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Questionnaire Background for Interviewer |
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This questionnaire can be used as a supplemental questionnaire for any outbreaks where pet food/treats are suspected in an investigation. The investigator can remove sections/modify accordingly to the investigation. |
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Section 1. Animal Exposure |
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*Please ask about exposure in the home or outside the home where animals are kept (e.g., pet stores, petting zoos, work, long-term care facilities, daycares), even if case didn’t have direct contact with the animal or their habitat. Exposures include any direct or indirect contact (e.g., changing water in an aquarium or bedding in a cage, preparing food for animals, cleaning up water spilled from an aquarium, or residing in a household where an Animal(s) is kept). In the ___ days before onset of illness, that is from ________ through _________: |
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Did you have exposure to this animal? |
Did you handle food or treats for this animal? |
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Dog
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☐ Y ☐ P ☐ N ☐ DK
Location: |
☐ Y ☐ P ☐ N ☐ DK
Location: |
If Y or P, to exposure in the home complete Section 3. If Y or P, to exposure outside the home collect the contact information of the exposure setting to complete section 3. |
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Cat
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☐ Y ☐ P ☐ N ☐ DK
Location: |
☐ Y ☐ P ☐ N ☐ DK
Location : |
If Y or P, to exposure in the home complete Section 3. If Y or P, to exposure outside the home collect the contact information of the exposure setting to complete section 3. |
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Reptiles (e.g. snakes, turtles)
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☐ Y ☐ P ☐ N ☐ DK
Location: |
☐ Y ☐ P ☐ N ☐ DK
Location: |
If Y or P, to exposure in the home complete Section 4. If Y or P, to exposure outside the home collect the contact information of the exposure setting to complete section 4. |
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Amphibians (e.g. frogs)
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☐ Y ☐ P ☐ N ☐ DK
Location: |
☐ Y ☐ P ☐ N ☐ DK
Location: |
If Y or P, to exposure in the home complete Section 5. If Y or P, to exposure outside the home collect the contact information of the exposure setting to complete section 5. |
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Small mammals (e.g. rats, mice, hamsters, gerbils, guinea pigs)
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☐ Y ☐ P ☐ N ☐ DK
Location: |
☐ Y ☐ P ☐ N ☐ DK
Location: |
If Y or P, to exposure in the home complete Section 6. If Y or P, to exposure outside the home collect the contact information of the exposure setting to complete section 6. |
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Birds (e.g. parrots, budgies, cockatiel) |
☐ Y ☐ P ☐ N ☐ DK
Location: |
☐ Y ☐ P ☐ N ☐ DK
Location: |
If Y or P, to exposure in the home complete Section 7. If Y or P, to exposure outside the home collect the contact information of the exposure setting to complete section 7. |
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Section 2. Dog and Cat Food/Treats Product Details: (Select all that apply) INSTRUCTIONS FOR INTERVIEWER: Please collect as much detail as possible about each product. If the case reports multiple food/pet treats for their pet, please complete another sheet for each product reported. (Select all that apply) |
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Type |
Brand |
Package details |
Purchase Information |
Samples |
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☐ Dry pet food
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Expiration date or Lot Code #: Flavour: Package Size: UPC code:
Can photos of packaging be provided? ☐Y ☐ N
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Store Type:
Address (physical or Website in online purchase):
Date of purchase: (prompt for receipts)
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Are there leftovers available for sampling? ☐ Y ☐ N Are the available samples open or closed? ☐ Open ☐ Closed
Are the samples from the same package handled prior to illness? ☐ Y ☐ N
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☐ Wet/canned pet food |
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Expiration date or Lot Code #: Flavour: Package Size: UPC code:
Can photos of packaging be provided? ☐ Y ☐ N |
Store Type:
Store Name:
Address (physical or Website in online purchase):
Date of purchase: (prompt for receipts) |
Are there leftovers available for sampling? ☐ Y ☐ N
Are the available samples open or closed? ☐ Open ☐ Closed
Are the samples from the same package handled prior to illness? ☐ Y ☐ N
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☐ Raw/fresh/freeze-dried pet food |
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Expiration date or Lot Code #: Flavour: Package Size: UPC code:
Can photos of packaging be provided? ☐ Y ☐ N |
Store Type:
Store Name: Address (physical or Website in online purchase):
Date of purchase: (prompt for receipts) |
Are there leftovers available for sampling? ☐ Y ☐ N
Are the available samples open or closed? ☐ Open ☐ Closed
Are the samples from the same package handled prior to illness? ☐ Y ☐ N |
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☐ Processed animal treats (e.g. chews, biscuits) Specify:__________ |
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Expiration date or Lot Code #: Flavour: Package Size: UPC code:
Can photos of packaging be provided? ☐ Y ☐ N |
Store Type:
Store Name:
Address (physical or Website in online purchase):
Date of purchase: (prompt for receipts) |
Are there leftovers available for sampling? ☐ Y ☐ N
Are the available samples open or closed? ☐ Open ☐ Closed
Are the samples from the same package handled prior to illness? ☐ Y ☐ N
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☐ Treats derived from animal parts (e.g. pig ears, rawhide, cow hooves) Specify:___________ |
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Expiration date or Lot Code #: Flavour: Package Size: UPC code:
Can photos of packaging be provided? ☐ Y ☐ N
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Store Type:
Store Name:
Address (physical or Website in online purchase):
Date of purchase: (prompt for receipts) |
Are there leftovers available for sampling? ☐ Y ☐ N
Are the available samples open or closed? ☐ Open ☐ Closed
Are the samples from the same package handled prior to illness? ☐ Y ☐ N
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☐ Other Food (e.g. table scraps, home-prepared food only for pet’s consumption) |
Additional Details:
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Additional Notes:
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Do you have any loyalty card information for the animal food purchased? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N ☐ DK *Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC |
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Store Name |
Location/Address |
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A |
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B
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C
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Section 3. Reptile Food Items: Specify where the food is purchased/obtained (mark all that apply) |
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☐ Insects (e.g., crickets, mealworms, beetles, etc.): Specify: ____________________________________________________ If yes to crickets, are the crickets ‘gut-loaded’? ☐ Y ☐ N ☐ DK If crickets are ‘gut loaded (e.g. fed a special diet): ☐ Purchased gut loaded ☐ Owner gut loads Please specify source: ☐ Owner Breeds ☐ Pet Store ☐ Other:________________________________ If Store or Other, please specify name/address: ___________________________________________________ ☐ Feeder Rodents (e.g., pinky mice, fuzzy mice) or small mammals: Type: ☐ Mice ☐ Rats ☐ Other: _________________________________________________ Please specify source: ☐ Owner Breeds ☐ Pet Store ☐ Other: ______________ If Store or Other ☐ PetSmart: _______________________________________Date: ____________ ☐ PetValu: ________________________________________ Date: ____________ ☐ Chico: __________________________________________Date: ____________ ☐ Other Pet Store (specify):___________________________ Date: ____________ ☐ On the Internet (specify website): _____________________Date: ____________ ☐ Other, please specify:______________________________ Date: ____________ Please describe the packaging the feeder rodents/small mammals come in, including any labels (e.g. clear plastic bag with label reading “Not for Human Consumption”). Do you have any receipts for the feeder rodents or small mammals you purchased that were fed to your pet prior to your illness? ☐ Y ☐ N ☐ DK o Other Food (e.g. worms, vegetables, fruit) please specify: __________________________________________________ Specify source: ☐ Grocery Store ☐ Pet Store ☐ Other:________________ If Store or Other, please specify name/address: ____________________________________________ Are there leftover food items available for sampling? ☐ Y ☐ N |
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Do you have any loyalty card information for the animal food purchased? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N ☐ DK *Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC |
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Store Name |
Location/Address |
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A |
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B
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C
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Section 4. Amphibian Food Items: |
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☐ Insects (e.g. beetles, flies, grasshoppers): Specify: ____________________________________________________ Specify source: ☐ Owner Breeds ☐ Pet Store ☐ Other:________________________________ If Store or Other, specify name/address: ___________________________________________________ o Other Food (e.g. worms, vegetables, fruit) please specify: __________________________________________________ Specify source: ☐ Grocery Store ☐ Pet Store ☐ Other:________________ If Store or Other, specify name/address: ____________________________________________ Are there leftover food items available for sampling? ☐ Y ☐ N |
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Do you have any loyalty card information for the animal food purchased? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N ☐ DK *Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC |
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Store Name |
Location/Address |
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A
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B
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C
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Section 5. Small Mammals Food Items: |
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☐ Commercial Diet (e.g., pellets, seeds, wet canned food, etc.): Specify: ____________________________________________________ Purchase Location: ☐ Pet Store ☐ Grocery Store ☐ Other: __________________________________________ If Store or Other, please specify name/address: __________________________________________ Brand: Package Details: Expiration date or Lot Code #: Flavour: Package Size: UPC code: |
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o Other Food (e.g. leafy greens, grass, hay) specify: __________________________________________________ Specify source: ☐ Grocery Store ☐ Pet Store ☐ Other:________________ If Store or Other, specify name/address: ____________________________________________ Are there leftover food items available for sampling? ☐ Y ☐ N |
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Do you have any loyalty card information for the animal food purchased? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N ☐ DK *Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC |
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Store Name |
Location/Address |
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A
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B
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C
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Section 6. Bird Food Items : |
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☐ Commercial Diet (e.g., pellets, seeds, etc.): Specify: ____________________________________________________ Purchase location: ☐ Pet Store ☐ Grocery Store ☐ Other: __________________________________________ If Store or Other, specify name/address: __________________________________________ Brand: Package Details: Expiration date or Lot Code #: Flavour: Package Size: UPC code: o Other Food specify: __________________________________________________ Specify source: ☐ Grocery Store ☐ Pet Store ☐ Other:________________ If Store or Other, please specify name/address: ____________________________________________ Are there leftover food items available for sampling? ☐ Y ☐ N |
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Do you have any loyalty card information for the animal food purchased? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N ☐ DK *Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC |
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Store Name |
Location/Address |
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A
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B |
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C |
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INSTRUCTIONS FOR INTERVIEWER: If case reports “N” to handling pet food/treats then complete Section 9. If case reports “Y” to handling pet food/treats then complete Sections 8 and 9
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Section 7. Handling and Storage Sometimes the person responsible for handling pet food/treats is not the person who became ill. Please answer questions below based on person who is most likely to have contact with pet food/treats. Methods described for: ☐ case ☐ proxy ☐ reptile caretaker (specify relation to case): |
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Do you/case always wash your hands after handling pet food and treats? ☐ Y ☐ N ☐ DK What tools/utensils are used to prepare and serve pet food and treats? (e.g. scoops, bowls, feeding toys) How are the tools/utensils cleaned? ☐ rinsing with water only ☐ washing with soap ☐ sanitizing after washing ☐ washing in dishwasher ☐ other:______________ Where are the tools/utensils cleaned?
How do you/case clean up pet food spills?
Where are the pet food and treats stored?
If applicable: how is the frozen food thawed?
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Section 8. Pet Interactions and Practices Sometimes the person responsible for pet hygiene practices is not the person who became ill. Please answer questions below based on person who is most likely to have had direct contact with the pet. Methods described for: ☐ case ☐ proxy ☐ reptile caretaker (specify relation to case): |
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Do you/case always wash your hands after contact with pets, or their waste, or their environment? ☐ Y ☐ N ☐ DK Do you/case always wash your hands after feeding the pet(s)? ☐ Y ☐ N ☐ DK Do you/case have any of the following contact with the pets? (check all that apply):
Was your pet ill while you/case had contact with the pet? ☐ Y ☐ N ☐ DK |
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Section 9. Additional Notes |
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Include any additional context around pet/pet food/pet treat exposures that has not been captured already.
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