Accessible Cyclosporiasis Hypothesis Generating Questionnaire

Questionnaire Background for Interviewer

This questionnaire is designed to collect comprehensive information on possible risk factors for cyclosporiasis. More details are collected on high risk foods (berries, herbs and leafy greens), but please ask the case about all food items listed. Text is included above each food section to explain what information we are trying to capture and prompts to remind cases to include garnishes.

Since outbreaks of cyclosporiasis are often linked back to contaminated food products, it is critical to collect as much detail as possible on food exposures. Please collect as much detail as possible for each item, including restaurant exposures. Also consider using a calendar to probe and collecting receipts, purchase data or loyalty cards if available.

The questionnaire is estimated to take 30 minutes to complete.

For local use only – please remove this page if sending to PHAC

I. Case information

Case Name:	Proxy Name:
Health Card Number:
Street Address: City/Town: Postal Code:	Home phone: Work phone: Cell Phone:
Physician:	Physician Phone:
Occupation:	Place(s) of employment:

II. Symptoms

Date of first symptom onset: d____/m____/y____ Asymptomatic: ▢ Y ▢ N ▢ DK

Symptoms: Watery Diarrhea* ▢ Y ▢ N ▢ DK Fever ▢ Y ▢ N ▢ DK Abdominal cramps ▢ Y ▢ N ▢ DK

Fatigue ▢ Y ▢ N ▢ DK Gas ▢ Y ▢ N ▢ DK Nausea ▢ Y ▢ N ▢ DK

Vomiting ▢ Y ▢ N ▢ DK Other: ▢ Y ▢ N ▢ DK If other, please specify:

*3 or more loose stools in a 24 hour period

Underlying conditions or medications that suppress the immune system (e.g. pregnancy, diabetes, cancer, steroids)? ▢ Y ▢ N ▢ DK

If yes, please specify:

Cyclosporiasis Hypothesis Generating Questionnaire

Section 1: Case information

National ID:	Date of interview: d____/m____/y____
Case Interviewed by:	Date reported to Health Unit/Authority: d____/m____/y____
Health Unit/Authority:	Province/Territory:
Age:	Sex: ▢ M ▢ F
Respondent was: ▢ Case ▢ Parent ▢ Spouse ▢ Caretaker ▢ Other, specify:

Section 2: Clinical information

Positive specimen type(s):

▢ Stool ▢ Other, specify:

Date of first symptom onset: d____/m____/y____

Asymptomatic? ▢ Y ▢ N ▢ DK

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

Date of diarrhea onset: d____/m____/y____

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

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

Date of admission: d____/m____/y____

Date of discharge: d____/m____/y____ ▢ Still hospitalized

Case deceased? ▢ Y ▢ N Date of Death: d____/m____/y____

Section 3: Travel information

In the 14 days before onset of illness, that is, from d____/m____/y____ through d____/m____/y____ , did (you/case) travel within or outside of Canada? ▢ Y ▢ N ▢ DK

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

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

Departure (dd/mm/yy): Return (dd/mm/yy):

If case spent entire incubation period outside of Canada, then stop interview here. If case spent part of incubation period within Canada, then continue interview to capture domestic exposures only.

Section 4: Social Gatherings

Did (you/case) attend any social gatherings in the 14 days prior to illness onset? ▢ Y ▢ N ▢ DK

(Note: can include weddings, parties, potlucks, religious events, community events, conferences, etc.

If yes, complete the information below:

Event Name, Location, Description:	Date(s) of gathering (dd/mm/yy to dd/mm/yy)	Are you aware of anyone else who became ill with diarrhea following the gathering?
	d____/m____/y____ to d____/m____/y____	▢ Y ▢ N ▢ DK If yes, number ill?
	d____/m____/y____ to d____/m____/y____	▢ Y ▢ N ▢ DK If yes, number ill?
	d____/m____/y____ to d____/m____/y____	▢ Y ▢ N ▢ DK If yes, number ill?
Notes:

Section 5: Food Establishments outside the home

In the 14 days prior to illness onset did (you/case) eat at any food establishments? (including food taken from a restaurant and eaten at home and samples eaten at establishments such as grocery stores)? We will ask you about what you ate later in this questionnaire.

Food Establishment	Name(s)	Date(s)	Location(s)

Section 6: Home Food Purchases

Where did (you/case) usually purchase food for home consumption (include grocery stores, farmers markets, specialty stores, ethnic markets, food banks, etc)?

*Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC

	Store Name	Location/Address
A	Loyalty card available? ▢ Y ▢ N ▢ DK
B	Loyalty card available? ▢ Y ▢ N ▢ DK
C	Loyalty card available? ▢ Y ▢ N ▢ DK
D	Loyalty card available? ▢ Y ▢ N ▢ DK
E	Loyalty card available? ▢ Y ▢ N ▢ DK
	Willing to share purchase information from your loyalty card if needed? ▢ Y ▢ N

Section 7: Food Exposures

INSTRUCTIONS TO READ TO CASE

I am interested in the food you ate during the 14 days before your illness onset date; that is from d____/m_____/y_____ through d____/m____/y____. For each food item please give me your best guess as to whether you ate the food, you’re not sure but you probably ate the food, or you did not eat the food.

Berries

I have some questions about fresh berries, not canned, cooked, or frozen, you might have eaten during the 14 days before your illness began. You could have eaten these either in your home or away from home. I am only interested in fresh berries that were not grown at home. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick. Please remember that berries are often served as garnishes on top of or on the sides of salads and desserts or in smoothies.

Product and consumption	Details
Fresh strawberries ▢Y ▢P ▢N ▢DK Were they eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how were they packaged ▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other: Please include as much information as possible on the berries purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Fresh raspberries ▢Y ▢P ▢N ▢DK Were they eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how were they packaged ▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other: Please include as much information as possible on the berries purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Fresh blackberries ▢Y ▢P ▢N ▢DK Were they eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how were they packaged ▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other: Please include as much information as possible on the berries purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Fresh blueberries ▢Y ▢P ▢N ▢DK Were they eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how were they packaged ▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other: Please include as much information as possible on the berries purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Other fresh berries (e.g., mixed fruit platter) ▢Y ▢P ▢N ▢DK	Product details:

Product and consumption

Details

Fresh strawberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh raspberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh blackberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh blueberries

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ plastic clamshell ▢ cardboard box/basket ▢ plastic basket ▢ from a salad bar ▢ other:

Please include as much information as possible on the berries purchased:

▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other fresh berries
(e.g., mixed fruit platter)

▢Y ▢P ▢N ▢DK

Product details:

Herbs

I have questions about fresh herbs that you may have eaten during the 14 days before illness began. Remember, these could have been part of a dish such as pesto, salsa, sauces, etc. I am interested in fresh herbs, not dried or bottled herbs. I am also only interested in fresh herbs that were not grown at home. Please remember that fresh herbs are often served as garnishes on top of or on the sides of entrees and desserts. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Product and consumption	Details
Fresh basil ▢Y ▢P ▢N ▢DK Specify: ▢ Thai Basil (green leaves and purple stems) ▢ Other basil: Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Fresh cilantro/coriander ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Fresh parsley ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Other fresh herbs ▢Y ▢P ▢N ▢DK	Product details

Product and consumption

Details

Fresh basil

▢Y ▢P ▢N ▢DK

Specify:

▢ Thai Basil (green leaves and purple stems)

▢ Other basil:

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh cilantro/coriander

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Fresh parsley

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ plastic clamshell ▢ tube ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other fresh herbs

▢Y ▢P ▢N ▢DK

Product details

Lettuce and leafy greens

I have some questions about lettuce and leafy greens you might have eaten raw or uncooked during the 14 days before your illness began. You could have eaten this either in your home or away from home. This does not include canned or frozen items, but these foods could have been eaten alone or as part of a dish. I am only interested in lettuce and leafy greens that were not grown at home. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick. Please include lettuce or leafy greens you may have eaten on on sandwiches or burgers or as a garnish.

Product and location of consumption	Details
Iceberg lettuce ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ prepackaged, precut ▢ prepackaged, whole ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Romaine lettuce ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ prepackaged, precut ▢ prepackaged, whole ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Spinach ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Mesclun lettuce ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Arugula ▢Y ▢P ▢N ▢DK Were they eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Prepackaged salad mix ▢Y ▢P ▢N ▢DK Was it eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how was it packaged ▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Other lettuce/leafy greens ▢Y ▢P ▢N ▢DK	Product details

Product and location of consumption

Details

Iceberg lettuce

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged, precut ▢ prepackaged, whole ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Romaine lettuce

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged, precut ▢ prepackaged, whole ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Spinach

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Mesclun lettuce

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Arugula

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Prepackaged salad mix

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how was it packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other lettuce/leafy greens

▢Y ▢P ▢N ▢DK

Product details

Other fresh vegetables

Now I have some questions about other fresh vegetables, not grown at home, that you may have eaten in the 14 days before your illness began. This does not include canned items, but these foods could have been eaten alone or as part of a dish. I am only interested in vegetables that were not grown at home. As I read each food, please answer as yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Product and location of consumption	Details
Peas ▢Y ▢P ▢N ▢DK Specify: Snow peas (flat pods containing tiny peas) ▢Y ▢P ▢N ▢DK Snap peas (plump, crisp edible pods) ▢Y ▢P ▢N ▢DK Other peas: ▢Y ▢P ▢N ▢DK Were they eaten: ▢ at home ▢ restaurant (name and location): ▢ other, specify:	If purchased, how were they packaged ▢ loose ▢ prepackaged in a bag ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:
Green onions ▢Y ▢P ▢N ▢DK	If purchased, how were they packaged ▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar ▢ other: Please include as much information as possible on the product purchased: ▢ Local (grown in Canada) ▢ Imported (grown outside Canada) Country: Brand/lot code: Store name/location: Date purchased: Date consumed:

Product and location of consumption

Details

Peas

▢Y ▢P ▢N ▢DK

Specify:

Snow peas (flat pods containing tiny peas)
▢Y ▢P ▢N ▢DK

Snap peas (plump, crisp edible pods)
▢Y ▢P ▢N ▢DK

Other peas:
▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If purchased, how were they packaged

▢ loose ▢ prepackaged in a bag ▢ from a salad bar ▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Green onions

▢Y ▢P ▢N ▢DK

If purchased, how were they packaged

▢ loose ▢ prepackaged in a bag ▢ prepackaged in a box/clamshell ▢ from a salad bar

▢ other:

Please include as much information as possible on the product purchased:

▢ Local (grown in Canada)

▢ Imported (grown outside Canada) Country:

Brand/lot code:

Store name/location:

Date purchased:

Date consumed:

Other foods

Now I have some questions about other products containing fresh fruits, vegetables or herbs. This does not include canned items. I am only interested in that were not grown at home. As I read each food, please answer as yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Fresh Salsa

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Guacamole

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Pesto

▢Y ▢P ▢N ▢DK

Was it eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Any other foods containing fresh berries or herbs (salad, dip or salad dressing)

▢Y ▢P ▢N ▢DK

Were they eaten:

▢ at home

▢ restaurant (name and location):

▢ other, specify:

If homemade, list ingredients:

If purchased, how was it packaged

▢ in a jar ▢ in a plastic container ▢ other:

Please include as much information as possible on the product purchased:

Brand/lot code

Store name/location:

Date purchased:

Date consumed:

Other fresh fruit and vegetables

Now I have some questions about fresh fruits and vegetables, not canned, cooked, or frozen, you might have eaten during the 14 days before your illness began. You could have eaten these either in your home or away from home. I am only interested in fresh fruits that were not grown at home. As I read each food, please answer yes, no, probably, or don’t know if you ate the food in the 14 days before you got sick.

Other fresh fruit:
Food item	Eaten	Product details	Food item	Eaten	Product details
Melon	▢Y ▢P ▢N ▢DK		Grapes	▢Y ▢P ▢N ▢DK
Peaches	▢Y ▢P ▢N ▢DK		Mangos	▢Y ▢P ▢N ▢DK
Nectarines	▢Y ▢P ▢N ▢DK		Avocado	▢Y ▢P ▢N ▢DK
Apricots	▢Y ▢P ▢N ▢DK		Coconut	▢Y ▢P ▢N ▢DK
Plums	▢Y ▢P ▢N ▢DK		Citrus Fruits	▢Y ▢P ▢N ▢DK
Cherries	▢Y ▢P ▢N ▢DK		Unpasteurized Fruit juice/cider	▢Y ▢P ▢N ▢DK
Other fresh fruits:	▢Y ▢P ▢N ▢DK

Other fresh vegetables:
Food item	Eaten	Product details	Food item	Eaten	Product details
Tomatoes	▢Y ▢P ▢N ▢DK		Broccoli	▢Y ▢P ▢N ▢DK
Cabbage	▢Y ▢P ▢N ▢DK		Cauliflower	▢Y ▢P ▢N ▢DK
Sprouts	▢Y ▢P ▢N ▢DK		Celery	▢Y ▢P ▢N ▢DK
Cucumbers	▢Y ▢P ▢N ▢DK		Carrot	▢Y ▢P ▢N ▢DK
Bell pepper	▢Y ▢P ▢N ▢DK		Onions	▢Y ▢P ▢N ▢DK
Hot pepper	▢Y ▢P ▢N ▢DK		Garlic	▢Y ▢P ▢N ▢DK
Other fresh vegetables:	▢Y ▢P ▢N ▢DK

Notes/General Comments:

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