{"id":6274,"date":"2025-03-26T13:37:26","date_gmt":"2025-03-26T17:37:26","guid":{"rendered":"https:\/\/outbreaktools.ca\/?page_id=6274"},"modified":"2025-03-27T16:14:20","modified_gmt":"2025-03-27T20:14:20","slug":"campylobacter-hypothesis-generating-questionnaire","status":"publish","type":"page","link":"https:\/\/outbreaktools.ca\/fr\/tools\/toolkit-questionnaire-repository\/campylobacter-hypothesis-generating-questionnaire\/","title":{"rendered":"Questionnaire g\u00e9n\u00e9rateur d\u2019hypoth\u00e8ses visant le Campylobacter"},"content":{"rendered":"

T\u00e9l\u00e9charger le format de rechange<\/a><\/p>\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 est con\u00e7u pour recueillir des informations sur les expositions pr\u00e9c\u00e9dant une infection \u00e0 Campylobacter<\/em> dans le contexte d’un agr\u00e9gat ou d\u2019un groupe de cas dont la source d\u2019infection est inconnue, mais il pourrait \u00eatre utilis\u00e9 pour enqu\u00eater sur des cas sporadiques.<\/p>\n\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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Des donn\u00e9es captur\u00e9es incluent :<\/p>\n<\/td>\n

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– les caract\u00e9ristiques d\u00e9mographiques du cas<\/p>\n<\/td>\n

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– des expositions aux aliments<\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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– des donn\u00e9es cliniques<\/p>\n<\/td>\n

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– des expositions aux animaux<\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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– des donn\u00e9es laboratoires<\/p>\n<\/td>\n

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– des autres facteurs de risque<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Puisque les \u00e9closions de campylobact\u00e9riose sont souvent li\u00e9es \u00e0 des produits alimentaires contamin\u00e9s, il est essentiel de recueillir autant de d\u00e9tails que possible sur les expositions aux aliments ou aux animaux. Ce questionnaire inclut donc un historique alimentaire et une liste d\u00e9taill\u00e9e des aliments sp\u00e9cifiques; cela peut sembler r\u00e9p\u00e9titif mais est utilis\u00e9 pour s’assurer que toutes les expositions possibles aux aliments sont captur\u00e9es. S\u2019il vous plait, recueillir autant de d\u00e9tails que possible pour chaque exposition, incluant les expositions aux restaurants. Consid\u00e9rer aussi l\u2019utilisation d\u2019un calendrier, ou, le cas \u00e9ch\u00e9ant, de recueillir des re\u00e7us ou des donn\u00e9es des cartes de fid\u00e9lit\u00e9.<\/p>\n

Le questionnaire devrait prendre de 45 \u00e0 60 minutes \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\u00a0<\/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 de la carte de sant\u00e9\u00a0: ________________________________<\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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

Ville\/Village\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u><\/p>\n

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

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T\u00e9l\u00e9phone \u00e0 domicile\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u><\/p>\n

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

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

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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 d\u2019emploi\u00a0:\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\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

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Date de d\u00e9but des sympt\u00f4mes\u00a0: j______ \/ m______ \/\u00a0 a______\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Asymptomatique\u00a0: \u2610 O\u00a0 \u2610 N \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n

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Sympt\u00f4mes\u00a0:\u00a0\u00a0\u00a0 Diarrh\u00e9e*\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP\u00a0\u00a0 Fi\u00e8vre\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP\u00a0\u00a0\u00a0\u00a0 Crampes abdominales\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Diarrh\u00e9e sanglante\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP\u00a0\u00a0 C\u00e9phal\u00e9e\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP\u00a0\u00a0\u00a0\u00a0 Naus\u00e9es\u00a0\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 \u2610 N \u2610 NSP<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Vomissements\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP\u00a0\u00a0 Autre\u00a0:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \u2610 O\u00a0 \u2610 N \u2610 NSP\u00a0\u00a0\u00a0\u00a0 Si \u00ab\u00a0Autre\u00a0\u00bb, veuillez pr\u00e9ciser\u00a0:<\/p>\n

*3\u00a0selles aqueuses ou plus sur une p\u00e9riode de 24\u00a0heures<\/em><\/p>\n<\/td>\n<\/tr>\n

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

Si oui, pr\u00e9cisez\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\u00a0<\/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 10\u00a0jours<\/strong> pr\u00e9c\u00e9dant la malade ?\u00a0<\/p>\n

\u2610 O\u00a0 \u2610 N \u2610 NSP Si vous avez r\u00e9pondu \u00ab\u00a0Oui\u00a0\u00bb, 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.<\/em><\/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\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u>\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\u00a0\u00a0\u00a0 Num\u00e9ro de t\u00e9l\u00e9phone\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u><\/p>\n

Lien\u00a0avec le cas\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u>\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\u00a0\u00a0\u00a0 <\/u>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Date de l\u2019apparition de la diarrh\u00e9e\u00a0: j______ \/ m______ \/\u00a0 a______<\/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\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u>\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\u00a0\u00a0\u00a0 Num\u00e9ro de t\u00e9l\u00e9phone\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u><\/p>\n

Lien\u00a0avec le cas\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u>\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\u00a0\u00a0\u00a0 <\/u>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Date de l\u2019apparition de la diarrh\u00e9e\u00a0: j______ \/ m______ \/\u00a0 a______<\/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\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u>\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\u00a0\u00a0 Num\u00e9ro de t\u00e9l\u00e9phone\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u><\/p>\n

Lien\u00a0avec le cas\u00a0: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/u>\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\u00a0\u00a0\u00a0 <\/u>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Date de l\u2019apparition de la diarrh\u00e9e\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

Section 1 : <\/strong>Renseignements sur le cas\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

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

\n

Date de l\u2019entrevue\u00a0: j______ \/ m______ \/\u00a0 a______<\/p>\n<\/td>\n<\/tr>\n

\n

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

\n

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

\n

Province ou territoire\u00a0:<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

R\u00e9pondant\u00a0: \u2610 Cas \u2610 Parent \u2610 Conjoint \u2610 Soignant \u2610 Autre (pr\u00e9ciser)\u00a0: ___________________________<\/p>\n<\/td>\n<\/tr>\n

\n

Genre:\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

\n

\u00c2ge\u00a0: _______\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\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<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n
\n

Section 2 : <\/strong>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 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 <\/strong>ID du laboratoire provincial\u00a0:<\/span><\/p>\n<\/td>\n<\/tr>\n<\/thead>\n

\n

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

\n

Esp\u00e8ce\u00a0:<\/p>\n<\/td>\n

\n

Code de d\u2019agr\u00e9gat de s\u00e9quen\u00e7age du g\u00e9nome entier\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

Type d\u2019\u00e9chantillon positif\u00a0:<\/p>\n

\u2610 Selles \u2610 Sang \u2610 Urine \u2610 Autre (pr\u00e9ciser)\u00a0:________________\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

Date du premier pr\u00e9l\u00e8vement des \u00e9chantillons positifs\u00a0:<\/p>\n

j______ \/ m______ \/\u00a0 a______<\/p>\n<\/td>\n<\/tr>\n

\n

Date d\u2019 apparition des premiers sympt\u00f4mes\u00a0:
\nj______ \/ m______ \/\u00a0 a______ Asymptomatique\u00a0: \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

Date d\u2019apparition de la diarrh\u00e9e\u00a0: j______ \/ m______ \/\u00a0 a______<\/p>\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Admission* \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 une salle d\u2019urgence ou \u00e0 une clinique externe<\/p>\n<\/td>\n

\n

Date de l\u2019admission\u00a0: j______ \/ m______ \/\u00a0 a______<\/p>\n

Date du cong\u00e9\u00a0: j______ \/ m______ \/\u00a0 a______ \u2610 Toujours hospitalis\u00e9<\/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 Date de d\u00e9c\u00e8s\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\u00a0\u00a0 Si oui, l\u2019infection \u00e0 Campylobacter<\/em> est-elle la cause sous-jacente du d\u00e9c\u00e8s ou ayant contribu\u00e9 au d\u00e9c\u00e8s ?\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 Si oui, la d\u00e9termination est-elle fond\u00e9e sur le certificat de d\u00e9c\u00e8s ?\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\n\n
\n

Section 3 : <\/strong>Renseignements relatifs aux voyages<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Dans les 10 jours<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, c\u2019est-\u00e0-dire du j____ \/ m____ \/\u00a0 a______ au j____ \/ m____ \/\u00a0 a______, avez-vous (ou le cas a-t-il) voyag\u00e9 au Canada ou \u00e0 l\u2019ext\u00e9rieur du Canada ?<\/p>\n

\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’int\u00e9rieur de la province ou territoire\u00a0 \u2610 Dans d\u2019autres provinces ou territoires\u00a0 \u2610 \u00c0 l’ext\u00e9rieur du Canada<\/p>\n<\/td>\n<\/tr>\n

\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Pr\u00e9cisez la ou 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: j____ \/ m____ \/\u00a0 a______ Retour\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

Section 4 : <\/strong>R\u00e9gimes sp\u00e9ciaux ou pr\u00e9f\u00e9rences alimentaires\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout d\u2019abord, je tiens \u00e0 vous poser quelques questions g\u00e9n\u00e9rales sur le r\u00e9gime alimentaire et les pr\u00e9f\u00e9rences alimentaires (les v\u00f4tres ou ceux du cas).<\/p>\n<\/td>\n<\/tr>\n

\n

Est-ce que vous-m\u00eame ou le cas \u00eates v\u00e9g\u00e9tariens?\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?\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u0152ufs\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 \u00a0Produits laitiers\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Poisson\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\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 Volaille \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Viandes rouges \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP\u00a0\u00a0\u00a0\u00a0 \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Autres viandes\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\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Si oui, veuillez pr\u00e9cisez\u00a0: ___________________<\/p>\n<\/td>\n<\/tr>\n

\n

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<\/p>\n

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<\/p>\n

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

\n

Au cours des 10 jours<\/strong> pr\u00e9c\u00e9dant la maladie, est-ce que vous-m\u00eame ou le cas avez\u00a0:<\/p>\n

Suivi un r\u00e9gime alimentaire particulier ou restreint (p. ex., r\u00e9gime alimentaire crudivore, v\u00e9g\u00e9talien, pour les personnes diab\u00e9tiques, casher, halal)?<\/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\u00a0\u00a0Si oui, veuillez pr\u00e9ciser\u00a0:__________________________________________________________________________<\/p>\n

Est-ce que vous-m\u00eame ou le cas avez 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\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\u00a0Si oui, veuillez pr\u00e9ciser (indiquez le lieu d\u2019achat)\u00a0:_______________________________________________________<\/p>\n

Avez-vous consomm\u00e9 des boissons sant\u00e9 pr\u00e9par\u00e9es et embouteill\u00e9es? (p.\u00a0ex.\u00a0Kombucha, eau de noix de coco)\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\u00a0Si oui, veuillez pr\u00e9ciser (indiquez le lieu d\u2019achat) : ________________________________________________________<\/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

Section 5 : <\/strong>Consommation d\u2019aliments \u00e0 l\u2019ext\u00e9rieur de la maison<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Dans les 10 jours<\/strong> avant 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 \u00e0 des \u00e9tablissements comme des supermarch\u00e9s).<\/p>\n<\/td>\n<\/tr>\n

\n

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

\n

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

\n

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’autres 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

\u00a0\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 du pr\u00eat-\u00e0-manger ou dans 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

\n

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

\n

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

\n

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

\n

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

\n

\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

\n

\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

\n

\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

\n

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

\n

 <\/p>\n<\/td>\n

\n

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

\n

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

\n

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

\n

\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
\n

Section 6 : <\/strong>Achat d\u2019aliments pour la maison\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

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

*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.<\/p>\n<\/td>\n<\/tr>\n

\n

A<\/p>\n<\/td>\n

\n

 <\/p>\n

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

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\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

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/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 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

B<\/p>\n<\/td>\n

\n

 <\/p>\n

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

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\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

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/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 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

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

\n

 <\/p>\n

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

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\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

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/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 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

D<\/p>\n<\/td>\n

\n

 <\/p>\n

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

 <\/p>\n

 <\/p>\n

Adresse\u00a0:<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n<\/td>\n

\n

Aliments achet\u00e9s en ligne (livraison ou collecte \u00e0 l\u2019auto)\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

Les re\u00e7us, les factures et les avis par courriel sont-ils disponibles? \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/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 N\u00a0\u00a0<\/p>\n<\/td>\n<\/tr>\n

\n

Renseignements suppl\u00e9mentaires sur les commerces mentionn\u00e9s ci-dessus. Le cas \u00e9ch\u00e9ant, veuillez fournir des renseignements sur les achats types effectu\u00e9s dans les 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<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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

Section 7 : <\/strong>Achat de repas pr\u00eat-\u00e0-cuisiner<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Au cours des dix jours<\/strong> 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 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0\u00a0\u00a0\u00a0Si 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 :<\/strong><\/p>\n

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

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

\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\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

Section 8\u00a0: Aliments consomm\u00e9s dans les 10\u00a0jours pr\u00e9c\u00e9dant le d\u00e9but de la maladie<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

J\u2019aimerais vous parler des aliments ou des boissons que vous avez (ou que le cas a) consomm\u00e9s avant de devenir malade. En commen\u00e7ant par la journ\u00e9e o\u00f9 vous avez ou le cas a connu les premiers sympt\u00f4mes\u00a0:<\/p>\n

(Note \u00e0 l\u2019intention de l\u2019intervieweur\u00a0: Veuillez demander o\u00f9 les aliments ont \u00e9t\u00e9 consomm\u00e9s ou comment ils ont \u00e9t\u00e9 pr\u00e9par\u00e9s, p. ex. pr\u00e9par\u00e9s et consomm\u00e9s \u00e0 la maison, consomm\u00e9s dans un restaurant, comptoir de commandes \u00e0 emporter, repas pr\u00eats-\u00e0-manger, repas surgel\u00e9s, etc.)<\/em><\/p>\n<\/td>\n<\/tr>\n

\n

Journ\u00e9e de la maladie<\/strong> \u00a0j____ \/ m____ \/\u00a0 a______\u00a0 <\/strong>\u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Une journ\u00e9e avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

\n

Deux jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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Trois jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

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 <\/p>\n<\/td>\n

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 <\/p>\n<\/td>\n<\/tr>\n

\n

Quatre jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

Souper<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Cinq jours avant le d\u00e9but de la maladie<\/strong>:<\/em>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

Souper<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Six jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Sept jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/td>\n\u00a0<\/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\n\n\n
\n

Huit jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Neuf jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

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

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Dix jours avant le d\u00e9but de la maladie<\/strong>\u00a0\u00a0 j____ \/ m____ \/ a______\u00a0 \u2610 Lun \u00a0\u00a0\u2610 Mar\u00a0\u00a0 \u2610 Mer\u00a0\u00a0 \u2610 Jeu\u00a0\u00a0 \u2610 Ven\u00a0\u00a0 \u2610 Sam\u00a0\u00a0 \u2610 Dim<\/p>\n<\/td>\n<\/tr>\n

\n

D\u00e9jeuner\u00a0\u00a0<\/p>\n<\/td>\n

\n

D\u00eener\u00a0\u00a0\u00a0<\/p>\n<\/td>\n

\n

Souper<\/p>\n<\/td>\n

\n

Collations<\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/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

Section 9 : Expositions \u00e0 des 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 dix\u00a0journ\u00e9es<\/strong> pr\u00e9c\u00e9dant le d\u00e9but de la maladie, c\u2019est-\u00e0-dire du j____\/m_____\/a_____ au j____\/m____\/a____.\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.\u00a0 Il y a quatre options possibles pour chaque exposition \u00e0 des aliments.<\/p>\n

Oui \u2013 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 NSP \u2013 Le cas ne sait pas<\/strong> s\u2019il a consomm\u00e9 l\u2019aliment<\/p>\n

Prob. \u2013 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 Non \u2013 Le cas n\u2019a pas consomm\u00e9<\/strong> l\u2019aliment<\/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\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\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

\n

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

\n

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

\n

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

\n

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

\n

IMPORTANT. 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 de l\u2019aliment\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

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

\n

Tout type de poulet (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\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

Poulet pan\u00e9 achet\u00e9 en magasin (p. ex. croquettes, lani\u00e8res ou burgers de poulet)<\/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

Produit de poulet farcies achet\u00e9 en magasin (p. ex. poulet \u00e0 la Kiev, poulet cordon bleu)<\/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

Poulet hach\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

Morceaux de poulet (p. ex. poulet entier r\u00f4ti, poitrines, ailes, cuisse, dans une soupe ou un mets, en excluant 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

 <\/p>\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre viande de poulet (en excluant 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

\n

Tout type de dinde (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\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

Dinde hach\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

Morceaux de dinde (p. ex. dinde enti\u00e8re r\u00f4tie, poitrines, ailes, cuisses, dans une soupe ou un mets, en excluant 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

\n

Autre viande de dinde (en excluant la charcuterie) (p. ex. bacon de dinde)<\/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 viande de volaille (p. ex. poulet de Cornouailles, canard, en excluant 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


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

\u0152UFS ET PLATS CONTENANT DES \u0152UFS<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

\u0152ufs (p. ex. \u0153ufs brouill\u00e9s, omelettes)<\/p>\n

Si oui, 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

\u0152ufs consomm\u00e9s crus ou peu cuits (p.\u00a0ex. \u00ab\u00a0dont le jaune est coulant\u00a0\u00bb ou \u00ab\u00a0\u0153ufs tourn\u00e9s\u00a0\u00bb), tout produit fait avec des \u0153ufs crus (p.\u00a0ex. p\u00e2te \u00e0 biscuits crue, pr\u00e9paration pour g\u00e2teau, sauces, cr\u00e8me glac\u00e9e fait maison, mayonnaise, vinaigrette, ou dans une boisson)<\/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<\/strong><\/p>\n

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

\n

Tout type de porc (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\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

Jambon (en excluant la charcuterie)<\/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

Bacon<\/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

Porc hach\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

Morceaux de porc (p. ex. r\u00f4tis de porc, c\u00f4tes lev\u00e9es, c\u00f4telettes, dans une soupe ou un mets, en excluant la charcuterie ou le jambon)<\/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 viande de porc (en excluant 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

<\/p>\n

B\u0152UF<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Tout type de b\u0153uf (en excluant la charcuterie)<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\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

Tout type de b\u0153uf hach\u00e9 (p.\u00a0ex.\u00a0hamburger, lasagne, chili)<\/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

B\u0153uf hach\u00e9 consomm\u00e9 cru ou peu cuit (p. ex. hamburgers pas assez cuits ou kibbeh)<\/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

Morceaux de b\u0153uf (p. ex. r\u00f4tis, c\u00f4tes lev\u00e9es, c\u00f4telettes, dans une soupe ou un mets, en excluant 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

\n

Veau<\/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 viande de b\u0153uf (en excluant 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

\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, 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 saucisse sur b\u00e2tonnet<\/p>\n

Si oui, chauff\u00e9 avant d\u2019\u00eatre consomm\u00e9 <\/em><\/p>\n

\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

Saucisse<\/p>\n

Si oui, veuillez pr\u00e9ciser le type ci-dessous\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

Saucisse de b\u0153uf<\/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

Saucisse de porc<\/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

Saucisse de poulet<\/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

Saucisse de dinde<\/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<\/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

Produits de viande s\u00e9ch\u00e9e\/fum\u00e9e (p.\u00a0ex. pepperettes, 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

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

P\u00e2t\u00e9\/viande \u00e0 tartiner<\/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

Agneau<\/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

Ch\u00e8vre<\/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 type de gibier ou de nourriture traditionnelle (p. ex. venaison, faisan, li\u00e8vre, caribou, phoque, cailles, orignal, bison)<\/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

Abats (p. ex. foie, rein, c\u0153ur)<\/p>\n

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

Si oui, ont-ils \u00e9t\u00e9 consomm\u00e9 peu cuits ? <\/em><\/p>\n

\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

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

Autre viande, excluant le poisson et les fruits de mer<\/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

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 type ci-dessous\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 fum\u00e9 (p. ex. 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

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Poisson consomm\u00e9 cru (p. ex. 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

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Autre type de poisson (p. ex. frais, congel\u00e9, cuits ou s\u00e9ch\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

 <\/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>\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

Palourdes<\/p>\n

Si oui, mang\u00e9es crues<\/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

Crevettes<\/p>\n

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

Si oui, mang\u00e9es crues <\/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

Hu\u00eetres<\/p>\n

\u00a0Si oui, mang\u00e9es crues <\/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

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>\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

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

\n

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

\n

Lait pasteuris\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

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

Boisson v\u00e9g\u00e9tale (p.\u00a0ex. soja, amande, noix de coco, riz, noix de cajou, avoine)<\/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

Produits laitiers en poudre (p. ex. lait en poudre, \u00e9vapor\u00e9 Carnation, de marque Ovaltine)<\/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

Cr\u00e8me fouett\u00e9e ou \u00e0 fouetter<\/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

Cr\u00e8me sure<\/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

Cr\u00e8me glac\u00e9e\/gelato<\/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

Desserts laitiers glac\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

Desserts contenant du lait ou de la cr\u00e8me (p. ex. tartes ou p\u00e2tisseries fourr\u00e9es \u00e0 la cr\u00e8me, pouding)<\/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

Yogourt<\/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<\/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 type de fromage<\/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

Fromage cheddar<\/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 mozzarella<\/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 parmesan<\/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

Gouda<\/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 feta<\/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

Fromages \u00e0 p\u00e2te molle comme le brie, le camembert.<\/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

Fromages persill\u00e9s comme le fromage bleu ou le gorgonzola<\/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 cottage, ricotta, ou autre fromage frais<\/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 \u00e0 base de lait de ch\u00e8vre ou de brebis<\/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

Tout autre fromage g\u00e9n\u00e9ralement vendu en bloc ou tranch\u00e9 \u00e0 partir d’une meule (p. ex. emmental, jarlsberg, monterey jack, havarti, colby ou oka)<\/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

 <\/p>\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Fromage fondu (p. ex. fromage en tranches, fromage en lani\u00e8res ou en b\u00e2tonnets, en pot)<\/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

Tout fromage \u00e0 base de 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

Substituts de fromage non laitiers<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0 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\u00c9GUMES\u00a0: <\/strong>Incluent les l\u00e9gumes crus ou cuits (exclure les l\u00e9gumes 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

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

\n

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

\n

Tomate 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

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\/t\u00eate<\/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 pr\u00e9emball\u00e9e \u2610 non pr\u00e9emball\u00e9e\/t\u00eate<\/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 pr\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

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

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

\u2610 pr\u00e9emball\u00e9s \u2610 non pr\u00e9emball\u00e9e\/t\u00eate<\/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

\n

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\/t\u00eate<\/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 fait 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

\n

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, 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

Micropousses<\/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

Luzerne<\/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

Germes de haricot<\/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 germes<\/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<\/em><\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Concombres<\/p>\n

\u2610 Anglais\u00a0\u00a0\u00a0\u00a0 \u2610 De champ\u00a0\u00a0\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. ex. 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

\u00a0<\/em><\/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 (ou miniatures)<\/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

Radis<\/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\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

Oignons blancs 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

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: ___________________<\/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

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

Ail frais (pas en poudre)\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

Gingembre frais (non moulu)<\/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

Courgettes<\/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\u00e9gume (p.\u00a0ex.\u00a0jus 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

FRUITS :<\/strong> Inclure les fruits crus ou cuits (exclure les fruits 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

Melons<\/p>\n

Si oui, veuillez pr\u00e9ciser les types ci-dessous\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

Cantaloup<\/p>\n

\u2610 Frais\u00a0\u00a0\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\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 d’eau<\/p>\n

\u2610 Frais\u00a0\u00a0\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

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\u00a0 \u2610 Congel\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 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\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.\u00a0oranges, 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\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

Fraises\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u2610 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\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 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\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 Frais\u00a0\u00a0\u00a0 \u2610 Congel\u00e9s\u00a0 \u2610 S\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\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\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.\u00a0ex.\u00a0canneberges, 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\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\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 Fra\u00eeches\u00a0\u00a0\u00a0 \u2610 Congel\u00e9es\u00a0 \u2610 S\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

Grenades<\/p>\n

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

\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\u00a0 \u2610 Congel\u00e9e\u00a0 \u2610 S\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 Frais\u00a0\u00a0\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

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

Autres fruits<\/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<\/em>\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

<\/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

HERBES ET \u00c9PICES\u00a0:<\/strong><\/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

Herbes fra\u00eeches (p.\u00a0ex.\u00a0basilic, coriandre, persil)<\/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

Herbes ou \u00e9pices s\u00e9ch\u00e9es<\/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

TARTINADES ET TREMPETTES PR\u00c9PAR\u00c9ES DU COMMERCE<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Salsa<\/p>\n

\u2610 Fra\u00eeche (p. ex. pico de gallo)\u00a0\u00a0\u00a0\u00a0<\/p>\n

\u2610 Dans un pot en verre ou une bo\u00eete de conserve<\/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

Houmous achet\u00e9 dans un commerce ou un restaurant (excluant le houmous fait 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

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

\n

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

\n

Toute autre trempette<\/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

ALIMENTS CONGEL\u00c9S<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Pizzas congel\u00e9es<\/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

P\u00e2t\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

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

\n

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

\n

Repas congel\u00e9s dans un sac ou une bo\u00eete (p.\u00a0ex.\u00a0saut\u00e9s, plats cuisin\u00e9s congel\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

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

\n

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

\n

Collations ou entr\u00e9es congel\u00e9es (p.\u00a0ex.\u00a0b\u00e2tonnets de fromage mozzarella, piments jalape\u00f1o farcis, frites)<\/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

Autres aliments congel\u00e9s (p.\u00a0ex.\u00a0desserts, gaufres)<\/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

NOIX ET GRAINES<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Noix consomm\u00e9es seules, en m\u00e9lange, en beurre\/tartinade ou dans un lait de noix fait maison, dans une barre granola, en garniture ou dans un plat<\/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

Arachides (excluant le beurre\/tartinade d\u2019arachides)<\/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

Beurre\/tartinade d\u2019arachides<\/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

Amandes (excluant le beurre\/tartinade d\u2019amandes)<\/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

Beurre\/tartinade d\u2019amandes<\/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 Grenoble<\/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

Noisettes\/avelines (excluant le beurre\/tartinade de noisettes)<\/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

Beurre\/tartinade contenant des noisettes (p.\u00a0ex.\u00a0Nutella)<\/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

Pacanes<\/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 noix (p.\u00a0ex.\u00a0noix macadamia, noix du Br\u00e9sil, pistaches, noix de pin)<\/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\u00e2te, beurre ou tartinade de noix (p.\u00a0ex.\u00a0beurre de noix du Br\u00e9sil, beurre de pistaches)<\/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

Graines de tournesol<\/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

Beurre ou p\u00e2te contenant des graines de tournesol<\/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

Graines de s\u00e9same<\/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

Tahini (beurre de s\u00e9same), halva ou autre produit fait de graines de s\u00e9same, y compris le houmous fait 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

\n

Autres graines (p.\u00a0ex. chia\/poudre de chia, lin, chanvre)<\/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

ALIMENTS S\u00c9CH\u00c9S\/TRANSFORM\u00c9S OU AUTRES\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Substituts de viande \u00e0 base de plantes (p.\u00a0ex.\u00a0tofu, galettes ou hot-dogs v\u00e9g\u00e9tariens)<\/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

Fruits s\u00e9ch\u00e9s (p.\u00a0ex.\u00a0raisins, canneberges, abricots)<\/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

Barres granola, barres \u00e9nerg\u00e9tiques ou autres barres prot\u00e9in\u00e9es<\/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

Croustilles ou bretzels<\/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 collations pr\u00e9emball\u00e9es (p.\u00a0ex.\u00a0craquelins, biscuits, petits g\u00e2teaux)<\/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

Chocolat ou friandises contenant du chocolat<\/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

Aliments ou breuvages contenant du cannabis comme ingr\u00e9dient (ex. brownies ou autre p\u00e2tisseries, jujubes ou friandises, chocolat, huiles, th\u00e9s, jus ou boissons gazeuses, etc.).<\/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\u00e9r\u00e9ales \u00e0 d\u00e9jeuner froides<\/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\u00e9r\u00e9ales chaudes (p.\u00a0ex.\u00a0gruau, cr\u00e8me de bl\u00e9, flocons d’avoine)<\/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\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Section 10 : <\/strong>Facteurs de risque\u00a0<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Enfin, j’aimerais vous poser des questions sur d\u2019autres expositions. Dans les 10 jours<\/strong> pr\u00e9c\u00e9dant l\u2019apparition de la maladie, avez-vous (ou le cas a-t-il)\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

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

(p.\u00a0ex.\u00a0maison de soins infirmiers, \u00e9tablissement de soins de longue dur\u00e9e, prison, dortoir pensionnat,\u00a0etc.)<\/p>\n<\/td>\n

\n

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

\n

\u00c9t\u00e9 dans une garderie ou un \u00e9tablissement de soins ? \u00a0\u00a0\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n

(p.\u00a0ex.\u00a0pour enfants ou adultes)\u00a0<\/p>\n<\/td>\n

\n

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

\n

\u00c9t\u00e9 \u00e0 l\u2019\u00e9cole ? \u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

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

\n

Travaill\u00e9 (b\u00e9n\u00e9volement ou non) en tant que manipulateur d\u2019aliments ?\u00a0 \u2610 O\u00a0\u00a0 \u2610 N\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

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

\n

Manipul\u00e9 de la volaille\/viande crue, saignante ou insuffisamment cuite ? \u2610 O\u00a0\u00a0 \u2610 N\u00a0 \u2610 NSP<\/p>\n<\/td>\n

\n

Manipul\u00e9 des \u0153ufs crus ?\u00a0\u00a0\u00a0\u00a0\u00a0 \u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n

\n

Utilis\u00e9 les sources d’eau potable suivantes ? (cochez toutes les cases qui s\u2019appliquent)<\/p>\n

\u2610 Source d\u2019eau potable municipale\u00a0\u00a0\u00a0 \u2610 Puits\/source d\u2019eau priv\u00e9e\u00a0\u00a0\u00a0 \u2610 Eau en bouteille (pr\u00e9cisez\u00a0: _______________)<\/p>\n

\u2610 Autres (pr\u00e9cisez\u00a0: _______________)<\/p>\n<\/td>\n<\/tr>\n

\n

Nag\u00e9\/entr\u00e9 dans l\u2019oc\u00e9an, un lac, une rivi\u00e8re, une piscine ou un spa?\u00a0<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0Si oui, pr\u00e9cisez le type de source d’eau et le lieu\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9t\u00e9 en contact avec des animaux domestiques ou de compagnie (y compris les chats, les chiens, les rongeurs, les reptiles, les amphibiens, les poissons, les oiseaux,\u00a0etc.) ou leurs d\u00e9chets (y compris les mati\u00e8res f\u00e9cales, les liti\u00e8res, les aquariums,\u00a0etc.) \u00e0 la maison ou \u00e0 l’ext\u00e9rieur de la maison ?<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0Si oui, pr\u00e9cisez les types d’animaux\u00a0: _________________\u00a0 Lieux\u00a0: _________________<\/p>\n<\/td>\n<\/tr>\n

\n

\u00c9t\u00e9 en contact avec des animaux de ferme ou d\u2019\u00e9levage (p.\u00a0ex.\u00a0b\u00e9tail, ch\u00e8vres, moutons, chevaux, poules\/poussins, animaux de zoo apprivois\u00e9s,\u00a0etc.), des animaux sauvages (y compris la faune, les animaux de zoo,\u00a0etc.) ou leurs d\u00e9chets (y compris les mati\u00e8res f\u00e9cales, les liti\u00e8res,\u00a0etc.)?<\/p>\n

\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP \u00a0Si oui, pr\u00e9cisez les types d’animaux\u00a0: _________________\u00a0 Lieux\u00a0: _________________<\/p>\n<\/td>\n<\/tr>\n

\n

Manipul\u00e9 des aliments\/friandises pour animaux dans les dix\u00a0jours pr\u00e9c\u00e9dant le d\u00e9but de la maladie?\u00a0 \u00a0\u00a0\u00a0\u2610 O\u00a0\u00a0 \u2610 N\u00a0\u00a0 \u2610 NSP<\/p>\n<\/td>\n<\/tr>\n

\n

Si oui, avez-vous (ou le cas a-t-il) manipul\u00e9\u00a0:<\/p>\n<\/td>\n

\n

D\u00e9tails (type, marque)\u00a0:<\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des aliments crus pour animaux?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des aliments secs pour animaux?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des aliments humides ou en conserve pour animaux?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des friandises d\u00e9riv\u00e9es de parties d\u2019animaux (p.\u00a0ex.\u00a0oreilles de porc, peau crue, sabots de vache)?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des friandises transform\u00e9es pour animaux (p.\u00a0ex.\u00a0bouch\u00e9es, biscuits)?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des rongeurs\/insectes pour les reptiles?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 Des aliments pour animaux de ferme?<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

\u2610 D\u2019autres produits?<\/p>\n

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

\n

 <\/p>\n<\/td>\n<\/tr>\n

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

 <\/p>\n\n\n\n\n\n
\n

Section 11 : <\/strong>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 Campylobacter<\/em> 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

\u2610 Noire (p.\u00a0ex. africaine, afro-carib\u00e9enne, canadienne d\u2019origine africaine)<\/p>\n

\u2610 Asiatique de l\u2019Est ou du Sud-Est (p.\u00a0ex.\u00a0chinoise, cor\u00e9enne, japonaise, ta\u00efwanaise, philippine, vietnamienne, cambodgienne, tha\u00eflandaise, 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. ex. Am\u00e9rique latine, origine hispanique)<\/p>\n

\u2610 Moyen-orientale (p.\u00a0ex. arabe, perse, origine de l\u2019Asie occidentale \u2013 par exemple, afghane, \u00e9gyptienne, iranienne, libanaise, turque, kurde)<\/p>\n

\u2610 Sud-asiatique (p\u00a0.ex. origine sud-asiatique, par exemple, indienne d\u2019Asie, pakistanaise, bangladaise, sri-lankaise, indo-carib\u00e9enne)<\/p>\n

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

\u2610 Autre groupe (pr\u00e9ciser)\u00a0: _________________________<\/p>\n

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

Notes\/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 est con\u00e7u pour recueillir des informations sur les expositions pr\u00e9c\u00e9dant une infection \u00e0 Campylobacter dans le contexte d’un agr\u00e9gat ou d\u2019un groupe de cas dont la source d\u2019infection est inconnue, mais il pourrait \u00eatre utilis\u00e9 pour enqu\u00eater sur des cas sporadiques. Des donn\u00e9es […]<\/p>\n","protected":false},"author":33,"featured_media":0,"parent":417,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"fullpage.php","meta":{"footnotes":""},"class_list":["post-6274","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/6274","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\/33"}],"replies":[{"embeddable":true,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/comments?post=6274"}],"version-history":[{"count":5,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/6274\/revisions"}],"predecessor-version":[{"id":6326,"href":"https:\/\/outbreaktools.ca\/fr\/wp-json\/wp\/v2\/pages\/6274\/revisions\/6326"}],"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=6274"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}