{"id":2626,"date":"2017-03-07T14:54:07","date_gmt":"2017-03-07T18:54:07","guid":{"rendered":"http:\/\/phac.hyperinteractive.ca\/?page_id=2626"},"modified":"2025-03-27T16:06:25","modified_gmt":"2025-03-27T20:06:25","slug":"hepatitis-a-hypothesis-generating-questionnaire","status":"publish","type":"page","link":"https:\/\/outbreaktools.ca\/fr\/tools\/toolkit-questionnaire-repository\/hepatitis-a-hypothesis-generating-questionnaire\/","title":{"rendered":"H\u00e9patite A \u2013 Questionnaire exploratoire"},"content":{"rendered":"

T\u00e9l\u00e9charger le format de rechange<\/a><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
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Contexte du questionnaire pour l\u2019intervieweur<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Ce questionnaire vise \u00e0 recueillir des renseignements exhaustifs sur les facteurs de risque possibles de l\u2019h\u00e9patite\u00a0A dans le contexte d\u2019une enqu\u00eate sur un agr\u00e9gat ou une \u00e9closion de cas dont la source d\u2019infection est inconnue, mais il pourrait \u00e9galement \u00eatre utilis\u00e9 pour enqu\u00eater sur des cas sporadiques.<\/p>\n

Donn\u00e9es saisies\u00a0: – caract\u00e9ristiques d\u00e9mographiques du cas\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 – autres facteurs de risque<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0– donn\u00e9es cliniques\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0– expositions aux aliments<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0– donn\u00e9es de laboratoire\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

Comme les \u00e9closions d\u2019h\u00e9patite\u00a0A sont souvent li\u00e9es \u00e0 des produits alimentaires contamin\u00e9s, veuillez recueillir autant de d\u00e9tails que possible sur chaque aliment, y compris les expositions aux restaurants. Envisagez d\u2019utiliser un calendrier lorsque vous posez les questions. Le questionnaire devrait prendre environ 1\u00a0heure \u00e0 remplir.<\/p>\n<\/td>\n<\/tr>\n

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R\u00c9SERV\u00c9 \u00c0 L\u2019USAGE LOCAL \u2013 VEUILLEZ SUPPRIMER CETTE PAGE EN CAS D\u2019ENVOI DU FORMULAIRE \u00c0 L\u2019ASPC<\/strong><\/p>\n<\/td>\n<\/tr>\n

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i.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong>Renseignements sur le cas<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Nom du cas\u00a0:<\/p>\n<\/td>\n

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Nom du mandataire\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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Num\u00e9ro d\u2019assurance maladie\u00a0: ____________________________<\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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Adresse\u00a0:\u00a0 ______________________________<\/p>\n

Ville\/village\u00a0:\u00a0\u00a0 ______________________________<\/p>\n

Code postal\u00a0:\u00a0\u00a0 ______________________________<\/p>\n<\/td>\n

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T\u00e9l\u00e9phone au domicile\u00a0: ____________________________<\/p>\n

T\u00e9l\u00e9phone au travail\u00a0: ______________________________<\/p>\n

T\u00e9l\u00e9phone cellulaire\u00a0: ______________________________<\/p>\n<\/td>\n<\/tr>\n

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Nom du m\u00e9decin\u00a0:<\/p>\n<\/td>\n

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T\u00e9l\u00e9phone du m\u00e9decin\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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Profession\u00a0:<\/p>\n<\/td>\n

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Lieu(x) de travail\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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ii.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong>Sympt\u00f4mes<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Asymptomatique\u00a0:\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si oui, raison pour laquelle le cas a \u00e9t\u00e9 test\u00e9\u00a0: \u2610 Facteurs de risque, pr\u00e9cisez\u00a0:<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 Aucun facteur de risque\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 Autre<\/p>\n<\/td>\n<\/tr>\n

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Sympt\u00f4mes\u00a0:\u00a0\u00a0\u00a0\u00a0 Jaunisse\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0 Si oui, date d\u2019apparition de la jaunisse\u00a0\u00a0 : j____ \/ m____ \/\u00a0 a______<\/p>\n

\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Douleur abdominale\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Fatigue\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Urine fonc\u00e9e\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Vomissement\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Anorexie\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Fi\u00e8vre\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Selles p\u00e2les\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Enzymes h\u00e9patiques \u00e9lev\u00e9es\u00a0\u00a0 \u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Autre\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u2610\u00a0 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si autre, veuillez pr\u00e9ciser\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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Condition, probl\u00e8mes m\u00e9dicaux sous-jacents ou m\u00e9dicaments qui inhibent le syst\u00e8me immunitaire (p.\u00a0ex. grossesse, diab\u00e8te, cancer, st\u00e9ro\u00efdes)\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

Si oui, veuillez pr\u00e9ciser\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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iii.\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong>Contacts avec des personnes malades<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Avez-vous (ou le cas a-t-il) eu des contacts avec des personnes pr\u00e9sentant des sympt\u00f4mes similaires dans les 7\u00a0jours pr\u00e9c\u00e9dant la maladie?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP Si vous avez r\u00e9pondu oui, pouvez-vous me dire qui?<\/p>\n

* Les contacts incluent les membres d\u2019un m\u00e9nage, les partenaires sexuels, les personnes ayant pr\u00e9par\u00e9 la nourriture pour vous ou le cas, les enfants ou les adultes que vous ou le cas avez aid\u00e9s \u00e0 utiliser les toilettes ou \u00e0 changer les couches, ou toute autre personne avec qui vous ou le cas \u00eates entr\u00e9 en contact par le vomi ou les selles.<\/p>\n<\/td>\n<\/tr>\n

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Nom\u00a0:___________________________________________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Genre\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Num\u00e9ro de t\u00e9l\u00e9phone\u00a0: ___________________________<\/p>\n

Lien avec le cas\u00a0:________________________________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00c2ge\u00a0: ________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

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Nom\u00a0:___________________________________________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Gendre\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Num\u00e9ro de t\u00e9l\u00e9phone\u00a0: __________________________<\/p>\n

Lien avec le cas\u00a0:________________________________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00c2ge\u00a0: ________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

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Nom\u00a0:___________________________________________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Gendre\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Num\u00e9ro de t\u00e9l\u00e9phone\u00a0: __________________________<\/p>\n

Lien avec le cas\u00a0:________________________________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00c2ge\u00a0: ________\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n
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Num\u00e9ro du dossier :\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Num\u00e9ro d\u2019identification national\u00a0:<\/strong><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n\n
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Section\u00a01. Renseignements sur le cas<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Cas interrog\u00e9 par\u00a0:<\/p>\n<\/td>\n

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Date de l\u2019entrevue\u00a0: j_____ \/ m______ \/a_____<\/p>\n<\/td>\n<\/tr>\n

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Bureau ou autorit\u00e9 de sant\u00e9\u00a0:<\/p>\n<\/td>\n

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Date de d\u00e9claration au bureau ou \u00e0 l\u2019autorit\u00e9 de sant\u00e9\u00a0: j____\/m____a______<\/p>\n<\/td>\n<\/tr>\n

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Province ou territoire :<\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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Le r\u00e9pondant est\u00a0: \u2610 Le cas\u00a0 \u2610 Un parent\u00a0\u00a0 \u2610 Le conjoint\u00a0\u00a0 \u2610 Le soignant\u00a0\u00a0 \u2610 Autre, pr\u00e9cisez\u00a0: ______________________________<\/p>\n<\/td>\n<\/tr>\n

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Genre\u00a0:\u00a0\u00a0 \u2610\u00a0 M\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 F\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 Autre\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 Pas demand\u00e9\/Inconnu\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

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\u00c2ge\u00a0: _________\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n\n\n
Section 2. Donn\u00e9es cliniques<\/strong><\/td>\n<\/tr>\n<\/thead>\n
\n

\u00c0 remplir par l’intervieweur<\/strong><\/p>\n<\/td>\n

\n

Date du premier pr\u00e9l\u00e8vement d\u2019\u00e9chantillon positif\u00a0:<\/p>\n

\u00a0j____ \/ m____ \/\u00a0 a______<\/p>\n<\/td>\n

\n

IgM anti-VHA\u00a0:_______________________<\/p>\n

\u2610 Positif\u00a0\u00a0 \u2610 Ind\u00e9termin\u00e9\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9chantillon envoy\u00e9 pour le g\u00e9notypage\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

Si oui, pr\u00e9cisez le g\u00e9notype\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

Asymptomatique\u00a0:\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Si non, date de l\u2019apparition des premiers sympt\u00f4mes\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0j_______ \/ m_______ \/\u00a0 a______<\/p>\n<\/td>\n

\n

Date d\u2019apparition de la jaunisse\u00a0: j_______ \/ m_______ \/\u00a0 a______<\/p>\n<\/td>\n<\/tr>\n

\n

Admis* \u00e0 l\u2019h\u00f4pital en raison de la maladie?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

*Ne comprend pas les personnes qui se rendent \u00e0 l\u2019urgence ou consultent une clinique externe.<\/p>\n<\/td>\n

\n

Date d\u2019admission\u00a0: j_____ \/ m______ \/a_____<\/p>\n

Date du cong\u00e9\u00a0: j_____ \/ m______ \/a_____ \u2610 Toujours hospitalis\u00e9<\/p>\n<\/td>\n<\/tr>\n

\n

Avez-vous d\u00e9j\u00e0 re\u00e7u un diagnostic d\u2019h\u00e9patite\u00a0A par le pass\u00e9?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Si oui, date : j_______ \/ m_______ \/\u00a0 a______<\/p>\n<\/td>\n

\n

Avez-vous d\u00e9j\u00e0 re\u00e7u le vaccin contre l\u2019h\u00e9patite\u00a0A? \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Si oui, date : j_______ \/ m_______ \/\u00a0 a______ nombre de doses :<\/p>\n<\/td>\n<\/tr>\n

\n

Avez-vous re\u00e7u de l\u2019immunoglobuline au cours des 5\u00a0derniers mois? \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si oui, date: j______ \/ m______ \/\u00a0 a_______\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c0 remplir par l\u2019intervieweur<\/strong><\/p>\n<\/td>\n

\n

Cas d\u00e9c\u00e9d\u00e9?\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Date du d\u00e9c\u00e8s\u00a0: j_____ \/ m______ \/a_____<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si oui, l\u2019infection \u00e0 l\u2019h\u00e9patite\u00a0A \u00e9tait-elle une cause sous-jacente ou ayant contribu\u00e9 au d\u00e9c\u00e8s?\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si oui, ce constat est-il fond\u00e9 sur le certificat de d\u00e9c\u00e8s?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n
\n

Section\u00a03\u00a0: P\u00e9riode d\u2019exposition et de contagion<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Inscrivez la date d\u2019apparition des sympt\u00f4mes, en l\u2019utilisant comme le jour\u00a00, puis comptez \u00e0 rebours pour d\u00e9terminer la p\u00e9riode d\u2019exposition. En l\u2019absence d\u2019une date d\u2019apparition des sympt\u00f4mes et pour les cas asymptomatiques, veuillez utiliser, par ordre de pr\u00e9f\u00e9rence, i) la date de collecte de l\u2019\u00e9chantillon, ou ii) la date du rapport de laboratoire, pour calculer les p\u00e9riodes d\u2019exposition et de contagion.<\/p>\n

\"Period<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n
\n

Section\u00a04\u00a0: Renseignements relatifs aux voyages<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Au cours des 50 \u00e0 15\u00a0jours<\/strong> pr\u00e9c\u00e9dant l\u2019apparition de la maladie, soit du j____\/m_____\/a_____ au j____\/m_____\/a_____, avez-vous (ou le cas a-t-il) voyag\u00e9 au Canada ou \u00e0 l\u2019ext\u00e9rieur du Canada?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n

\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si la r\u00e9ponse est oui\u00a0: \u2610 \u00c0 l\u2019int\u00e9rieur de la province ou du territoire\u00a0\u00a0 \u2610 Dans d\u2019autres provinces ou territoires\u00a0\u00a0 \u2610 \u00c0 l\u2019ext\u00e9rieur du Canada<\/p>\n<\/td>\n<\/tr>\n

\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Pr\u00e9cisez les destinations (pays\/ville\/vill\u00e9giature)\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 D\u00e9part\u00a0:\u00a0\u00a0 j____ \/ m____ \/\u00a0 a______ \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Retour\u00a0:\u00a0\u00a0 j____ \/ m____ \/\u00a0 a______<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Section\u00a05. Facteurs de risque<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

J\u2019aimerais vous poser quelques questions sur les facteurs de risque courants de l\u2019h\u00e9patite\u00a0A. Dans les 50 \u00e0 15\u00a0jours pr\u00e9c\u00e9dant l\u2019apparition de la maladie, avez-vous (ou le cas a-t-il)\u00a0:<\/p>\n

**Veuillez saisir tout contact rapproch\u00e9 potentiel \u00e0 la section iii<\/p>\n<\/td>\n<\/tr>\n

\n

Eu des contacts avec un cas connu d\u2019h\u00e9patite\u00a0A\u00a0:\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

Eu des contacts avec une personne atteinte de jaunisse\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n

\n

Consomm\u00e9 un repas ou un aliment ayant \u00e9t\u00e9 manipul\u00e9 par une personne malade? \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n

\n

Habit\u00e9\/s\u00e9journ\u00e9 dans un \u00e9tablissement r\u00e9sidentiel? \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

(p.\u00a0ex. maison de soins, r\u00e9sidence de soins de longue dur\u00e9e, prison, dortoir ou pensionnat)<\/p>\n<\/td>\n

\n

Nom\/lieu\/dates\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9t\u00e9 \u00e0 la garderie ou dans un centre de jour? \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

(p.\u00a0ex. pour enfant ou adulte)\u00a0<\/p>\n<\/td>\n

\n

Nom\/lieu\/dates\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

Travaill\u00e9\/fait du b\u00e9n\u00e9volat dans une garderie ou un \u00e9tablissement r\u00e9sidentiel ou un h\u00f4pital\/centre de sant\u00e9 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

Nom\/lieu\/dates\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

Chang\u00e9 les couches d\u2019un enfant ou aid\u00e9 un enfant ou un adulte \u00e0 aller \u00e0 la toilette? \u2610\u00a0 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

Re\u00e7u une transfusion sanguine ou des produits sanguins au cous de la p\u00e9riode d\u2019incubation? \u2610\u00a0 O\u00a0 \u2610 N\u00a0 \u2610 NSP<\/p>\n

Si oui, date: j______ \/ m______ \/\u00a0 a_______<\/p>\n<\/td>\n

\n

Re\u00e7u une greffe d\u2019organe pendant la p\u00e9riode d\u2019incubation?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610\u00a0 O\u00a0 \u2610 N\u00a0 \u2610 NSP<\/p>\n

Si oui, date: j______ \/ m______ \/\u00a0 a_______<\/p>\n<\/td>\n<\/tr>\n

\n

Donn\u00e9 du sang pendant la p\u00e9riode d\u2019incubation?\u2610 \u00a0O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Si oui, date: j______ \/ m______ \/\u00a0 a_______<\/p>\n<\/td>\n<\/tr>\n

\n

Utilis\u00e9 les sources d\u2019eau potable suivantes? (cochez toutes les r\u00e9ponses applicables)<\/p>\n

\u2610 Municipale\u00a0\u00a0\u00a0 \u2610 Puits\/source d\u2019eau priv\u00e9e\u00a0\u00a0\u00a0 \u2610 Eau embouteill\u00e9e (pr\u00e9cisez)\u00a0: _______________ \u2610 Autre (pr\u00e9cisez)\u00a0: _______________<\/p>\n<\/td>\n<\/tr>\n

\n

Nag\u00e9\/baign\u00e9 dans l\u2019oc\u00e9an, un lac, une rivi\u00e8re, une piscine ou un spa?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0 Si la r\u00e9ponse est oui, veuillez pr\u00e9ciser le type de source d\u2019eau et le lieu\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

Avez-vous (le cas a-t-il) \u00e9t\u00e9 en contact avec l\u2019eau d\u2019un refoulement d\u2019\u00e9gout ou y avez-vous (le cas y a-t-il) \u00e9t\u00e9 expos\u00e9?\u00a0 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0\u00a0<\/p>\n

\u00a0 Si oui, veuillez pr\u00e9ciser\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9tiez-vous sans domicile fixe, c\u2019est-\u00e0-dire viviez-vous dans la rue, dans un refuge, dans une chambre d\u2019h\u00f4tel, dans une voiture ou sur un divan?<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 Pr\u00e9f\u00e8re ne pas r\u00e9pondre\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/strong><\/p>\n\n\n\n\n\n\n\n\n
\n

Section\u00a06. Activit\u00e9 sexuelle et consommation de drogue\u00a0: Passez cette section si le cas a d\u00e9j\u00e0 \u00e9t\u00e9 interrog\u00e9 \u00e0 ce sujet <\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

INSTRUCTIONS POUR L\u2019INTERVIEWEUR\u00a0:<\/u> Veuillez poser ces questions aux cas adultes (>\u00a018\u00a0ans)<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9tiez-vous (le cas \u00e9tait-il) actif sexuellement au cours des 50 \u00e0 15\u00a0jours pr\u00e9c\u00e9dant l\u2019apparition des sympt\u00f4mes?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 Refuse de r\u00e9pondre<\/p>\n<\/td>\n<\/tr>\n

\n

Si oui, avez-vous (le cas a-t-il) eu des contacts sexuels oraux-anaux au cours de cette p\u00e9riode?\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 Refuse de r\u00e9pondre<\/p>\n<\/td>\n<\/tr>\n

\n

Avez-vous (le cas a-t-il) utilis\u00e9 des drogues injectables au cours des 50 \u00e0 15\u00a0jours pr\u00e9c\u00e9dant l\u2019apparition des sympt\u00f4mes?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 Refuse de r\u00e9pondre<\/p>\n<\/td>\n<\/tr>\n

\n

Avez-vous (le cas a-t-il) utilis\u00e9 des drogues non injectables au cours des 50 \u00e0 15\u00a0jours pr\u00e9c\u00e9dant l\u2019apparition des sympt\u00f4mes?\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 Refuse de r\u00e9pondre<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n\n
\n

Section\u00a07. R\u00e9gimes particuliers ou pr\u00e9f\u00e9rences alimentaires<\/strong><\/p>\n<\/td>\n<\/tr>\n

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J\u2019aimerais d\u2019abord vous poser quelques questions g\u00e9n\u00e9rales sur votre r\u00e9gime et vos pr\u00e9f\u00e9rences alimentaires (ou ceux du cas).<\/p>\n<\/td>\n<\/tr>\n

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\u00cates-vous (le cas est-il) v\u00e9g\u00e9tarien?\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Si oui, est-ce que vous-m\u00eame ou le cas mangez parfois les aliments suivants? \u0152ufs\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0Produits laitiers \u2610 O\u00a0 \u2610 N\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Poisson\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Volaille\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0 Viande rouge\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Autre viande\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP Si oui, pr\u00e9cisez\u00a0: ________________<\/p>\n<\/td>\n<\/tr>\n

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Est-ce que vous-m\u00eame ou le cas \u00eates allergique \u00e0 certains aliments?\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0 Si oui, veuillez pr\u00e9ciser les aliments\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

Y a-t-il des aliments ou des groupes alimentaires que vous-m\u00eame ou le cas ne mangez jamais?\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0 Si oui, veuillez pr\u00e9ciser\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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Au cours des 50 \u00e0 15\u00a0jours<\/strong> pr\u00e9c\u00e9dant la maladie, est-ce que vous-m\u00eame ou le cas avez\u00a0:<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Suivi un r\u00e9gime alimentaire particulier ou restreint (p. ex., r\u00e9gime alimentaire crudivore, v\u00e9g\u00e9talien, pour les personnes diab\u00e9tiques, casher, halal)?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0 Si oui, veuillez pr\u00e9ciser\u00a0: _________________________________________________________________________<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Consomm\u00e9 un compl\u00e9ment alimentaire ou un suppl\u00e9ment nutritif (p. ex., substituts de repas, poudre de prot\u00e9ines, vitamines, herbes, kratom)?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0 Si oui, veuillez pr\u00e9ciser (indiquez le lieu d\u2019achat) : _____________________________________________________<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Avez-vous consomm\u00e9 des boissons sant\u00e9 pr\u00e9par\u00e9es et embouteill\u00e9es (p.\u00a0ex.\u00a0Kombucha, eau de noix de coco)?\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0 \u00a0Si oui, veuillez pr\u00e9ciser\u00a0(indiquez le lieu d\u2019achat)\u00a0: _______________________________________________________<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
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Section\u00a08. Aliments consomm\u00e9s \u00e0 l\u2019ext\u00e9rieur de la maison<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Dans les 50 \u00e0 15\u00a0jours<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, avez-vous (ou le cas a-t-il) consomm\u00e9 des aliments \u00e0 l\u2019ext\u00e9rieur du domicile, soit dans un rassemblement social ou \u00e0 l\u2019un des \u00e9tablissements alimentaires suivants (y compris les aliments achet\u00e9s\/command\u00e9s dans un restaurant et consomm\u00e9s \u00e0 la maison et des \u00e9chantillons consomm\u00e9s dans des \u00e9tablissements comme des supermarch\u00e9s)?<\/p>\n<\/td>\n<\/tr>\n

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Type de rassemblement\/nom de l\u2019\u00e9tablissement\u00a0<\/strong><\/p>\n<\/td>\n

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D\u00e9tails sur les aliments consomm\u00e9s<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Rassemblement ou \u00e9v\u00e9nement social (p.\u00a0ex. au domicile d\u2019un ami ou d\u2019un membre de la famille, collations au travail, congr\u00e8s, mariage ou soir\u00e9e)<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Si oui, connaissez-vous d\u2019autres personnes qui ont pr\u00e9sent\u00e9 des diarrh\u00e9es apr\u00e8s<\/u> ce rassemblement?<\/em><\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

\u00a0Si oui, combien? ______<\/p>\n<\/td>\n

\n

Nom de l\u2019\u00e9v\u00e9nement\/description\u00a0:<\/p>\n

 <\/p>\n

Lieu\u00a0:<\/p>\n

 <\/p>\n

Date du rassemblement\u00a0: j_____ \/ m_____ \/ a_____<\/p>\n

 <\/p>\n

Nombre de personnes pr\u00e9sentes\u00a0:<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Avez-vous mang\u00e9 dans un restaurant rapide ou \u00e0 un autre restaurant? Il pourrait s\u2019agir de nourriture ou de boissons provenant d\u2019un caf\u00e9, d\u2019une caf\u00e9t\u00e9ria, d\u2019un marchand ambulant, d\u2019un kiosque ou d\u2019un d\u00e9panneur. \u00c9num\u00e9rez \u00e9galement tout \u00e9chantillon d\u2019un supermarch\u00e9.<\/p>\n<\/td>\n<\/tr>\n

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Nom de l\u2019\u00e9tablissement alimentaire<\/strong><\/p>\n<\/td>\n

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Adresse\/emplacement<\/strong><\/p>\n<\/td>\n

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Dates(s)<\/strong><\/p>\n<\/td>\n

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Aliments command\u00e9s\/consomm\u00e9s<\/strong><\/p>\n<\/td>\n<\/tr>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

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\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

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\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

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\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

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D\u00e9tails suppl\u00e9mentaires sur les \u00e9tablissements alimentaires mentionn\u00e9s ci-dessus\u00a0:<\/p>\n<\/td>\n<\/tr>\n

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\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n
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Section\u00a09. Achat d\u2019aliments pour consommation \u00e0 domicile <\/strong><\/p>\n<\/td>\n<\/tr>\n

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O\u00f9 est-ce que vous-m\u00eame ou le cas achetez habituellement les aliments pour la consommation \u00e0 domicile? Il peut s\u2019agir d\u2019\u00e9piceries, de march\u00e9s fermiers, d\u2019\u00e9piceries sp\u00e9cialis\u00e9es, de banques alimentaires ou d\u2019achats en ligne comme Amazon, Well.ca ou d\u2019autres commerces en ligne.<\/p>\n

Il peut \u00eatre utile de recueillir les re\u00e7us, les donn\u00e9es d\u2019achat ou les cartes de fid\u00e9lit\u00e9, lorsque disponibles, \u00e9tant donn\u00e9 la longue p\u00e9riode d\u2019incubation. Le formulaire de consentement pour la collecte de renseignements sur la carte de fid\u00e9lit\u00e9 est disponible aupr\u00e8s de l\u2019autorit\u00e9 de sant\u00e9 de votre province ou territoire, ou de l\u2019ASPC.\u00a0<\/p>\n<\/td>\n<\/tr>\n

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A<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n

Nom du magasin ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Emplacement\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

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Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Des re\u00e7us, des factures ou des avis par courriel sont-ils disponibles? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

B<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Nom du magasin ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Emplacement\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

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Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Des re\u00e7us, des factures ou des avis par courriel sont-ils disponibles? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

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C<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Nom du magasin ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Emplacement\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

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Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Des re\u00e7us, des factures ou des avis par courriel sont-ils disponibles? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

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D<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Nom du magasin ou du site Web\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

Emplacement\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Des re\u00e7us, des factures ou des avis par courriel sont-ils disponibles? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n

Carte de fid\u00e9lit\u00e9?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

Accepteriez-vous de nous communiquer le num\u00e9ro de votre carte de fid\u00e9lit\u00e9 et vos renseignements d\u2019achat? \u2610 O\u00a0\u00a0 \u2610\u00a0 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

Renseignements suppl\u00e9mentaires sur les magasins mentionn\u00e9s ci-dessus. Le cas \u00e9ch\u00e9ant, veuillez fournir des renseignements sur les achats types effectu\u00e9s dans des magasins sp\u00e9cialis\u00e9s ou en ligne ainsi que des d\u00e9tails sur la m\u00e9thode d\u2019achat et indiquer si le cas est dispos\u00e9 \u00e0 pr\u00e9senter les re\u00e7us, les factures, etc.<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/strong><\/p>\n\n\n\n\n\n\n
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Section\u00a010. Achat de repas pr\u00eat-\u00e0-cuisiner <\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Au cours des 50 \u00e0 15\u00a0jours pr\u00e9c\u00e9dant l\u2019apparition de la maladie, est-ce que vous-m\u00eame ou le cas avez consomm\u00e9 des aliments pr\u00e9par\u00e9s \u00e0 partir de repas pr\u00eat-\u00e0-cuisiner (Goodfood, Hello Fresh, Chef\u2019s Plate, Red Apron, etc.)?<\/p>\n

\u2610 Oui\u00a0\u00a0 \u2610 Probablement\u00a0\u00a0 \u2610 Non<\/p>\n

Si oui, veuillez fournir les renseignements demand\u00e9s ci-dessous.<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Renseignements sur l\u2019achat <\/strong><\/p>\n<\/td>\n

\n

Noms des repas, dates de consommation, ingr\u00e9dients et substitutions <\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Nom de l\u2019entreprise\u00a0: <\/strong><\/p>\n

Date de livraison\u00a0: <\/strong><\/p>\n

Des re\u00e7us, des factures, des avis par courriel ou des fiches de recette sont-ils disponibles?<\/p>\n

\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/strong><\/p>\n\n\n\n\n
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Section\u00a011\u00a0: Exposition aux aliments<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

DIRECTIVES \u00c0 LIRE AU CAS<\/p>\n

J\u2019aimerais conna\u00eetre les aliments que vous avez (ou que le cas a) consomm\u00e9s au cours des 50 \u00e0 15\u00a0jours<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, c\u2019est-\u00e0-dire du j____\/m_____\/a_____ au j____\/m_____\/a_____.\u00a0\u00a0 Pour chaque aliment, veuillez me donner votre meilleure estimation \u00e0 savoir si l\u2019aliment a \u00e9t\u00e9 consomm\u00e9, si vous n\u2019\u00eates pas s\u00fbr de l\u2019avoir consomm\u00e9 mais que vous l\u2019avez probablement fait, ou si vous ne l\u2019avez pas consomm\u00e9. Veuillez inclure les aliments mang\u00e9s, seuls ou dans une salade, un sandwich ou un mets.<\/p>\n

 <\/p>\n

DIRECTIVES \u00c0 L\u2019INTENTION DE L\u2019INTERVIEWEUR<\/p>\n

Pour chaque aliment consomm\u00e9 par le cas, demandez la marque et le lieu d\u2019achat du produit. Veuillez s\u00e9lectionner une r\u00e9ponse pour chaque question ou indiquer si la question n\u2019a pas \u00e9t\u00e9 pos\u00e9e. Il y a quatre options possibles pour chaque exposition \u00e0 des aliments.<\/p>\n

Oui – Le cas a consomm\u00e9 <\/strong>l\u2019aliment\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0NSP – Le cas ne sait pas<\/strong> s\u2019il a consomm\u00e9 l\u2019aliment\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

Prob. – Le cas a probablement<\/strong> consomm\u00e9 l\u2019aliment\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Non – Le cas n\u2019a pas consomm\u00e9<\/strong> l\u2019aliment<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

\u00a0<\/strong><\/p>\n<\/td>\n

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Oui<\/strong><\/p>\n<\/td>\n

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Prob.<\/strong><\/p>\n<\/td>\n

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Non<\/strong><\/p>\n<\/td>\n

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NSP<\/strong><\/p>\n<\/td>\n

\n

IMPORTANT\u00a0: Veuillez inclure autant de pr\u00e9cisions que possible<\/em><\/strong><\/p>\n

Type \/ Vari\u00e9t\u00e9 \/ Marque<\/strong><\/p>\n<\/td>\n

\n

Lieu d\u2019achat ou de consommation\u00a0:<\/strong><\/p>\n

Pr\u00e9cisez le nom de l\u2019\u00e9picerie ou du restaurant<\/em><\/p>\n<\/td>\n<\/tr>\n<\/thead>\n

\n

L\u00c9GUMES<\/strong> Incluent les l\u00e9gumes crus ou cuits (excluent les l\u00e9gumes achet\u00e9s en conserve)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de tomate, y compris dans un plat ou un repas comme une salade, un sandwich, un burger ou un taco<\/p>\n

Si oui, veuillez pr\u00e9ciser\u00a0:<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tomates cerises ou raisins<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Semi-s\u00e9ch\u00e9es<\/p>\n

\u2610 dans l\u2019huile\u00a0 \u00a0 \u2610\u00a0en sac<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

S\u00e9ch\u00e9es au soleil<\/p>\n

\u2610 dans l\u2019huile\u00a0 \u00a0 \u2610\u00a0en sac<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Laitue ou l\u00e9gume-feuille, y compris dans un plat ou un repas comme une salade, un sandwich, un burger ou un taco<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Iceberg<\/p>\n

\u2610 pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e\/pomm\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Romaine<\/p>\n

\u2610\u00a0pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e\/pomm\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9pinards<\/p>\n

\u2610\u00a0pr\u00e9emball\u00e9s \u2610 non pr\u00e9emball\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Laitue mesclun\/m\u00e9lange printanier<\/p>\n

\u2610 Pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Kale<\/p>\n

\u2610\u00a0Pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Roquette<\/p>\n

\u2610 Pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres laitues ou l\u00e9gumes-feuilles<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/p>\n

\u2610 pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9\/pomm\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salades pr\u00e9emball\u00e9es du commerce (p.\u00a0ex. dans un sac ou un contenant, peut comprendre la vinaigrette et la garniture), excluant les salades pr\u00e9par\u00e9es pr\u00eates \u00e0 manger<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

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Salade verte pr\u00e9par\u00e9e ou pr\u00eate \u00e0 manger du commerce (p.\u00a0ex. salade C\u00e9sar pr\u00e9par\u00e9e, salade de kale, salade du jardin, salade d\u2019\u00e9pinards)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade de pommes de terre du commerce<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade de p\u00e2tes du commerce<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre salade du commerce (p.\u00a0ex. grecque, quinoa, haricots)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Chou (p.\u00a0ex.\u00a0entier, hach\u00e9, salade de chou)<\/p>\n

\u2610 pr\u00e9emball\u00e9 \u2610 non pr\u00e9emball\u00e9\/pomm\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Salade de chou<\/p>\n

\u2610 pr\u00e9emball\u00e9e \u2610 faite maison<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

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Micropousses ou germes, y compris dans un plat ou un repas comme dans un sandwich ou une salade (p.\u00a0ex.\u00a0germes de haricot ou de luzerne, micropousses de brocoli)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Concombres<\/p>\n

\u2610 anglais\u00a0 \u00a0 \u2610 de champ\u00a0 \u00a0 \u2610 Mini<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poivrons (p.\u00a0ex. rouges, verts, jaunes)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Piments forts (p.\u00a0ex. jalape\u00f1o, serrano, habanero)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

C\u00e9leri<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Carottes (non mini)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Mini-carottes (b\u00e9b\u00e9s carottes)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Pois (frais, cosses de pois crues, pois mange-tout)<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Haricots verts ou jaunes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Brocoli<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Chou-fleur<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons blancs\/jaunes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons verts<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Oignons rouges<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres oignons<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poireaux<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Champignons<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres l\u00e9gumes<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

L\u00e9gumes congel\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Jus de l\u00e9gumes (p.\u00a0ex. jus de tomate, jus de carotte)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

FINES HERBES ET \u00c9PICES<\/strong> Incluent les fines herbes et les \u00e9pices fra\u00eeches (excluent les fines herbes et les \u00e9pices s\u00e9ch\u00e9es)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Basilic frais<\/p>\n

\u2610 Tha\u00ef\u00a0 \u00a0 \u2610 Traditionnel<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Coriandre fra\u00eeche<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Persil frais<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Autres fines herbes fra\u00eeches (p.\u00a0ex. origan, aneth, menthe, romarin, ciboulette, thym)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n

\n

\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

FRUITS<\/strong> Incluent les fruits crus ou cuits (excluent les fruits achet\u00e9s en conserve)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Salade de fruits\/fruits pr\u00e9coup\u00e9s ou plateau de fruits<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Melon<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cantaloup<\/p>\n

\u2610\u00a0Frais\u00a0 \u2610 Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Melon miel<\/p>\n

\u2610 Frais\u00a0 \u00a0 \u2610\u00a0Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Melon d\u2019eau<\/p>\n

\u2610\u00a0Frais\u00a0 \u00a0 \u2610\u00a0Congel\u00e9\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres melons<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Pommes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poires<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00eaches<\/p>\n

\u2610 Fra\u00eeches\u00a0 \u00a0 \u2610\u00a0Congel\u00e9es\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Nectarines<\/p>\n

\u2610\u00a0Fra\u00eeches\u00a0 \u00a0 \u2610Congel\u00e9es\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Abricots<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Prunes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Agrumes (p.\u00a0ex. oranges, pamplemousses, citrons, limes)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Petits fruits (baies)<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous :<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fraises<\/p>\n

\u2610 Fra\u00eeches\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610\u00a0S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Framboises<\/p>\n

\u2610\u00a0Fra\u00eeches\u00a0 \u00a0 \u2610\u00a0Congel\u00e9es\u00a0 \u2610\u00a0S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Bleuets<\/p>\n

\u2610\u00a0Frais\u00a0 \u00a0 \u2610\u00a0Congel\u00e9s\u00a0 \u2610\u00a0S\u00e9ch\u00e9s\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

M\u00fbres<\/p>\n

\u2610 Fra\u00eeches\u00a0 \u00a0 \u2610 Congel\u00e9es\u00a0 \u2610\u00a0S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres baies (p. ex. canneberges, groseilles \u00e0 maquereau, framboises-m\u00fbres de Tay)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Sac de baies ou fruits m\u00e9lang\u00e9s congel\u00e9s<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cerises<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Raisins<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Bananes<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Mangues<\/p>\n

\u2610 Fra\u00eeches\u00a0 \u00a0 \u2610 Congel\u00e9es\u00a0 \u2610\u00a0S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Papayes<\/p>\n

\u2610\u00a0Fra\u00eeches\u00a0 \u00a0 \u2610\u00a0Congel\u00e9es\u00a0 \u2610\u00a0S\u00e9ch\u00e9es\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Kiwis<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Grenade<\/p>\n

\u2610 Fra\u00eeche (y compris les p\u00e9pins pr\u00eats \u00e0 manger)\u00a0 \u2610 Congel\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Ananas<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Noix de coco<\/p>\n

\u2610 Fra\u00eeche\u00a0 \u00a0 \u2610 Congel\u00e9e\u00a0 \u2610\u00a0S\u00e9ch\u00e9e\/r\u00e2p\u00e9e<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Avocat (y compris le guacamole)<\/p>\n

\u2610\u00a0Frais\u00a0 \u00a0 \u2610\u00a0Congel\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Olives<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre fruit<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cidre de pommes ou jus de fruits non pasteuris\u00e9s<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

<\/p>\n

Boisson fouett\u00e9e aux fruits contenant des fruits ou l\u00e9gumes frais ou congel\u00e9s, pr\u00e9par\u00e9e \u00e0 la maison ou achet\u00e9e fra\u00eeche dans un commerce, un restaurant ou un caf\u00e9<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Boisson fouett\u00e9e pr\u00e9par\u00e9e, en bouteille<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

POISSONS ET FRUITS DE MER<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout poisson (y compris poisson frais, en conserve, en pot, surgel\u00e9)<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poisson fum\u00e9 (p.\u00a0ex. saumon fum\u00e9)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poisson consomm\u00e9 cru (p.\u00a0ex. sushi, tartare, sashimi, ceviche)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre type de poisson (p.\u00a0ex. frais, congel\u00e9, cuit, s\u00e9ch\u00e9)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Mollusques et crustac\u00e9s<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Moules<\/p>\n

Si oui, mang\u00e9es crues<\/em> oO oN oNSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Palourdes<\/p>\n

Si oui, mang\u00e9es crues<\/em> oO oN oNSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Crevettes<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n

Si oui, mang\u00e9es crues<\/em> oO oN oNSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hu\u00eetres<\/p>\n

\u00a0Si oui, mang\u00e9es crues<\/em> oO oN oNSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Tout autre mollusque ou crustac\u00e9 (p.\u00a0ex.\u00a0p\u00e9toncle, coque, crabe, \u00e9crevisse, homard)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n

Si oui, mang\u00e9 cru<\/em> oO oN oNSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres fruits de mer ou produits d\u2019algues<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

<\/p>\n

AUTRES VIANDES OU PRODUITS ANIMAUX<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Charcuterie\/viande froide (p.\u00a0ex. saucisson de Bologne, salami, pepperoni, dinde, jambon)<\/p>\n

Si oui, veuillez pr\u00e9ciser le(s) type(s) ci-dessous<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Charcuterie pr\u00e9emball\u00e9e<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Charcuterie tranch\u00e9e au comptoir de charcuterie<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Hot-dogs ou pogos<\/p>\n

Si oui, chauff\u00e9 avant d\u2019\u00eatre consomm\u00e9\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0<\/em> \u2610O \u2610N \u2610NSP<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Produits de viande s\u00e9ch\u00e9e\/fum\u00e9e (p.\u00a0ex. charqui de b\u0153uf, saucisse s\u00e9ch\u00e9e, saucisson)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00e2t\u00e9\/tartinade de viande<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Shawarma\/donair\/gyro<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

PRODUITS LAITIERS et SUBSTITUTS DE PRODUITS LAITIERS<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Lait non pasteuris\u00e9 (cru)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autres produits laitiers non pasteuris\u00e9s<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

FROMAGE<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout fromage fait de lait non pasteuris\u00e9 (cru)<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage tranch\u00e9 au comptoir de la charcuterie<\/p>\n

Si oui, pr\u00e9cisez\u00a0: ___________________<\/em><\/p>\n<\/td>\n

\n

\u2610O<\/p>\n<\/td>\n

\n

\u2610P<\/p>\n<\/td>\n

\n

\u2610N<\/p>\n<\/td>\n

\n

\u2610NSP<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n
\n

Section\u00a012\u00a0: Donn\u00e9es d\u00e9mographiques<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Ma derni\u00e8re question concerne votre origine ethnique. Dans notre soci\u00e9t\u00e9, les personnes sont souvent d\u00e9crites en fonction de leur origine ethnique et se consid\u00e8rent comme \u00e9tant \u00ab\u00a0blanches\u00a0\u00bb ou \u00ab\u00a0noires\u00a0\u00bb ou \u00ab\u00a0sud-asiatiques\u00a0\u00bb, par exemple. Cette information est recueillie afin de mieux comprendre la personne infect\u00e9e par l\u2019h\u00e9patite\u00a0A dans le but d\u2019orienter notre enqu\u00eate.<\/p>\n

(Note \u00e0 l\u2019intention de l\u2019intervieweur\u00a0: si le cas n\u2019est pas \u00e0 l\u2019aise de r\u00e9pondre, passez la question)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Quelle cat\u00e9gorie ethnique vous d\u00e9crit le mieux? S\u00e9lectionnez toutes les r\u00e9ponses applicables\u00a0:<\/p>\n

\u2610Noire (p.\u00a0ex. africaine, afro-carib\u00e9enne, canadienne d\u2019origine africaine)<\/p>\n

\u2610Asiatique de l\u2019Est ou du Sud-Est (p.\u00a0ex.\u00a0chinoise, cor\u00e9enne, japonaise, ta\u00efwanaise, philippines, vietnamienne, cambodgienne, tha\u00eflandaise, indon\u00e9sienne, autre origine asiatique du Sud-Est)<\/p>\n

\u2610 Autochtones (p.\u00a0ex. Premi\u00e8res Nations, Inuit, M\u00e9tis)\u00a0:\u00a0\u00a0\u00a0 \u2610 Premi\u00e8res Nations \u2610 Inuit \u2610 M\u00e9tis<\/p>\n

\u2610 Latine (p.\u00a0ex. Am\u00e9rique latine, origine hispanique)<\/p>\n

\u2610 Moyen-orientale (p.\u00a0ex. arabe, perse, origine asiatique de l\u2019Ouest \u2013 par exemple, afghane, \u00e9gyptienne, iranienne, libanaise, turque, kurde)<\/p>\n

\u2610 Sud-asiatique (p. ex. origine sud-asiatique, par exemple, indienne de l\u2019Est, pakistanaise, bangladaise, sri-lankaise, indo-carib\u00e9enne)<\/p>\n

\u2610 Blanche (p.\u00a0ex. origine europ\u00e9enne)<\/p>\n

\u2610 Autre groupe (pr\u00e9cisez)\u00a0: _________________________<\/p>\n

\u2610 Incertain\/pr\u00e9f\u00e8re ne pas r\u00e9pondre<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Remarques\/commentaires g\u00e9n\u00e9raux\u00a0:<\/p>\n

T\u00e9l\u00e9charger le format de rechange<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

T\u00e9l\u00e9charger le format de rechange Contexte du questionnaire pour l\u2019intervieweur Ce questionnaire vise \u00e0 recueillir des renseignements exhaustifs sur les facteurs de risque possibles de l\u2019h\u00e9patite\u00a0A dans le contexte d\u2019une enqu\u00eate sur un agr\u00e9gat ou une \u00e9closion de cas dont la source d\u2019infection est inconnue, mais il pourrait \u00e9galement \u00eatre utilis\u00e9 pour enqu\u00eater sur des […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":417,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"fullpage.php","meta":{"footnotes":""},"class_list":["post-2626","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/2626","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/comments?post=2626"}],"version-history":[{"count":38,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/2626\/revisions"}],"predecessor-version":[{"id":6323,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/2626\/revisions\/6323"}],"up":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/417"}],"wp:attachment":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/media?parent=2626"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}