Accessible Ecoli Hypothesis Generating Questionnaire

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Questionnaire Background for Interviewer

This questionnaire is designed to collect comprehensive information on possible risk factors for E. coli.  It is designed for cluster/outbreak investigations where the source of infection is unknown, but the questionnaire could be applied to investigate sporadic cases.

Data captured:    – Case demographics              – Food exposures

                               – Clinical information             – Pet exposures

                               – Laboratory information       – Other risk factors

Since outbreaks of E. coli are often linked back to contaminated food products, it is critical to collect as much detail as possible on food exposures.  Therefore this questionnaire has both an open ended food history followed by a detailed check list of food items; this may seem repetitive but is used to ensure all possible food exposures are captured. Please collect as much details 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 45 – 60 minutes to complete

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

I. Case information

Case Name:

Case ID National ID:

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 (dd/mm/yy):                                             Asymptomatic:   ▢ Y   ▢ N   ▢ DK

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

                            Bloody diarrhea     ▢ Y   ▢ N   ▢ DK              Headache     ▢ 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:

III. Ill Contacts

Were any of (your/case’s) contacts ill with similar symptoms in the 10 days before (you/case) became ill?  ▢ Y   ▢ N   ▢ DK

If yes, can you tell me who?

*Contacts include household members, sexual partners, individuals who prepared food for (you/case), children or adults that (you/case) assisted with bathroom use or diaper change, or other individuals with whom (you/case) may have come into contact with their vomit and/or stool

Name:                                                                            Sex:  ▢ M ▢ F                                             Phone Number:

Relationship to case:                                                  Age:                                                            Date of diarrhea onset (dd/mm/yy):

Name:                                                                            Sex: ▢ M ▢ F                                              Phone Number:

Relationship to case:                                                  Age:                                                            Date of diarrhea onset (dd/mm/yy):

Name:                                                                            Sex: ▢ M ▢ F                                              Phone Number:

Relationship to case:                                                  Age:                                                            Date of diarrhea onset (dd/mm/yy):

Escherichia coli Hypothesis Generating Questionnaire

Section 1: Case information

National ID:

Date of interview (dd/mm/yy):

Case Interviewed by:

Date reported to Health Unit/Authority(dd/mm/yy):

Health Unit/Authority:

Province/Territory:

Respondent was: ▢ Case ▢ Parent ▢ Spouse ▢ Caretaker ▢ Other, specify:

Age:

Sex: ▢ M ▢ F

Section 2: Clinical information

Serotype:

Phage Type:

PFGE 1:

PFGE 2:

Positive specimen type(s):

▢ Stool ▢ Blood ▢ Urine ▢ Other, specify:

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

Asymptomatic? ▢ Y ▢ N ▢ DK

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

Date of diarrhea onset (dd/mm/yy):

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 (dd/mm/yy):                                 ▢ Still hospitalized

Date of discharge (dd/mm/yy):

Hemolytic uremic syndrome (HUS)? ▢ Y ▢ N ▢ DK

Other complications? ▢ Y ▢ N ▢ DK

If yes, specify:

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

If yes, was E.coli infection the underlying/contributing cause of death? ▢ Y ▢ N ▢ DK

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

Section 3: Travel information

In the 10 days before onset of illness, 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):

Section 4: Special Diets or Food Preferences

First, I would like to ask some general questions about (your/case’s) diet and food preferences:

Are (you/case) a vegetarian? ▢ Y ▢ N ▢ DK

If yes, do (you/case) ever eat:

Eggs ▢ Y ▢ N ▢ DK                        Dairy ▢ Y ▢ N ▢ DK                           Fish ▢ Y ▢ N ▢ DK

Poultry ▢ Y ▢ N ▢ DK                   Red meat ▢ Y ▢ N ▢ DK                    Other Meat ▢ Y ▢ N ▢ DK              If yes, specify:

Are (you/case) allergic to any foods ?   ▢ Y ▢ N ▢ DK                          If yes, specify which foods:

Are there any foods/food groups that (you/case) never eat? ▢ Y ▢ N ▢ DK        If yes, describe:

In the 10 days prior to illness, were (you/case):

On a special or restricted diet? (e.g. raw food diet, vegan, diabetic diet, kosher, halal?     ▢Y ▢N ▢DK

If yes, describe:

Taking a dietary or nutritional supplement? (e.g. meal replacements, protein powder, vitamins, herbs) ▢ Y ▢ N ▢ DK

If yes, describe:

Did you consume any bottled, pre-made health drinks? (e.g. Kombucha, coconut water) ▢ Y ▢ N ▢ DK

If yes, describe:

Section 5: Foods eaten outside the home

In the 10 days prior to illness onset did (you/case) eat food outside home at a social gathering or at any of the following food establishments? (including food taken from a restaurant and eaten at home and samples eaten at establishments such as grocery stores)?

Places to eat out Type of Gathering/Establishment Name(s) Details of food(s) eaten Name(s), date(s) and location(s)

Social gathering or event
▢ Y ▢ N ▢ DK

If yes, are you aware of anyone else who became ill with diarrhea following the gathering?

▢ Y ▢ N ▢ DK

If yes, number ill?

▢ Homes of family or friend

▢ Snacks or food brought to school or worksite (e.g. cupcakes, potluck)

▢ Conference

▢ Community and/or Religious events

▢ Catered private event (weddings, parties, etc.)

▢ Group restaurant dinner

▢ Other:

 

 

Fast Food chain restaurant
▢ Y ▢ N ▢ DK

 

▢ McDonald’s              ▢ Wendy’s              ▢ Mr. Sub

▢ Burger King              ▢ Starbucks           ▢  A&W

▢ KFC/Taco Bell         ▢ Pizza Hut            ▢ Subway

▢ Dairy Queen            ▢ Tim Hortons       ▢ Harvey’s

▢ Pizza Pizza               ▢ Quizno’s

▢ Other:

   

Dining Chain restaurant
▢ Y ▢ N ▢ DK

 

▢ Boston Pizza                 ▢ Swiss Chalet 

▢ Keg Steakhouse            ▢ East Side Mario’s

▢ Kelsey’s                          ▢ Montana’s Cookhouse

▢ Other:

   

Other restaurant types
▢ Y ▢ N ▢ DK

 

▢ Mexican                               ▢ Steakhouse or grill

▢ Italian                                   ▢ Breakfast place

▢ Spanish                                 ▢ Seafood

▢ Greek                                     ▢ Pizzeria

▢ Vegetarian restaurant        ▢ Tavern or pub

▢ Buffet-style restaurant       ▢ Local restaurant/café

▢ Middle Eastern (e.g. shawarma, donair)

▢ Asian (Indian, Chinese, Thai, Korean, Japanese, etc.)

▢ Other:

   

Other food establishments
▢ Y  ▢ N ▢ DK

 

▢ Coffee Shop or Bakery

▢ Cafeteria or food served at an institution (school, university, hospital, workplace, etc.)

▢ Street vendor/ concession stand

▢ Meals served on plane, trains, buses or boats (not personal food)

▢ Ready to eat from Gas Stations/Convenience Stores

▢ Ready to eat from Grocery Store (including samples)

▢ Other:

   

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

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

Section 7: Online Food Purchases

In the 10 days prior to illness onset did (you/case) consume food/supplements purchased over the internet: ▢ Y ▢ P ▢ N

If yes please provide details:

Type / Variety / Brand Specify store name/website

 

 

 

Section 8: Ten Day Food History

I’d like to talk to you about the foods and drinks (you/case) ate/drank before (you/case) got sick. Starting with the day (you/case) were sick:

(Interviewer note: please probe regarding where foods were eaten and how prepared, e.g. prepared and eaten at home, eaten at a restaurant, take-out, ready-to-eat meal, frozen dinner, etc)

Day of illness (dd/mm/yy)  ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch

Dinner

Snacks

 

 

     

1 day before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch

Dinner

Snacks

 

 

     

2 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch

Dinner

Snacks

 

 

     

3 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch

Dinner

Snacks

 

 

     

4 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

5 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

6 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

7 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

8 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

9 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

10 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun

Breakfast

Lunch Dinner Snacks

 

 

     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 9: Food Exposures

I am interested in the food you ate during the 10 days before your illness onset date. For each food item please give me your best guess as to whether you ate the food, you’re not sure but you probably ate the food, or you did not eat the food. Please include food eaten on their own, or as part of a salad, sandwich, or dish.

INSTRUCTIONS FOR INTERVIEWER

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

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

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

Beef

 

Exposure

 

Response

 

Type / Variety / Brand

Where purchased or eaten:

Specify grocery store or restaurant name

Any beef (not including deli meat)

If yes, please specify type(s) below

▢Y ▢P ▢N ▢DK

   

Hamburgers (e.g. hamburger patties)

▢Y ▢P ▢N ▢DK

   

Hamburgers home made from ground beef

▢Y ▢P ▢N ▢DK

   

Store-bought frozen beef patties

▢Y ▢P ▢N ▢DK

   

Store-bought fresh beef patties

▢Y ▢P ▢N ▢DK

   

Any other ground beef (e.g. in hamburgers, tacos, spaghetti, lasagna)

▢Y ▢P ▢N ▢DK

   

Ground beef consumed raw or undercooked (e.g. under cooked hamburgers, tartare or kibbeh)

▢Y ▢P ▢N ▢DK

   

Raw beef (e.g., carpaccio)

Purchased:

▢ Fresh ▢ Frozen ▢DK

▢Y ▢P ▢N ▢DK

   

Steak

Purchased:

▢ Fresh ▢ Frozen ▢DK

▢Y ▢P ▢N ▢DK

   

Stewing beef

Purchased:

▢ Fresh ▢ Frozen ▢DK

▢Y ▢P ▢N ▢DK

   

Other whole cut beef products (e.g. roasts, ribs)

Purchased:

▢ Fresh ▢ Frozen ▢DK

▢Y ▢P ▢N ▢DK

   

Veal

▢Y ▢P ▢N ▢DK

   

Other beef (not including deli-meat)

▢Y ▢P ▢N ▢DK

   

Pork

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Any pork (not including deli meat)

If yes, please specify type(s) below

▢Y ▢P ▢N ▢DK

   

Ham (not including deli-meat)

▢Y ▢P ▢N ▢DK

   

Bacon

▢Y ▢P ▢N ▢DK

   

Ground pork

▢Y ▢P ▢N ▢DK

   

Any pork pieces or parts (e.g. roasts, ribs, chops, in soups, or as part of a dish, not including deli-meat or ham)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other pork (not including deli-meat)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Poultry

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Any chicken (not including deli-meat)

▢Y ▢P ▢N ▢DK

   

Store-bought breaded chicken (e.g. nuggets, strips or burgers)

▢Y ▢P ▢N ▢DK

   

Ground chicken

▢Y ▢P ▢N ▢DK

   

Any chicken pieces or parts (e.g. roasted whole chicken, breasts, wings, thighs, in soups, or as part of a dish, not including deli-meat)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other chicken (not including deli-meat)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any turkey (not including deli-meat)

If yes, please specify type(s) below

▢Y ▢P ▢N ▢DK

   

Turkey bacon

▢Y ▢P ▢N ▢DK

   

Ground turkey

▢Y ▢P ▢N ▢DK

   

Any turkey pieces or parts (e.g. roasted whole turkey, breasts, wings, thighs, in soups, or as part of a dish, not including deli-meat)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other turkey (not including deli-meat)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other poultry (not including deli meat e.g., Cornish hen, duck)

▢Y ▢P ▢N ▢DK

   

Eggs (e.g. scrambled eggs, omelets)

▢Y ▢P ▢N ▢DK

   

Eggs consumed raw or undercooked (e.g. “runny” or “over-easy”; anything made with raw eggs (e.g. raw cookie dough, cake batter, sauces, homemade ice cream, mayo, salad dressing, or in a drink)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other meat/animal products

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Any deli meats (e.g. Bologna, salami, pepperoni, turkey, ham)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Pre-packaged deli meat

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Deli-meat sliced at the deli counter

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Hot dogs or corn dogs

If yes, heated before eating

▢Y ▢P ▢N ▢DK

▢Y ▢P ▢N ▢DK

   

Sausage

▢ Beef     ▢ Pork     ▢ Chicken     ▢ Turkey

▢ Other (e.g. summer sausage)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Dried meat products (e.g. beef jerky, pepperettes)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Pâté/meat spread

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Lamb

▢Y ▢P ▢N ▢DK

   

Goat

▢Y ▢P ▢N ▢DK

   

Any kind of game/country food (e.g. venison, pheasant, rabbit, caribou, seal, quail, moose, bison)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any organ meats or offal (e.g. liver, kidney, heart)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other meat, excluding fish/seafood (e.g. shawarma/donair)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Fish and seafood

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Any fish (including fresh, canned, jarred, frozen)

If yes, please specify type(s) below

▢Y ▢P ▢N ▢DK

   

Smoked fish (e.g. smoked salmon)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Fish – eaten raw (e.g. sushi, tartare, sashimi, ceviche)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other fish (fresh, frozen, cooked, or dried fish)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Shellfish (e.g. oysters, clams, mussels, scallops, cockles)

If yes, specify:

If yes, was it eaten raw?

▢Y ▢P ▢N ▢DK

▢Y ▢P ▢N ▢DK

   

Crustaceans (e.g. crab, shrimp, prawns, crayfish, lobster)

If yes, specify:

If yes, was it eaten raw?

▢Y ▢P ▢N ▢DK

▢Y ▢P ▢N ▢DK

   

Other seafood or seaweed products

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Dairy and dairy substitutes

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Pasteurized dairy milk

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Unpasteurized (raw) dairy milk (excluding cheese)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Non-dairy milk (e.g. soy, almond, coconut, rice)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Powdered milk products (e.g. powdered milk, Carnation, Ovaltine)

▢Y ▢P ▢N ▢DK

   

Whipped/whipping cream

▢Y ▢P ▢N ▢DK

   

Sour cream

▢Y ▢P ▢N ▢DK

   

Ice cream/gelato

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Frozen dairy desserts

▢Y ▢P ▢N ▢DK

   

Milk or cream containing desserts (e.g. cream filled pies/pasteries, pudding)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Yogurt

▢Y ▢P ▢N ▢DK

   

Other dairy or dairy-alternative products

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Cheese

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Cheddar cheese

▢Y ▢P ▢N ▢DK

   

Mozzarella cheese

▢Y ▢P ▢N ▢DK

   

Parmesan cheese

▢Y ▢P ▢N ▢DK

   

Gouda

▢Y ▢P ▢N ▢DK

   

Feta cheese

▢Y ▢P ▢N ▢DK

   

Any brie, camembert or other soft cheeses

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any blue-veined cheese such as blue cheese or gorgonzola

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any cottage, ricotta or other fresh cheese

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any cheese made from goat/sheep milk

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any other cheese that is typically sold as block or cut from solid block or wheels (e.g. Emmental, jarlsberg, monterey jack, havarti, colby or oka)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Processed cheese (e.g. sliced cheese, cheese string/tubes or from a jar)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Any cheese made with unpasteurized (raw) milk

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Non-dairy cheese alternative

▢Y ▢P ▢N ▢DK

   

Vegetables

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Tomatoes

If yes, please specify type(s) below:

▢Y ▢P ▢N ▢DK

   

Roma/Plum

▢Y ▢P ▢N ▢DK

   

Hothouse

▢Y ▢P ▢N ▢DK

   

Beef steak

▢Y ▢P ▢N ▢DK

   

Cherry or grape

▢Y ▢P ▢N ▢DK

   

Other tomatoes (e.g. heirloom, vine-ripened)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Lettuce or leafy greens

(e.g. in a salad, on a sandwich or burger)

If yes, please specify type(s) below:

▢Y ▢P ▢N ▢DK

   

Iceberg

▢ prepackaged ▢ loose/head

▢Y ▢P ▢N ▢DK

   

Romaine

▢ prepackaged ▢ loose/head

▢Y ▢P ▢N ▢DK

   

Spinach

▢ prepackaged ▢ loose

▢Y ▢P ▢N ▢DK

   

Mesclun lettuce

▢ prepackaged ▢ loose

▢Y ▢P ▢N ▢DK

   

Kale

▢ prepackaged ▢ loose

▢Y ▢P ▢N ▢DK

   

Arugula

▢ prepackaged ▢ loose

▢Y ▢P ▢N ▢DK

   

Other lettuce/leafy greens

If yes, specify:

▢ prepackaged ▢ loose/head

▢Y ▢P ▢N ▢DK

   

Salad kits (e.g. in a bag)

▢Y ▢P ▢N ▢DK

   

Store-bought prepared green salad (e.g. Caesar, garden, chef’s, spinach)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Cabbage (include if eaten as coleslaw)

▢ prepackaged ▢ loose/head

▢Y ▢P ▢N ▢DK

   

Coleslaw

▢Y ▢P ▢N ▢DK

   

Sprouts (including on a sandwich or salads)

If yes, please specify type(s) below:

▢Y ▢P ▢N ▢DK

   

Alfalfa sprouts

▢Y ▢P ▢N ▢DK

   

Bean sprouts

▢Y ▢P ▢N ▢DK

   

Other sprouts, (e.g. onion, clover, broccoli)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Cucumbers

▢ English     ▢ Field     ▢ Mini

▢Y ▢P ▢N ▢DK

   

Bell peppers (e.g. red, green, yellow peppers)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Hot peppers (e.g. jalapeno, serrano, habanero)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Celery

▢Y ▢P ▢N ▢DK

   

Carrots (not mini)

▢Y ▢P ▢N ▢DK

   

Mini/baby carrots

▢Y ▢P ▢N ▢DK

   

Peas (fresh, raw pea pods, snap peas, snow peas)

▢Y ▢P ▢N ▢DK

   

Green or yellow beans

▢Y ▢P ▢N ▢DK

   

Broccoli

▢Y ▢P ▢N ▢DK

   

Cauliflower

▢Y ▢P ▢N ▢DK

   

Onions

If yes, please specify type(s) below:

▢Y ▢P ▢N ▢DK

   

White / yellow onions

▢Y ▢P ▢N ▢DK

   

Green onions

▢Y ▢P ▢N ▢DK

   

Red onions

▢Y ▢P ▢N ▢DK

   

Other onions

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Leeks

▢Y ▢P ▢N ▢DK

   

Fresh garlic (not powdered)

▢Y ▢P ▢N ▢DK

   

Mushrooms

▢Y ▢P ▢N ▢DK

   

Zucchini

▢Y ▢P ▢N ▢DK

   

Other vegetables

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Frozen vegetables

▢Y ▢P ▢N ▢DK

   

Fermented vegetables (e.g. kimchi, sauerkraut)

▢Y ▢P ▢N ▢DK

   

Store-bought potato salad

▢Y ▢P ▢N ▢DK

   

Store-bought pasta salad

▢Y ▢P ▢N ▢DK

   

Store-bought other salad (e.g. Greek, quinoa, bean)

▢Y ▢P ▢N ▢DK

   

Fruit

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Fruit salad/pre-cut fruit or fruit platter

▢Y ▢P ▢N ▢DK

   

Melon

If yes, please specify type(s) below:

▢Y ▢P ▢N ▢DK

   

Cantaloupe

▢Y ▢P ▢N ▢DK

   

Honeydew melon

▢Y ▢P ▢N ▢DK

   

Watermelon

▢Y ▢P ▢N ▢DK

   

Other melons

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Apples

▢Y ▢P ▢N ▢DK

   

Pears

▢Y ▢P ▢N ▢DK

   

Peaches

▢Y ▢P ▢N ▢DK

   

Nectarines

▢Y ▢P ▢N ▢DK

   

Apricots

▢Y ▢P ▢N ▢DK

   

Plums

▢Y ▢P ▢N ▢DK

   

Citrus fruits (e.g. oranges, grapefruit, lemons, limes)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Berries

If yes, please specify type(s) below:

▢Y ▢P ▢N ▢DK

   

Strawberries

▢Y ▢P ▢N ▢DK

   

Raspberries

▢Y ▢P ▢N ▢DK

   

Blueberries

▢Y ▢P ▢N ▢DK

   

Blackberries

▢Y ▢P ▢N ▢DK

   

Other berries (e.g. cranberries, gooseberries, tayberries)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Frozen berries

▢Y ▢P ▢N ▢DK

   

Frozen fruit other than frozen berries

▢Y ▢P ▢N ▢DK

   

Cherries

▢Y ▢P ▢N ▢DK

   

Grapes

▢Y ▢P ▢N ▢DK

   

Bananas

▢Y ▢P ▢N ▢DK

   

Mangos

▢Y ▢P ▢N ▢DK

   

Papaya

▢Y ▢P ▢N ▢DK

   

Kiwi

▢Y ▢P ▢N ▢DK

   

Pomegranate

▢Y ▢P ▢N ▢DK

   

Pineapple

▢Y ▢P ▢N ▢DK

   

Coconut

▢Y ▢P ▢N ▢DK

   

Avocado

▢ guacamole

▢Y ▢P ▢N ▢DK

   

Olives

▢Y ▢P ▢N ▢DK

   

Other fruit

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Beverages

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Vegetable juices (e.g. tomato juice, carrot juice)

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Any unpasteurized fruit juices (e.g. unpasteruzied apple cider)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Smoothies made with fresh or frozen fruit or produce, made at home or purchased fresh-made from a store, restaurant, or café

▢Y ▢P ▢N ▢DK

   

Bottled, pre-made smoothie

▢Y ▢P ▢N ▢DK

   

Herbs and spices

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Fresh Thai basil

▢Y ▢P ▢N ▢DK

   

Fresh basil

▢Y ▢P ▢N ▢DK

   

Fresh cilantro/coriander

▢Y ▢P ▢N ▢DK

   

Fresh parsley

▢Y ▢P ▢N ▢DK

   

Other fresh herbs (e.g. oregano, dill, mint, rosemary, chives and thyme)

If yes, specify: 

▢Y ▢P ▢N ▢DK

   

Any dried herbs or spices

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Store bought prepared spreads and dips

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Salsa

▢ Fresh (e.g. pico de gallo)         

▢ In a jar or can

▢Y ▢P ▢N ▢DK

   

Hummus

▢Y ▢P ▢N ▢DK

   

Any other dip:

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Frozen foods

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Frozen pizza

▢Y ▢P ▢N ▢DK

   

Frozen pot pies

▢Y ▢P ▢N ▢DK

   

Frozen meals in a bag or box (e.g. stir fry, frozen dinners)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Frozen snack foods/appetizers (e.g. mozzarella sticks, jalapeno poppers, fries)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Other frozen foods, (e.g. desserts, waffles)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Nuts and seeds

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Peanuts (not including peanut butter)

▢Y ▢P ▢N ▢DK

   

Almonds

▢Y ▢P ▢N ▢DK

   

Walnuts

▢Y ▢P ▢N ▢DK

   

Hazelnuts (filberts)

▢Y ▢P ▢N ▢DK

   

Cashews

▢Y ▢P ▢N ▢DK

   

Pecans

▢Y ▢P ▢N ▢DK

   

Pistachios

▢Y ▢P ▢N ▢DK

   

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

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Peanut butter

▢Y ▢P ▢N ▢DK

   

Nut paste, butter or spread (e.g. almond butter or chocolate hazelnut spread)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Sunflower seeds

▢Y ▢P ▢N ▢DK

   

Sesame seeds

▢Y ▢P ▢N ▢DK

   

Tahini, halva, or other products made from sesame seeds

▢Y ▢P ▢N ▢DK

   

Other seeds (e.g. chia/chia powder, flax, hemp)

If yes, specify:

▢Y ▢P ▢N ▢DK

   

Dried/Processed/Other foods

Exposure Response Specify type/variety, and brand Grocery store or restaurant name

Raw flour used in the household (e.g. for baking, cooking, playdough)

▢Y ▢P ▢N ▢DK

   

Eat, taste, or lick any uncooked or unbaked dough or batter (e.g. cookie dough, cake or muffin batter)

▢Y ▢P ▢N ▢DK

   

Tofu

▢Y ▢P ▢N ▢DK

   

Other soy products (e.g. tempeh, soy burgers, soy chicken)

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Dried fruits (e.g. raisins, cranberries, apricots, coconut)

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Granola bars, power bars or other protein bars

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Chips or pretzels

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Other prepackaged snack food (e.g. crackers, cookies, snack cakes)

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Chocolate or chocolate-containing candy

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Cold breakfast cereal

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Hot breakfast cereal (e.g. oatmeal, cream of wheat, porridge)

If yes, specify :

▢Y ▢P ▢N ▢DK

   

Section 10: Risk Factors

Finally, I’d like to ask you about other exposures. In the 10 days before onset of illness did (you/case):

Live in a residential institution? ▢ Y ▢ N ▢ DK

(e.g. Nursing home, long term care facility, prison, boarding school)

Name/location:

Attend a day care or day facility ? ▢ Y ▢ N ▢ DK

(Child or adult)

Name/location :

Attend school ▢ Y ▢ N ▢ DK

Name/location:

Work/volunteer as a food handler ▢ Y ▢ N ▢ DK

Name/location:

Handle any raw, bloody, or undercooked meat? ▢ Y ▢ N ▢ DK

Use the following sources of drinking water? (check all that apply)

▢ Municipal ▢ Well/Private water source ▢ Bottled water, specify: ▢ Other, specify:

Swim in/go into the ocean, a lake, a river, a pool or a hot tub?

▢ Y ▢ N ▢ DK If yes, specify type of water source and location:

Have any contact with companion animals, or pets, (including cats, dogs, rodents, reptiles, amphibians, fish, birds, etc) or their waste (including feces, bedding, litter, aquariums, etc), either at home or outside of the home?

▢ Y ▢ N ▢ DK If yes, specify type of animal(s): Location(s):

Have any contact with farm animals, or livestock (such as cattle, goats, sheep, horses, chickens/chicks, petting zoos, etc) or wild animals (including wildlife, zoo animals, etc), or their waste (including feces, bedding, litter, etc)?

▢ Y ▢ N ▢ DK If yes, specify type of animal(s): Location(s):

Visit a petting zoo?

▢ Y ▢ N ▢ DK   location(s):

 

Handle any animal foods/treats in the 10 days prior to illness onset? ▢ Y ▢ N ▢ DK

If yes did (you/case) handle:

Details (type, brand):

▢ Raw pet food

 

▢ Dry pet food

 

▢ Canned/wet pet food

 

▢ Treats derived from animal parts (e.g. pig ears, rawhide, cow hooves)

 

▢ Processed animal treats (e.g. chews, biscuits)

 

▢ Rodents/insects for reptiles

 

▢ Animal feed

 

▢ Other

If yes, specify:

 

Notes/General Comments:

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