredded/cut

Size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling? oY  oN  oDK

 

Have samples already been collected? oY  oN  oDK

 

If no: May we collect samples?

oY  oN

If yes, complete section 6

Item 3 :

o Romaine Lettuce

oOther Lettuce

Specify:

Brand:

Product:

o Prepackaged o Loose

o Whole head o Whole leaf o Shredded/cut

Size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling? oY  oN  oDK

 

Have samples already been collected? oY  oN  oDK

 

If no: May we collect samples?

oY  oN

If yes, complete section 6

 

Frozen ground beef products

Item Description of product and packaging Purchase information Samples

Item 1:

 

o Frozen pre-packaged hamburgers

 

o Any other frozen pre-packaged ground beef product

 

Specify:

Brand:

Product:

Package size:

Patty size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling? oY  oN  oDK

 

Have samples already been collected? oY  oN  oDK

 

If no: May we collect samples?

oY  oN

If yes, complete section 6

Item 2:

 

o Frozen pre-packaged hamburgers

 

o Any other frozen pre-packaged ground beef product

 

Specify:

Brand:

Product:

Package size:

Patty size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling? oY  oN  oDK

 

Have samples already been collected? oY  oN  oDK

 

If no: May we collect samples?

oY  oN

If yes, complete section 6

Item 3:

 

o Frozen pre-packaged hamburgers

 

o Any other frozen pre-packaged ground beef product

 

Specify:

Brand:

Product:

Package size:

Patty size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling? oY  oN  oDK

 

Have samples already been collected? oY  oN  oDK

 

If no: May we collect samples?

oY  oN

If yes, complete section 6

 

Fresh ground beef products

Item Description of product and packaging Purchase information Samples

Item 1:

o Prepackaged fresh (not frozen) hamburgers

o Homemade hamburgers or meatballs made from fresh ground beef

o Any ther fresh (not frozen) ground beef product

Specify:

Brand:

Product:

Package size:

Patty size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling?

oY  oN

Have samples already been collected?

oY  oN

If no: May we collect samples?

oY  oN

If yes, complete section 6

Item 1:

o Prepackaged fresh (not frozen) hamburgers

o Homemade hamburgers or meatballs made from fresh ground beef

o Any ther fresh (not frozen) ground beef product

Specify:

Brand:

Product:

Package size:

Patty size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling?

oY  oN

Have samples already been collected?

oY  oN

If no: May we collect samples?

oY  oN

If yes, complete section 6

Item 1:

o Prepackaged fresh (not frozen) hamburgers

o Homemade hamburgers or meatballs made from fresh ground beef

o Any ther fresh (not frozen) ground beef product

Specify:

Brand:

Product:

Package size:

Patty size:

Best before date:

Lot code #:

Store

Address

Date of purchase

Are there leftovers available for sampling?

oY  oN

Have samples already been collected?

oY  oN

If no: May we collect samples?

oY  oN

If yes, complete section 6

 

Ground beef from a restaurant or fast food location

Item Description of product (e.g. name, other ingredients) Restaurant Information Did any of your dining companions have similar symptoms after your meal?

Item 1:

o Hamburger made from ground beef

o Other fresh ground beef product

Specify:

 

Store

Address

Date of visit

oY  oN  oDK

If yes:

Did they also eat ground beef products?

oY  oN  oDK

If yes, specify:

Item 2:

o Hamburger made from ground beef

o Other fresh ground beef product

Specify:

 

Store

Address

Date of visit

oY  oN  oDK

If yes:

Did they also eat ground beef products?

oY  oN  oDK

If yes, specify:

Item 3:

o Hamburger made from ground beef

o Other fresh ground beef product

Specify:

 

Store

Address

Date of visit

oY  oN  oDK

If yes:

Did they also eat ground beef products?

oY  oN  oDK

If yes, specify:

 

Section 6:

Product Name/ Description Lot code Best before date Opened or closed
      o Opened  o Closed
      o Opened  o Closed
      o Opened  o Closed
      o Opened  o Closed
      o Opened  o Closed

 

Comments/Notes:

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