info@outbreaktools.ca 
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Section 1. Interviewer Details
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Case interviewed by: |
Date of interview: d____/m____/y____ |
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Health Unit/Authority: |
Date reported to Health Unit/Authority: d____/m____/y____ |
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Province/Territory: |
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Respondent was: ▢ Case ▢ Parent ▢ Spouse ▢ Caretaker ▢ Other, specify: Name of person interviewed (if not case): Phone number: |
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Section 2. Case Information
| Black-out shaded cells if sending to PHAC | |
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Case Name: |
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Street Address: City/Town: Postal Code: |
Home phone: Work phone: Cell phone: |
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Physician: |
Physician Phone: |
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Health #: |
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Sex: ▢ M ▢ F |
Date of birth: d____/m____/y____ Age: |
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Country of birth: |
When immigrated to Canada: d____/m____/y____ |
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Aboriginal Person, that is, First Nations (North American Indian), Metis, or Inuit? ▢Y ▢N If FN or Metis, living on reserve? ▢Y ▢N What ethnic group do you most identify with? ▢ White ▢ South Asian (i.e. East Indian, Pakistani, Sri Lankan, etc.) ▢ Chinese ▢ Black ▢ Filipino ▢ Latin-American ▢ Arab ▢ Southeast Asian (i.e. Vietnamese, Cambodian, Malaysian, Laotian,etc. ) ▢ West Asian (i.e. Iranian, Afghan, etc.) ▢ Korean ▢ Japanese ▢ Other (includes mixed ethnicity), please specify: |
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Place(s) of Employment/Volunteer work: Last day worked: d____/m____/y____ Food/beverage handler: ▢Y ▢N Last day worked: d____/m____/y____ Specify duties: Daycare: ▢Y ▢N Last day worked: d____/m____/y____ Adult care facility*: ▢Y ▢N Last day worked: d____/m____/y____ Hospital/Health Care: ▢Y ▢N Last day worked: d____/m____/y____ In your place(s) of employment do you assist others with bathroom use/diapering? ▢Y ▢N * Adult care facility is defined as: a home or residence that provides residential care and/or services for adults (e.g., adult day care centre, retirement home, group home, shelter or prison/correction facility) |
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Attends Post-Secondary Institution: ▢Y ▢N
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If yes, Name and location of college/university: Date of last attendance: d____/m____/y____ |
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Attends Daycare: ▢Y ▢N
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If yes, Name and location of Daycare: Is case in diapers? ▢Y ▢N Toileting with assistance: ▢Y ▢N Toileting on own: ▢Y ▢N Date of last attendance: d____/m____/y____ |
Section 3: Clinical information (Historical and Current)
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Date of first positive specimen collection: d____/m____/y____ |
Anti-HAV IgM: ▢ Positive ▢ Indeterminate |
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Specimen submitted for genotyping: ▢Y ▢N ▢DK If yes, specify genotype: |
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Asymptomatic? ▢Y ▢N If yes, reason case was tested: ▢ Reported risk factors, specify: ▢ No risk factors (i.e., patient requested) ▢ Other: For Asymptomatic cases, please complete Sections 4, 5 and 12 only. |
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Symptoms: Jaundice ▢Y ▢N ▢DK If yes, date onset jaundice: d____/m____/y____ Abdominal Pain ▢Y ▢N ▢DK Anorexia ▢Y ▢N ▢DK Fatigue ▢Y ▢N ▢DK Fever ▢Y ▢N ▢DK Dark Urine ▢Y ▢N ▢DK Pale Stool ▢Y ▢N ▢DK Vomiting ▢Y ▢N ▢DK Elevated liver enzyme (i.e. ALT/AST) ▢Y ▢N ▢DK Other: |
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Admitted* to hospital because of Hepatitis A? ▢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 |
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When did symptoms resolve (recovery date)? d____/m____/y____ ▢ Still ill ▢ Don’t Know Complications related to illness: ▢Y ▢N ▢DK If yes, specify: |
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Have (you/case) been diagnosed with hepatitis A in the past? ▢Y ▢N ▢DK If yes, date: d____/m____/y____ |
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Have (you/case) received immunoglobulin in the past 5 months? ▢Y ▢N ▢DK If yes, date: d____/m____/y____ |
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Have (you/case) received hepatitis A vaccine in the past? ▢Y ▢N ▢DK If yes, date of last vaccine: d____/m____/y____ # of doses: |
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Case deceased? ▢ Y ▢ N If yes, Hepatitis A infection was (i) ▢ underlying or (ii) ▢ contributing cause of death, or ▢ DK Date of Death: d____/m____/y____ |
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Section 4: Incubation and Infectious Period
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Date of first symptom onset: d____/m____/y____ OR Proxy for onset date* (in order of preference): Specimen collection date: d____/m____/y____ Lab reporting date: d____/m____/y____ *In absence of a symptom onset date and for asymptomatic cases, please use, in order of preference, (i) specimen collection date, or (ii) lab reporting date, to calculate incubation and infectious periods Incubation Period : 50 days prior to first symptom onset d____/m____/y____: to 15 days prior to first symptom onset d____/m____/y____: Infectious Period: 14 days prior to first symptom onset d____/m____/y____: to 10 days after onset of jaundice d____/m____/y____: |
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To be filled out by interviewer: Should case be excluded from daycare, school, work or volunteer activities due to the diagnosis of hepatitis A? ▢Y ▢N ▢DK If yes, start date of exclusion d____/m____/y____: end date of exclusion d____/m____/y____: Was case formally excluded from daycare, school, work or volunteer activities due to the diagnosis of hepatitis A? ▢Y ▢N ▢DK If yes, start date of exclusion d____/m____/y____: end date of exclusion d____/m____/y____: |
Section 5: Preparing foods for others outside the home (excluding place of employment and for immediate family members)
Did the case prepare or handle food for others during the Infectious Period – 14 days prior to symptom onset to 10 days after onset of jaundice? ▢Y ▢N
If yes, please list and include details of food handling below and fill out Section 12 “Household and Close Contacts”
| Date | Occasion / Location (Include social gatherings, church gatherings, etc.) |
|---|---|
| d____/m____/y____ | |
| d____/m____/y____ | |
| d____/m____/y____ |
Section 6: Risk Factors for Acquiring Disease/Infection
During the incubation period, did (you/case) have:
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Contact with a known hepatitis A case: ▢Y ▢N Contact with a jaundiced individual: ▢Y ▢N If yes, provide name of contact and contact information (phone numbers, etc.): (black-out if sending to PHAC)
▢ Refused to provide name and/or contact information
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Receive a blood transfusion or blood products during the incubation period? ▢Y ▢N ▢DK If yes, date: d____/m____/y____ |
Receive an organ transplant during the incubation period? ▢Y ▢N ▢DK If yes, date: d____/m____/y____ |
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Donate blood during the incubation period? ▢Y ▢N ▢DK If yes, date: d____/m____/y____ |
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Travel within or outside of Canada? ▢Y ▢N ▢DK |
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If yes: ▢Within Province ▢ Within Canada ▢ Outside Canada Specify travel destination(s) (country/town/resort): |
Departure: d____/m____/y____ Return: d____/m____/y____ |
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If yes: ▢Within Province ▢ Within Canada ▢ Outside Canada Specify travel destination(s) (country/town/resort): |
Departure (dd/mm/yy): Return (dd/mm/yy): |
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If yes: ▢Within Province ▢ Within Canada ▢ Outside Canada Specify travel destination(s) (country/town/resort): |
Departure (dd/mm/yy): Return (dd/mm/yy): |
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Live/Stay in a residential institution/facility? ▢Y ▢N ▢DK If yes, please specify: ▢Prison/Correction facility ▢Community residential program (i.e. group home, shelter) ▢Acute care facility (i.e. hospital) Institution/facility name: ▢Residential facility serving the developmentally disabled ▢Long-term care facility/nursing home ▢Other (specify): |
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Diaper a child or assist a child or adult with bathroom use? ▢Y ▢N ▢DK |
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What were (your/case’s) sources of drinking water during incubation period? (check all that apply) ▢Municipal ▢Well/Private water source ▢Bottled water (specify brand): ▢Other: Did (you/case) come in contact with, or were (you/case) exposed to, sewage back-up? ▢Y ▢N ▢DK If yes, please specify: |
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Were (you/case) sexually active within the incubation period? ▢Y ▢N ▢Refuse (please ask both question regardless of case’s sex) If yes, how many male partners? How many female partners? |
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Did (you/case) use intravenous drugs (IDU) during the incubation period? ▢Y ▢N ▢Refuse |
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Did (you/case) use non-intravenous drugs (non-IDU) during the incubation period? ▢Y ▢N ▢Refuse |
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Section 7: Special Diets or Food Preferences
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Are (you/case) a vegetarian? ▢Y ▢ N ▢ DK If yes, do (you/case) ever eat: Eggs ▢Y ▢N ▢DK Dairy ▢Y ▢N ▢DK Poultry ▢Y ▢N ▢DK Fish ▢Y ▢N ▢DK Red meat ▢Y ▢N ▢DK Other Meat ▢Y ▢N ▢DK If yes, specify: |
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Are (you/case) allergic to any foods ? ▢Y ▢N ▢DK If yes, specify which foods: |
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Are there any foods/food groups that (you/case) never eat? ▢Y ▢N ▢DK If yes, describe: |
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In the incubation period, 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: Consuming any foods that are associated with a specific culture (e.g., Chinese, Italian, Indian, Lebanese food)? ▢Y ▢N ▢DK If yes, describe: |
Section 8: Social Gatherings and Activities
Did (you/case) attend any social gatherings where food was served during Incubation Period – 15 to 50 days prior to illness onset? ▢Y ▢N ▢DK
(Note, social gatherings include weddings, pot lucks, parties, religious events, community events, conferences, movies, sports events, bars, clubs, fitness centers, etc.)
If yes, complete information below:
| Event names/description | Location | Food consumed | Date |
|---|---|---|---|
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d____/m____/y____ | ||
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d____/m____/y____ | ||
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d____/m____/y____ | ||
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d____/m____/y____ | ||
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d____/m____/y____ |
Section 9: Foods prepared outside the home
Did (you/case) eat foods prepared outside the home (including take-out food) during the Incubation Period – 15 to 50 days prior to illness onset? ▢Y ▢N ▢P ▢DK
(including restaurants, bars, fast food outlets, coffee shops or bakeries, cafeterias, street vendors or concession stands)
*P (Probably) = Case thinks he/she ate at the food establishment, or case usually eats at the food establishment, but is unsure if ate at the establishment during the time period in question
| Food Establishment | Location(s) | Items Consumed | Date(s) |
|---|---|---|---|
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Restaurant(s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
| d____/m____/y____ | |||
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Coffee Shop / Fast Food Outlet(s) (ie: Subway, McDonalds, Tim Horton’s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
| d____/m____/y____ | |||
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Cafeteria(s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
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Bakery / Deli(s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
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Ready-to-Eat Food from Grocery/Convenience Store(s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
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Street Vendor(s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
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Concession(s) at an Event ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
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Gas Stations(s) ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ | |||
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Other(s): Specify ▢ Y ▢ P |
d____/m____/y____ | ||
| d____/m____/y____ |
Section 10: Home Food Purchases
Where did (you/case) usually purchase food for home consumption before (your/case’s) illness (include grocery stores, farmers markets, specialty stores, ethnic markets, food banks etc)?
| Store Name | Location/Address | |
|---|---|---|
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A. |
Loyalty card available? ▢ Y ▢ N ▢ DK Loyalty card #: |
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B. |
Loyalty card available? ▢ Y ▢ N ▢ DK Loyalty card #: |
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C. |
Loyalty card available? ▢ Y ▢ N ▢ DK Loyalty card #: |
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D. |
Loyalty card available? ▢ Y ▢ N ▢ DK Loyalty card #: |
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E. |
Loyalty card available? ▢ Y ▢ N ▢ DK Loyalty card #: |
Section 11: Food exposures
I am interested in the food you ate during the 15 to 50 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. Please include food eaten on their own, or as part of a salad, sandwich, or dish.
*Prob (Probably Ate) = Case thinks he/she ate this food or case usually eats this food, but is unsure if eaten during time period in question
Fresh Vegetables
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Exposure |
Yes | Prob* | No | DK | IMPORTANT. Please complete as much detail as possible Type/ Variety/ Brand |
Where purchased: |
|---|---|---|---|---|---|---|
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Tomatoes (not grown at home) If yes, specify types below: |
▢Y |
▢P |
▢N |
▢DK |
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Roma Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Cherry Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Hot house Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Semi-dried Purchased: ▢ loose ▢ in oil Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Sun-dried Purchased: ▢ loose ▢ in oil Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Other (i.e. Beef steak) If yes, specify: Consumed: ▢ raw/fresh ▢ cooked ▢ sundried ▢ semi-dried |
▢Y |
▢P |
▢N |
▢DK |
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Salsa (If yes, specify types below): |
▢Y |
▢P |
▢N |
▢DK |
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Store-bought Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Homemade Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Iceberg lettuce Purchased as: ▢ prepackaged ▢ loose/head |
▢Y |
▢P |
▢N |
▢DK |
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Romaine Lettuce Purchased as: ▢ prepackaged ▢ loose/head |
▢Y |
▢P |
▢N |
▢DK |
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Mesclun ‘spring mix’ Purchased as: ▢ prepackaged ▢ loose |
▢Y |
▢P |
▢N |
▢DK |
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Spinach Purchased: ▢prepackaged ▢loose/bunch ▢frozen Consumed: ▢raw/fresh ▢cooked |
▢Y |
▢P |
▢N |
▢DK |
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Other lettuce (i.e. kale, arugula, etc.) If yes, specify: Purchased as: ▢ prepackaged ▢ loose/head |
▢Y |
▢P |
▢N |
▢DK |
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Salad kits (i.e. in a bag) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
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Store-bought prepared green salad (i.e. Caesar, garden, chef’s, spinach) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
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Coleslaw |
▢Y |
▢P |
▢N |
▢DK |
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Cabbage (also include if eaten in coleslaw) Consumed: ▢raw/fresh ▢cooked |
▢Y |
▢P |
▢N |
▢DK |
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Basil Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes |
▢Y |
▢P |
▢N |
▢DK |
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Parsley Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes |
▢Y |
▢P |
▢N |
▢DK |
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Cilantro Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes |
▢Y |
▢P |
▢N |
▢DK |
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Other fresh herbs (specify): Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes |
▢Y |
▢P |
▢N |
▢DK |
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Sprouts (i.e. alfalfa, bean, onion; including sprouts on sandwiches, in a stir fry, etc.) If yes, specify: Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Cucumbers |
▢Y |
▢P |
▢N |
▢DK |
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Celery Purchased: ▢ loose ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Bell peppers (If yes, specify types below): |
▢Y |
▢P |
▢N |
▢DK |
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Green Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Red Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Yellow Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Orange Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Hot peppers (i.e. jalapeno, Serrano, habanero, etc) If yes, specify: Consumed: ▢ raw/fresh ▢ cooked ▢ dried |
▢Y |
▢P |
▢N |
▢DK |
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Carrots (not mini) Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Mini carrots Purchased: ▢ raw/fresh ▢ frozen Consumed:▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Peas Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Beans Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Broccoli Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Corn Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Cauliflower Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Onions (If yes, specify types below): |
▢Y |
▢P |
▢N |
▢DK |
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White Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Yellow Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Red Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Green/scallion Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Onions (continued): |
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Shallots Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Leeks Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Mushrooms (specify) : Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Other vegetables (i.e. radish, zucchini, rhubarb, kohlrabi, etc.) If yes, specify: Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
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Vegetable juice (i.e. tomato, carrot, V8, etc) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
Fruit (including fruits eaten in a fruit salad, fruits in drinks, etc)
|
Exposure |
Yes | Prob* | No | DK | IMPORTANT. Please complete as much detail as possible Type/ Variety/ Brand |
Where purchased: |
|---|---|---|---|---|---|---|
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Cantaloupe Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Honeydew Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Watermelon Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Other melons Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Apples |
▢Y |
▢P |
▢N |
▢DK |
||
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Pears |
▢Y |
▢P |
▢N |
▢DK |
||
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Peaches Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Nectarines |
▢Y |
▢P |
▢N |
▢DK |
||
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Apricots |
▢Y |
▢P |
▢N |
▢DK |
||
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Plums |
▢Y |
▢P |
▢N |
▢DK |
||
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Citrus fruits (e.g. oranges, grapefruit, lemons, limes) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
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Berries (If yes, specify types below): |
▢Y |
▢P |
▢N |
▢DK |
||
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Raspberries Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Strawberries Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Blueberries Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Blackberries Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Mixed berries Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Other, specify: Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Cherries |
▢Y |
▢P |
▢N |
▢DK |
||
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Pomegranate Purchased: ▢ whole fruit ▢ seeds |
▢Y |
▢P |
▢N |
▢DK |
||
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Grapes (If yes, specify types below): |
▢Y |
▢P |
▢N |
▢DK |
||
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Red: Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Green: Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Bananas |
▢Y |
▢P |
▢N |
▢DK |
||
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Mango Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
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Kiwi Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Pineapple Purchased: ▢ raw/fresh ▢ frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Fruit salad If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Dried fruits (i.e. raisins, cranberries, apricots) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Avocado |
▢Y |
▢P |
▢N |
▢DK |
||
|
Guacamole (If yes, specify types below): |
▢Y |
▢P |
▢N |
▢DK |
||
|
Store-bought: Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
||
|
Homemade: Consumed: ▢ raw/fresh ▢ cooked |
▢Y |
▢P |
▢N |
▢DK |
||
|
Other fruits (i.e. papaya, guava, etc.) Purchased: ▢ raw/fresh ▢ frozen If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Fresh apple juice or cider |
▢Y |
▢P |
▢N |
▢DK |
||
|
Fresh orange juice (not from concentrate) |
▢Y |
▢P |
▢N |
▢DK |
||
|
Any unpasteurized fruit juices (e.g. freshly squeezed orange juice, etc.) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Fruit smoothies (specify): |
▢Y |
▢P |
▢N |
▢DK |
Fish and seafood
|
Exposure |
Yes | Prob* | No | DK | IMPORTANT. Please complete as much detail as possible Type/ Variety/ Brand |
Where purchased: |
|---|---|---|---|---|---|---|
|
Fish – eaten RAW (i.e. sushi, tartare, etc) If yes, specify: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Fish – UNDERCOOKED If yes, specify: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Smoked or dried fish If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Oysters If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: ▢Y ▢N ▢DK Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Clams If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: ▢Y ▢N ▢DK Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Mussels If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: ▢Y ▢N ▢DK Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Scallops If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Cockles If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Crab If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: ▢Y ▢N ▢DK Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Shrimp/Prawns If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Crayfish If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Lobster If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
||
|
Other fish, seafood or seaweed products If yes, specify: If yes, eaten RAW: ▢Y ▢N ▢DK If yes, eaten UNDERCOOKED: Purchased: ▢raw/fresh ▢frozen |
▢Y |
▢P |
▢N |
▢DK |
Deli-meats and other meats
|
Exposure |
Yes | Prob* | No | DK | IMPORTANT. Please complete as much detail as possible Type/ Variety/ Brand |
Where purchased: |
|---|---|---|---|---|---|---|
|
Chicken-deli meat |
▢Y |
▢P |
▢N |
▢DK |
||
|
Turkey-deli meat |
▢Y |
▢P |
▢N |
▢DK |
||
|
Ham deli-meat |
▢Y |
▢P |
▢N |
▢DK |
||
|
Beef deli-meat |
▢Y |
▢P |
▢N |
▢DK |
||
|
Bologna |
▢Y |
▢P |
▢N |
▢DK |
||
|
Salami |
▢Y |
▢P |
▢N |
▢DK |
||
|
Corned beef |
▢Y |
▢P |
▢N |
▢DK |
||
|
Pepperoni |
▢Y |
▢P |
▢N |
▢DK |
||
|
Other deli meat (i.e. pastrami, kielbasa, parma ham, etc.) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Hot dogs If yes, was it heated before eating: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Pâté/meat spread If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
RAW meat (i.e. steak tartare, etc) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Other UNDERCOOKED meat (excluding fish/seafood) If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
Dairy and dairy substitutes
|
Exposure |
Yes | Prob* | No | DK | IMPORTANT. Please complete as much detail as possible Type/ Variety/ Brand |
Where purchased: |
|---|---|---|---|---|---|---|
|
Unpasteurized milk If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Unpasteurized cheese If yes, specify: |
▢Y |
▢P |
▢N |
▢DK |
||
|
Other unpasteurized dairy products If yes, specify |
▢Y |
▢P |
▢N |
▢DK |
||
|
Cheese slices bought at deli counter |
▢Y |
▢P |
▢N |
▢DK |
Section 12: Household and Close Contacts (remove if sending to PHAC)
Did you/case have any household or other close contacts* in the 14 days prior to symptom onset to 10 days after onset of jaundice? ▢Y ▢N
(Infectious Period: 14 days prior to first symptom onset: d____/m____/y____ to 10 days after onset of jaundice: d____/m____/y____)
If yes, please list and include details of contact:
| Name of contact | Type of contact* | Age | Gender | Phone # | Date of contact (YYYY/MM/DD) | Does contact work or volunteer as: | Is contact symptomatic? (Y/N) If yes, date of onset (YYYY/MM/DD) | Previous Immunizations/ Infections? (Y/N) | ||
|---|---|---|---|---|---|---|---|---|---|---|
| Food handler (Y/N) | Child care worker (Y/N) | Health care worker (Y/N) | ||||||||
*Consider: household contacts; contacts with a very close or physical relationship including sexual contacts; contacts for whom the case prepared food; contacts who shared cigarettes, food or eating or drinking utensils with case; contacts that share a common bathroom (i.e. workplace contacts)
Section 13: Prophylaxis (remove if sending to PHAC)
| Prophylaxis of Contact(s): ▢ Yes ▢ No If yes, total number of people eligible for prophylaxis: | ||
| Summary of eligible individuals: | ||
|
Vaccine Only: ▢ Yes ▢ No If yes: Number eligible for 1 dose: Number eligible for 2 doses: |
IG Only: ▢ Yes ▢ No If yes: Number eligible: |
Both Vaccine and IG: ▢ Yes ▢ No If yes: Number eligible for 1 dose: Number eligible for 2 doses: |
Notes: