Hepatitis A Hypothesis Generating Questionnaire

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Section 1. Interviewer Details

Case interviewed by:

Date of interview (dd/mm/yy):

Health Unit/Authority:

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

Province/Territory:

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

Name of person interviewed (if not case):                                                                                         Phone number:

Section 2. Case Information

Case ID:

National ID:

Case Name:

Street Address:

City/Town:

Postal Code:

Home phone:

Work phone:

Cell phone:

Physician:

Physician Phone:

Health #:

Sex: ▢ M ▢ F

Date of birth (dd/mm/yy):

Age: 

Country of birth:

When immigrated to Canada (dd/mm/yy):

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:

Place(s) of Employment/Volunteer work:                    Last day worked (dd/mm/yy):

Food/beverage handler: ▢Y ▢N                Last day worked (dd/mm/yy):                 Specify duties:

Daycare: ▢Y ▢N Last day worked (dd/mm/yy):

Adult care facility*: ▢Y ▢N Last day worked (dd/mm/yy):

Hospital/Health Care: ▢Y ▢N Last day worked (dd/mm/yy):

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)

Attends Post-Secondary Institution: ▢Y ▢N

 

If yes, Name and location of college/university:

Date of last attendance (dd/mm/yy):

Attends Daycare: ▢Y ▢N

 

If yes, Name and location of Daycare:

Is case in diapers? ▢Y ▢N Toiletting with assistance: ▢Y ▢N Toiletting on own: ▢Y ▢N

Date of last attendance (dd/mm/yy):

Section 3: Clinical information (Historical and Current)

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

Anti-HAV IgM: ▢ Positive ▢ Indeterminate

Specimen submitted for genotyping: ▢Y ▢N ▢DK

If yes, specify genotype:

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.

Symptoms:

Jaundice ▢Y ▢N ▢DK                   If yes, date onset jaundice (dd/mm/yy):

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:

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 (dd/mm/yy):               

Date of discharge (dd/mm/yy):                  ▢ Still hospitalized

When did symptoms resolve (recovery date) (dd/mm/yy)?                                             ▢ Still ill     ▢ Don’t Know

Complications related to illness:   ▢Y ▢N ▢DK           If yes, specify:

Have (you/case) been diagnosed with hepatitis A in the past?  ▢Y ▢N ▢DK      If yes, date (dd/mm/yy):

Have (you/case) received immunoglobulin in the past 5 months?  ▢Y ▢N ▢DK   If yes, date (dd/mm/yy):

Have (you/case) received hepatitis A vaccine in the past?    ▢Y ▢N ▢DK   If yes, date of last vaccine (dd/mm/yy):                            # of doses: 

Case deceased? ▢ Y ▢ N             If yes, Hepatitis A infection was (i) ▢ underlying or (ii) ▢ contributing cause of death, or ▢ DK

Date of Death (dd/mm/yy):

Section 4: Incubation and Infectious Period

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

OR

Proxy for onset date* (in order of preference):

Specimen collection date (dd/mm/yy) :

Lab reporting date (dd/mm/yy) :

*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 (dd/mm/yy): to 15 days prior to first symptom onset (dd/mm/yy):

Infectious Period:

14 days prior to first symptom onset (dd/mm/yy): to 10 days after onset of jaundice (dd/mm/yy):

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 (dd/mm/yy): end date of exclusion (dd/mm/yy):

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 (dd/mm/yy): end date of exclusion (dd/mm/yy):

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 (dd/mm/yy) Occasion / Location (Include social gatherings, church gatherings, etc.)
   
   
   

Section 6: Risk Factors for Acquiring Disease/Infection

During the incubation period, did (you/case) have:

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

 

Receive a blood transfusion or blood products during the incubation period?     ▢Y ▢N ▢DK

If yes, date (dd/mm/yy):

Receive an organ transplant during the incubation period?     ▢Y ▢N ▢DK

If yes, date (dd/mm/yy):

Donate blood during the incubation period? ▢Y ▢N ▢DK

If yes, date (dd/mm/yy):

 

Travel within or outside of Canada? ▢Y ▢N ▢DK

If yes: ▢Within Province ▢ Within Canada ▢ Outside Canada

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

Departure (dd/mm/yy):

Return (dd/mm/yy):

 

If yes: ▢Within Province ▢ Within Canada ▢ Outside Canada

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

Departure (dd/mm/yy):

Return (dd/mm/yy):

 

If yes: ▢Within Province ▢ Within Canada ▢ Outside Canada

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

Departure (dd/mm/yy):

Return (dd/mm/yy):

 

Live/Stay in a residential institution/facility? ▢Y ▢N ▢DK If yes, please specify:

▢Prison/Correction facility                                                                      ▢Residential facility serving the developmentally disabled

▢Community residential program (i.e. group home, shelter)          ▢Long-term care facility/nursing home

▢Acute care facility (i.e. hospital)                                                           ▢Other (specify):

Institution/facility name:

 

Diaper a child or assist a child or adult with bathroom use? ▢Y ▢N ▢DK

 

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:

 

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?

 

Did (you/case) use intravenous drugs (IDU) during the incubation period? ▢Y ▢N ▢Refuse

 

Did (you/case) use non-intravenous drugs (non-IDU) during the incubation period? ▢Y ▢N ▢Refuse

 

Section 7: Special Diets or 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                 Poultry ▢Y ▢N ▢DK

Fish ▢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 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 (dd/mm/yy)

 

     

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 restuarants, 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) (dd/mm/yy)

Restaurant(s)

▢ Y

▢ P

     
     
     

Coffee Shop / Fast Food Outlet(s) (ie: Subway, McDonalds, Tim Horton’s)

▢ Y

▢ P

     
     
     

Cafeteria(s)

▢ Y

▢ P

     
     

Bakery / Deli(s)

▢ Y

▢ P

     
     

Ready-to-Eat Food from Grocery/Convenience Store(s)

▢ Y

▢ P

     
     

Street Vendor(s)

▢ Y

▢ P

     
     

Concession(s) at an Event

▢ Y

▢ P

     
     

Gas Stations(s)

▢ Y

▢ P

     
     

Other(s): Specify

▢ Y

▢ P

     
     

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

A.

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

B.

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

C.

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

D.

Loyalty card available? ▢ Y ▢ N ▢ DK

Loyalty card #:

 

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 (dd/mm/yy) through (dd/mm/yy). 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

Exposure Response Type / Variety / Brand

Where purchased:

Use store code (i.e. ‘A’, ‘B’) from previous section

Tomatoes (not grown at home)

If yes, specify types below:

▢Y ▢P

▢N ▢DK

   

Roma

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Cherry

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Hot house

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Semi-dried

Purchased: ▢ loose ▢ in oil

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Sun-dried

Purchased: ▢ loose ▢ in oil

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Other (i.e. Beef steak)

If yes, specify:

Consumed: ▢ raw/fresh ▢ cooked ▢ sundried ▢ semi-dried

▢Y ▢P

▢N ▢DK

   

Salsa (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

   

Iceberg lettuce

Purchased as: ▢ prepackaged ▢ loose/head

▢Y ▢P

▢N ▢DK

   

Romaine Lettuce

Purchased as: ▢ prepackaged ▢ loose/head

▢Y ▢P

▢N ▢DK

   

Mesclun ‘spring mix’

Purchased as: ▢ prepackaged ▢ loose

▢Y ▢P

▢N ▢DK

   

Spinach

Purchased: ▢prepackaged ▢loose/bunch  ▢frozen

Consumed: ▢raw/fresh ▢cooked

▢Y ▢P

▢N ▢DK

 

   

Other lettuce (i.e. kale, arugula, etc.)

If yes, specify:

Purchased as: ▢ prepackaged ▢ loose/head

▢Y ▢P

▢N ▢DK

   

Salad kits (i.e. in a bag) 

If yes, specify:

▢Y ▢P

▢N ▢DK

   

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

If yes, specify:

▢Y ▢P

▢N ▢DK

   

Coleslaw

▢Y ▢P

▢N ▢DK

   

Cabbage (also include if eaten in coleslaw)

Consumed: ▢raw/fresh ▢cooked

▢Y ▢P

▢N ▢DK

   

Basil

Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes

▢Y ▢P

▢N ▢DK

   

Parsley

Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes

▢Y ▢P

▢N ▢DK

   

Cilantro

Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes

▢Y ▢P

▢N ▢DK

   

Other fresh herbs (specify):

Purchased: ▢ raw/fresh ▢ dried ▢ frozen ▢ tubes

▢Y ▢P

▢N ▢DK

   

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

   

Cucumbers

▢Y ▢P

▢N ▢DK

   

Celery

Purchased: ▢ loose ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Bell peppers (If yes, specify types below):

▢Y ▢P

▢N ▢DK

   

Green

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Red

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Yellow

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Orange

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Hot peppers (i.e. jalapeno, Serrano, habanero, etc)

If yes, specify:

Consumed: ▢ raw/fresh ▢ cooked ▢ dried

▢Y ▢P

▢N ▢DK

   

Carrots (not mini)

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Mini carrots

Purchased: ▢ raw/fresh ▢ frozen

Consumed:▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Peas

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Beans

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Broccoli

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Corn

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Cauliflower

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Onions (If yes, specify types below):

▢Y ▢P

▢N ▢DK

   

White

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Yellow

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Red

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Green/scallion

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Onions (continued):

▢Y ▢P

▢N ▢DK

   

Shallots

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Leeks

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

Mushrooms (specify) :

Purchased: ▢ raw/fresh ▢ frozen ▢ prepackaged

Consumed: ▢ raw/fresh ▢ cooked

▢Y ▢P

▢N ▢DK

   

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

   

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

Cantaloupe

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Honeydew

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Watermelon

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Other melons

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Apples

▢Y ▢P ▢N ▢DK

   

Pears

▢Y ▢P ▢N ▢DK

   

Peaches

Purchased: ▢ raw/fresh ▢ frozen

▢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, specify types below):

▢Y ▢P ▢N ▢DK

   

Raspberries

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Strawberries

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Blueberries

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Blackberries

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Mixed berries

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Other, specify:

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Cherries

▢Y ▢P ▢N ▢DK

   

Pomegranate

Purchased: ▢ whole fruit ▢ seeds

▢Y ▢P ▢N ▢DK

   

Grapes (If yes, specify types below):

▢Y ▢P ▢N ▢DK

   

Red: 

Purchased: ▢ raw/fresh ▢ frozen 

▢Y ▢P ▢N ▢DK

   

Green:

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

Bananas

▢Y ▢P ▢N ▢DK

   

Mango

Purchased: ▢ raw/fresh ▢ frozen

▢Y ▢P ▢N ▢DK

   

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

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:  ▢Y ▢N ▢DK

Purchased:  ▢raw/fresh ▢frozen

▢Y ▢P ▢N ▢DK

   

Cockles

If yes, eaten RAW:   ▢Y ▢N ▢DK

If yes, eaten UNDERCOOKED:  ▢Y ▢N ▢DK

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:  ▢Y ▢N ▢DK

Purchased:  ▢raw/fresh ▢frozen

▢Y ▢P ▢N ▢DK

   

Crayfish

If yes, eaten RAW:   ▢Y ▢N ▢DK

If yes, eaten UNDERCOOKED:  ▢Y ▢N ▢DK

Purchased:  ▢raw/fresh ▢frozen

▢Y ▢P ▢N ▢DK

   

Lobster

If yes, eaten RAW:   ▢Y ▢N ▢DK

If yes, eaten UNDERCOOKED:  ▢Y ▢N ▢DK

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:  ▢Y ▢N ▢DK

Purchased:  ▢raw/fresh ▢frozen

▢Y ▢P ▢N ▢DK

   

Deli meats and other meats

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

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 ▢N ▢DK

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

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: (dd/mm/yy) to 10 days after onset of jaundice: (dd/mm/yy)

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:

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