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Questionnaire Background for Interviewer
This questionnaire is designed to collect comprehensive information on possible risk factors for salmonellosis. It is designed for cluster/outbreak investigations where the source of infection is unknown, but the questionnaire could be applied to investigate sporadic cases. The exposure period for this questionnaire was extended to 7 days to reflect the observation that many Salmonella outbreaks have median incubations periods >3 days,
Data captured: – Case demographics – Food exposures
– Clinical information – Pet exposures
– Laboratory information – Other risk factors
Since outbreaks of salmonellosis 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
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Case Name: |
Proxy Name: |
| Health Card Number: | |
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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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Occupation: |
Place(s) of employment: |
II. Symptoms
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Date of first symptom onset (dd/mm/yy): d_______ / m_______ / y______ Asymptomatic: ▢ Y ▢ N ▢ DK |
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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, specify: *(3 or more loose stools in a 24 hour period) |
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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
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Were any of (your/case’s) contacts ill with similar symptoms in the 7 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 |
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Name:___________________________________________ Gender: Phone Number: ___________________________ Relationship to case:________________________________ Age: ________ Date of diarrhea onset: d____ / m____ / y______ |
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Name:___________________________________________ Gender Phone Number: ___________________________ Relationship to case:________________________________ Age: ________ Date of diarrhea onset: d____ / m____ / y______ |
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Name:___________________________________________ Gender Phone Number: ___________________________ Relationship to case:________________________________ Age: ________ Date of diarrhea onset: d____ / m____ / y______ |
Salmonella Hypothesis Generating Questionnaire
Section 1: Case information
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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: ______________________________ |
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Gender: ☐ M ☐ F ☐ Another Gender ☐ Not asked/Unknown |
Age: _________ |
Section 2: Clinical information
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Section 2. Clinical Information Provincial lab ID: |
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To be filled out by interviewer |
Serotype: |
Whole genome sequencing cluster code: |
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Positive specimen type(s): ☐ Stool ☐ Blood ☐ Urine ☐ Other, specify: ______________ |
Date of first positive specimen collection: d_____ / m______ / y______ |
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Date of first symptom onset: d_______ / m_______ / y______ Asymptomatic: ☐ Y ☐ N ☐ DK |
Date of diarrhea onset: d_______ / m_______ / y______ |
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Admitted* to hospital because of the illness? ☐ Y ☐ N ☐ DK *Do not include individuals who visit an emergency room or outpatient clinic |
Date of admission: d______ / m______ / y______ Date of discharge: d______ / m______ / y______ ☐ Still hospitalized |
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To be filled out by interviewer |
Case deceased? ☐ Y ☐ N Date of Death: d______ / m______ / y______ If yes, was Salmonella infection the underlying/contributing cause of death? ☐ Y ☐ N ☐ DK If yes, was determination based on death certificate? ☐ Y ☐ N ☐ DK |
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Section 3: Travel information
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In the 7 days before onset of illness, that is from d____/m_____/y_____ through d____/m____/y____, did (you/case) travel within or outside of Canada? ☐ Y ☐ N ☐ DK If yes: ☐ Within Province/Territory ☐ Other Province(s)/Territory(ies) ☐ Outside Canada |
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Specify travel destination(s) (country/town/resort): |
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Departure: d____ / m____ / y______ Return: d____ / m____ / y______ |
Section 4: Special Diets or Food Preferences
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First I would like to ask some general questions about (your diet/case’s) diet and 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 Fish ☐ Y ☐ N ☐ DK Poultry ☐ 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 7 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, kratom) ☐ Y ☐ N ☐ DK If yes, describe (include purchase location): _____________________________________________________ Did you consume any bottled, pre-made health drinks? (e.g. Kombucha, coconut water) ☐ Y ☐ N ☐ DK If yes, describe (include purchase location): _______________________________________________________ |
Section 5: Foods eaten outside the home
In the 7 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)?
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Type of Gathering/Establishment Name(s): |
Details of food(s) eaten |
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Social gathering or event (e.g. family or friends house, snacks at work, conferences, wedding or parties) ☐ 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? ______ |
Event name/description:
Location:
Date of gathering: d______ / m______ / y______
Number attended: |
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Did you eat any fast food or at other restaurants? This could include food or drinks from a coffee shop, cafeteria, street vendor, concession stand or convenience stores. Also list any samples from a grocery store. |
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Food Establishment Name |
Address/Location |
Dates(s) |
Food ordered/Eaten |
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Additional details from above-listed food establishments: |
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Section 6: Home Food Purchases
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Where do (you/case) usually purchase food for home consumption? This includes grocery stores, farmers markets, specialty stores, food banks, or online purchases such as Amazon, Well.ca or other e-commerce. *Consent form for collecting loyalty card information is available from your provincial/territorial health authority or PHAC |
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A
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Store/website name:
Location: |
Purchased food online (delivery or curbside pick-up) ☐ Y ☐ N ☐ DK Are receipts, invoices, email notifications available? ☐ Y ☐ N ☐ DK Loyalty Card? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N |
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B
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Store/website name:
Location: |
Purchased food online (delivery or curbside pick-up) ☐ Y ☐ N ☐ DK Are receipts, invoices, email notifications available? ☐ Y ☐ N ☐ DK Loyalty Card? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N |
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C
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Store/website name:
Location: |
Purchased food online (delivery or curbside pick-up) ☐ Y ☐ N ☐ DK Are receipts, invoices, email notifications available? ☐ Y ☐ N ☐ DK Loyalty Card? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N |
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D
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Store/website name:
Location:
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Purchased food online (delivery or curbside pick-up) ☐ Y ☐ N ☐ DK Are receipts, invoices, email notifications available? ☐ Y ☐ N ☐ DK Loyalty Card? ☐ Y ☐ N ☐ DK Would you be willing to share your loyalty card number and purchase information with us? ☐ Y ☐ N |
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Additional details from above-listed stores. If applicable, include information on typical purchases from specialty/online stores, details on purchase method, and if the case is willing to share receipts, invoices, etc. |
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Section 7: Meal delivery kit purchase
In the 7 days prior to illness onset did (you/case) consume food prepared from a meal delivery kit (e.g., Goodfood, Hello Fresh, Chef’s Plate, Red Apron, etc)?
☐ Y ☐ N ☐ DK If yes please provide details below.
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Purchase Information: |
Meal names, consumption dates, ingredients and substitutions: |
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Name of company: Date of delivery: Are receipts, invoices, email notifications, or recipe cards available? ☐ Y ☐ N ☐ DK |
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Section 8: Seven Day Food History
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I’d like to talk to you about the foods/drinks (you/case) consumed before (you/case) got sick. Starting with the day (you/case) were first developed symptoms: |
(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.)
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Day of illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch |
Dinner |
Snacks |
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1 day before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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2 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch |
Dinner |
Snacks |
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3 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch |
Dinner |
Snacks |
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4 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch | Dinner | Snacks | |||
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5 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch | Dinner | Snacks | |||
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6 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch | Dinner | Snacks | |||
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7 days before illness (dd/mm/yy) ▢ M ▢ T ▢ W ▢ Th ▢ F ▢ Sat ▢ Sun |
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Breakfast |
Lunch |
Dinner | Snacks | |||
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Section 8: Food Exposures
INSTRUCTIONS TO READ TO CASE
I am interested in the food you ate during the 7 days before your illness onset date; that is from ddd/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.
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
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
Poultry
| Exposure | Response | Type/Variety/Brand | Grocery store or restaurant name |
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Any chicken (not including deli-meat) If yes, please specify type(s) below |
▢Y ▢P ▢N ▢DK |
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Store-bought breaded chicken (e.g. chicken nuggets, strips or burgers) |
▢Y ▢P ▢N ▢DK |
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Ground chicken |
▢Y ▢P ▢N ▢DK |
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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 |
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Other chicken (not including deli-meat) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Any turkey (not including deli-meat) If yes, please specify type(s) below |
▢Y ▢P ▢N ▢DK |
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Turkey bacon |
▢Y ▢P ▢N ▢DK |
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Ground turkey |
▢Y ▢P ▢N ▢DK |
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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 |
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Other turkey (not including deli-meat) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Other poultry (not including deli meat e.g. Cornish hen, duck) |
▢Y ▢P ▢N ▢DK |
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Any eggs (e.g. scrambled eggs, omelets) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Eggs consumed raw or undercooked (e.g. “runny”, “over-easy” in raw cookie dough or in a drink) If yes, specify: |
▢Y ▢P ▢N ▢DK |
Pork
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
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Any pork (not including deli-meat) If yes, please specify type(s) below |
▢Y ▢P ▢N ▢DK |
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Ham (not including deli-meat) |
▢Y ▢P ▢N ▢DK |
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Bacon |
▢Y ▢P ▢N ▢DK |
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Ground pork |
▢Y ▢P ▢N ▢DK |
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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 |
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Other pork (not including deli-meat) If yes, specify: |
▢Y ▢P ▢N ▢DK |
Beef
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
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Any beef (not including deli-meat) If yes, please specify type(s) below |
▢Y ▢P ▢N ▢DK |
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Whole cut beef (e.g. roasts, ribs, steaks, in soups, or as part of a dish, not including deli-meat) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Ground beef (e.g. in hamburgers, tacos, spaghetti, lasagna) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Ground beef consumed raw or undercooked (e.g. under cooked hamburgers, tartare or kibbeh) |
▢Y ▢P ▢N ▢DK |
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Other beef (not including deli-meat) If yes, specify: |
▢Y ▢P ▢N ▢DK |
Other meat/animal products
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
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Deli Meats (e.g. Bologna, salami, pepperoni, turkey, ham) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Hot dogs If yes, heated before eating ▢Y ▢N ▢DK |
▢Y ▢P ▢N ▢DK |
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Sausage If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Dried meat products (e.g. beef jerky, pepperettes) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Pâté/meat spread If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Lamb |
▢Y ▢P ▢N ▢DK |
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Veal |
▢Y ▢P ▢N ▢DK |
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Goat |
▢Y ▢P ▢N ▢DK |
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Any kind of game/country food (e.g. venison, pheasant, rabbit, caribou, seal, quail, moose, bison) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Any organ meats or orfal (e.g. liver, kidney, heart) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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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 |
|---|---|---|---|
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Any fish (including fresh, canned, jarred, frozen) If yes, please specify type(s) below |
▢Y ▢P ▢N ▢DK |
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Smoked fish (e.g. smoked salmon) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Fish – eaten raw (e.g. sushi, tartare, sashimi, ceviche) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Other fish (e.g. cooked trout, salmon) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Shellfish (e.g. oysters, clams, mussels, scallops, cockles) If yes, specify: If yes, was it eaten raw? ▢Y ▢N ▢DK |
▢Y ▢P ▢N ▢DK |
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Crustaceans (e.g. crab, shrimp, prawns, crayfish, lobster) If yes, specify: If yes, was it eaten raw? ▢Y ▢N ▢DK |
▢Y ▢P ▢N ▢DK |
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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 |
|---|---|---|---|
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Pasteurized dairy milk If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Unpasteurized (raw) dairy milk (excluding cheese) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Powdered milk product |
▢Y ▢P ▢N ▢DK |
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Whipped/whipping cream |
▢Y ▢P ▢N ▢DK |
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Sour cream |
▢Y ▢P ▢N ▢DK |
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Ice cream/gelato If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Yogurt |
▢Y ▢P ▢N ▢DK |
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Milk or cream containing desserts (e.g. cream filled pies/pasteries, pudding) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Other dairy product If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Non-dairy milk (e.g. soy, almond, coconut, rice) If yes, specify: |
▢Y ▢P ▢N ▢DK |
Cheese
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
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Cheddar cheese |
▢Y ▢P ▢N ▢DK |
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Mozzarella cheese |
▢Y ▢P ▢N ▢DK |
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Parmesan cheese |
▢Y ▢P ▢N ▢DK |
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Gouda |
▢Y ▢P ▢N ▢DK |
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Feta cheese |
▢Y ▢P ▢N ▢DK |
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Any brie, camembert or other soft cheeses If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Any blue-veined cheese such as blue cheese or gorgonzola If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Any cottage, ricotta or other fresh cheese If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Any cheese made from goat/sheep milk If yes, specify: |
▢Y ▢P ▢N ▢DK |
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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 |
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Processed cheese (e.g. sliced cheese, cheese string/tubes or from a jar) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Any cheese made with unpasteurized (raw) milk If yes, specify: |
▢Y ▢P ▢N ▢DK |
Vegetables
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
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Tomatoes If yes, please specify type(s) below: |
▢Y ▢P ▢N ▢DK |
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Roma/Plum |
▢Y ▢P ▢N ▢DK |
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Hothouse |
▢Y ▢P ▢N ▢DK |
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Beef steak |
▢Y ▢P ▢N ▢DK |
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Cherry or grape |
▢Y ▢P ▢N ▢DK |
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Other tomatoes (e.g. heirloom, vine-ripened) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Lettuce or leafy greens If yes, please specify type(s) below: |
▢Y ▢P ▢N ▢DK |
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Iceberg ▢ prepackaged ▢ loose/head |
▢Y ▢P ▢N ▢DK |
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Romaine ▢ prepackaged ▢ loose/head |
▢Y ▢P ▢N ▢DK |
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Spinach ▢ prepackaged ▢ loose |
▢Y ▢P ▢N ▢DK |
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Mesclun lettuce ▢ prepackaged ▢ loose |
▢Y ▢P ▢N ▢DK |
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Other lettuce/leafy greens ▢ prepackaged ▢ loose/head |
▢Y ▢P ▢N ▢DK |
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Cabbage (include if eaten as coleslaw) ▢ prepackaged ▢ loose/head |
▢Y ▢P ▢N ▢DK |
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Sprouts (including on a sandwich or salads) If yes, please specify type(s) below: |
▢Y ▢P ▢N ▢DK |
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Alfalfa sprouts |
▢Y ▢P ▢N ▢DK |
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Bean sprouts |
▢Y ▢P ▢N ▢DK |
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Other sprouts, (e.g. onion, clover, broccoli) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Cucumbers |
▢Y ▢P ▢N ▢DK |
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Bell peppers (e.g. red, green, yellow peppers) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Hot peppers (e.g. jalapeno, serrano, habanero) If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Celery |
▢Y ▢P ▢N ▢DK |
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Carrots (not mini) |
▢Y ▢P ▢N ▢DK |
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Mini/baby carrots |
▢Y ▢P ▢N ▢DK |
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Peas (shelled or in pods) |
▢Y ▢P ▢N ▢DK |
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Green or yellow beans |
▢Y ▢P ▢N ▢DK |
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Broccoli |
▢Y ▢P ▢N ▢DK |
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Cauliflower |
▢Y ▢P ▢N ▢DK |
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Onions If yes, please specify type(s) below: |
▢Y ▢P ▢N ▢DK |
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White / yellow onions |
▢Y ▢P ▢N ▢DK |
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Green onions |
▢Y ▢P ▢N ▢DK |
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Red onions |
▢Y ▢P ▢N ▢DK |
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Other onions If yes, specify: |
▢Y ▢P ▢N ▢DK |
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Leeks |
▢Y ▢P ▢N ▢DK |
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Fresh garlic (not powdered) |
▢Y ▢P ▢N ▢DK |
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Mushrooms |
▢Y ▢P ▢N ▢DK |
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Zucchini |
▢Y ▢P ▢N ▢DK |
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Other vegetables If yes, specify: |
▢Y ▢P ▢N ▢DK |
||
|
Vegetable juices (e.g. tomato juice, carrot juice) If yes, specify: |
▢Y ▢P ▢N ▢DK |
Fruit – Include raw or cooked fruits (exclude fruits purchased frozen or canned)
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
|
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 types 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 |
||
|
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 |
||
|
Fresh coconut (e.g. pre-cut coconut pieces, frozen shredded coconut) |
▢Y ▢P ▢N ▢DK |
||
|
Avocado (including guacamole) |
▢Y ▢P ▢N ▢DK |
||
|
Olives |
▢Y ▢P ▢N ▢DK |
||
|
Other fruit If yes, specify: |
▢Y ▢P ▢N ▢DK |
||
|
Any fruit smoothies If yes, specify: |
▢Y ▢P ▢N ▢DK |
||
|
Any unpasteurized fruit juices (e.g. unpasteurized apple cider) If yes, specify: |
▢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 or thyme) If yes, specify: |
▢Y ▢P ▢N ▢DK |
|
|
|
Any dried herbs or spices If yes, specify: |
▢Y ▢P ▢N ▢DK |
|
|
Store bought prepared salads and dips
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
|
Green salad If yes, specify: |
▢Y ▢P ▢N ▢DK |
|
|
|
Coleslaw |
▢Y ▢P ▢N ▢DK |
|
|
|
Potato Salad |
▢Y ▢P ▢N ▢DK |
|
|
|
Pasta Salad |
▢Y ▢P ▢N ▢DK |
|
|
|
Fruit salad/pre-cut fruit or fruit platter |
▢Y ▢P ▢N ▢DK |
|
|
|
Salsa |
▢Y ▢P ▢N ▢DK |
|
|
|
Hummus |
▢Y ▢P ▢N ▢DK |
|
|
|
Any other salad or dip If yes, specify: |
▢Y ▢P ▢N ▢DK |
|
|
Frozen foods
| Exposure | Response | Specify type/variety, and brand | Grocery store or restaurant name |
|---|---|---|---|
|
Frozen vegetables |
▢Y ▢P ▢N ▢DK |
|
|
|
Frozen berries |
▢Y ▢P ▢N ▢DK |
|
|
|
Frozen fruit other than frozen berries |
▢Y ▢P ▢N ▢DK |
|
|
|
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 |
|---|---|---|---|
|
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 9: Risk Factors
Finally, I’d like to ask you about other exposures. In the 7 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 chicken ? ▢ Y ▢ N ▢ DK |
Handle any raw eggs? ▢ 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): |
||
|
Handle any animal foods/treats in the 7 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: |
||