Shigella Hypothesis Generating Questionnaire

Download the alternative format

Questionnaire Background for Interviewer
This questionnaire is designed to collect comprehensive information on possible risk factors for Shigella. It is designed for cluster/outbreak investigations where the source of infection is unknown, but the questionnaire could be applied to investigate sporadic cases. Data captured: – Case demographics – Food exposures – Clinical information – Sexual activity – Laboratory information – Other risk factors Outbreaks of Shigella have often linked back to person-to-person transmission, as well as food exposures. This questionnaire has both an open-ended food history and a detailed checklist of food items; this may seem repetitive, but is used to ensure all possible food exposures are captured. Please collect as much detail 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. Due to the sensitive nature of some of the questions in this questionnaire, it is important to remind the interviewee that they have the right to skip any question they are uncomfortable answering. The questionnaire is estimated to take 45 – 60 minutes to complete.
FOR LOCAL USE ONLY – PLEASE REMOVE THIS PAGE IF SENDING TO PHAC
i. Case Information
Case Name: _______________________	Proxy Name:__________________________
Health Card Number: ______________________________
Street Address: _______________ City/Town: _________________ Postal Code:_________________	Home Phone: _______________________ Work Phone: _______________________ Cell Phone: ________________________
Physician: _______________	Physician Phone: _____________________
Occupation: _______________	Place(s) of Employment:
ii. Symptoms
Date of first symptom onset: d_______ / m_______ / y______ Asymptomatic: ☐ Y ☐ N ☐ DK
Symptoms: Diarrhea* ☐ Y ☐ N ☐ DK Fever ☐ Y ☐ N ☐ DK Abdominal cramps ☐ Y ☐ N ☐ DK Bloody diarrhea ☐ Y ☐ N ☐ DK Nausea ☐ Y ☐ N ☐ DK Vomiting ☐ Y ☐ N ☐ DK Other ☐ Y ☐ N ☐ DK If other, please specify:_________________________ *3 or more loose stools in a 24 hour period
Underlying conditions or medications that suppress the immune system (e.g. pregnancy, diabetes, cancer, steroids)? ☐ Y ☐ N ☐ DK If yes, please specify:
iii. Contacts
Were any of (your/case’s) contacts ill with similar symptoms in the 4 days (7 days for S. dysenteriae if species is known) before (you/case) became ill? ☐ Y ☐ N ☐ DK If yes, can you tell me who? *Contacts include household members, sexual partners, individuals who prepared food for (you/case), children or adults that (you/case) assisted with bathroom use or diaper change, or other individuals with whom (you/case) may have come into contact with their vomit and/or stool
Name:___________________________________________ Gender: Phone Number: ___________________________ Relationship to case:________________________________ Age: ________ Date of diarrhea onset: d____ / m____ / y______
Name:___________________________________________ Gender: Phone Number: _________________________ Relationship to case:________________________________ Age: ________ Date of diarrhea onset: d____ / m____ / y______
Name:___________________________________________ Gender: Phone Number: __________________________ Relationship to case:________________________________ Age: ________ Date of diarrhea onset: d____ / m____ / y______

National ID:

Case ID:

Shigella Hypothesis Generating Questionnaire

Section 1. Case Information

Case Interviewed by:

Date of interview: d____ / m____ / y______

Health Unit/Authority:

Date reported to Health Unit/Authority: d____ / m____ / y______

Province/Territory:

Respondent was: ☐ Case ☐ Parent ☐ Spouse ☐ Caretaker ☐ Other, specify: ______________________________

Gender: ☐ M ☐ F ☐ Another Gender ☐ Not asked/Unknown

Age: _______

Provincial Lab ID:

Section 2. Clinical Information

To be filled out by

interviewer

Species (dysenteriae, flexneri, boydii, sonnei):

Whole genome sequencing cluster code:

Positive specimen type(s):

☐ Stool ☐ Blood ☐ Urine ☐ Other, specify: _____________

Date of first positive specimen collection: d____ / m____ / y______

Date of first symptom onset: d____ / m____ / y______

Asymptomatic: ☐ Y ☐ N ☐ DK

Date of diarrhea onset: d____ / m____ / y______

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

To be filled out by interviewer

Case deceased? ☐ Y ☐ N Date of Death: d____ / m____ / y______

If yes, was Shigella infection the underlying/contributing cause of death? ☐ Y ☐ N ☐ DK

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

Section 3. Travel Information
In the 4 days (7 days for S. dysenteriae if species is known) 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
Specify travel destination(s) (country/town/resort):
Departure: d____ / m____ / y______	Return: d____ / m____ / y______
Section 4. Special Diets or Food Preferences
First I would like to ask some general questions about (your/case’s) diet and food preferences.
Are (you/case) a vegetarian? ☐ Y ☐ N ☐ DK If yes, do (you/case) ever eat: Eggs ☐ Y ☐ N ☐ DK Dairy ☐ Y ☐ N ☐ DK Fish ☐ Y ☐ N ☐ DK Poultry ☐ Y ☐ N ☐ DK Red meat ☐ Y ☐ N ☐ DK Other meat ☐ Y ☐ N ☐ DK If yes, specify: ________________
Are (you/case) allergic to any foods ? ☐ Y ☐ N ☐ DK If yes, specify which foods:
Are there any foods/food groups that (you/case) never eat? ☐ Y ☐ N ☐ DK If yes, describe:
In the 4 days (7 days for S. dysenteriae) 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: _____________________________________________________________________________ Take a dietary or nutritional supplement? (e.g., meal replacements, protein powder, vitamins, herbs, kratom) ☐ Y ☐ N ☐ DK If yes, describe (include purchase location): _______________________________________________________ Consume any bottled, pre-made health drinks? (e.g. Kombucha, coconut water) ☐ Y ☐ N ☐ DK If yes, describe (include purchase location): ______________________________________________________

Section 5. Risk Factors
I’d like to ask you about some common exposures for Shigella. In the 4 days (7 days for S. dysenteriae) before onset of illness did (you/case):
Live in a residential institution? ☐ Y ☐ N ☐ DK (e.g. Nursing home, long term care facility, prison, dormitory or boarding school)	Name/location:
Attend a day care or day facility ? ☐ Y ☐ N ☐ DK (e.g. child or adult)	Name/location :
Attend or visit a school ☐ Y ☐ N ☐ DK (e.g. For work/volunteer purposes, or as a student)	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
Consume a meal or food product that was handled by someone who was ill? ☐ 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, river, pond, or stream? ☐ Y ☐ N ☐ DK If yes, specify type of water source and location: ___________________
Swim in/go into a swimming pool, hot tub, wading pool or water park? ☐ Y ☐ N ☐ DK If yes, specify type of water source and location: ___________________
Were you homeless, That is were you living on the street, in a shelter, in a single room occupancy hotel, in a car or couch surfing? ☐ Y ☐ N ☐ Prefer not to answer ☐ DK

Section 6. Sexual and Drug Activity: Skip this section if the case has already been asked

INTSRUCTIONS FOR INTERVIEWER: Please ask these questions to male and female adult cases (>18 years)

Are (you/case) currently sexually active? ☐Y ☐N ☐ Prefer not to answer ☐ DK

If Yes, have (you/case) engaged in oral-anal sexual contact in the past 4 days (7 days for S. dysenteriae)?

☐Y ☐N ☐ Prefer not to answer ☐ DK

Did (you/case) use intravenous drugs in the 4 days (7 days for S. dysenteriae) prior to symptom onset? ☐ Y ☐ N ☐ Prefer not to answer ☐ DK

Did (you/case) use non-intravenous drugs in the 4 days (7 days for S. dysenteriae)? prior to symptom onset?

☐ Y ☐ N ☐ Prefer not to answer ☐ DK

Section 7. Food eaten outside the home
In the 4 days (7 days for S. dysenteriae) prior to illness onset did (you/case) eat food outside home at a social gathering or at a food establishment? (Including food taken from a restaurant and eaten at home and samples eaten at establishments such as grocery stores)?
Type of Gathering/Establishment Name(s):			Details of food(s) eaten
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:
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.
Food Establishment Name	Address/Location	Dates(s)	Food ordered/Eaten




Additional details from above-listed food establishments:

Section 8. Home Food Purchase:

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

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

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

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

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

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.

Section 9. Meal Delivery Kit Purchase:
In the 4 days (7 days for S. dysenteriae) 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:
Purchase Information	Meal names, consumption dates, ingredients and substitutions
Name of company: Date of delivery: Are receipts, invoices, email notifications, or recipe cards available? ☐ Y ☐ N ☐ DK

*Section 10: Four Day Food History (7 for S. dysenteriae)*
I would like to talk to you about the foods and drinks (you/case) consumed before (you/case) got sick. Starting with the day (you/case) 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.)
Day of illness d____ / m____ / y______; ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast	Lunch			Dinner	Snacks




1 day before illness d____ / m____ / y______ ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks




2 days before illness d____ / m____ / y______; ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks




3 days before illness d____ / m____ / y______ ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks




4 days before illness d____ / m____ / y______ ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks




5 days before illness: d____ / m____ / y______ ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks




6 days before illness d____ / m____ / y______ ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks




7 days before illness d____ / m____ / y______ ☐ M ☐ T ☐ W ☐ Th ☐ F ☐ Sat ☐ Sun
Breakfast		Lunch	Dinner		Snacks

Section 11: Food Exposures

INSTRUCTIONS TO READ TO CASE:

I am interested in the food you ate during the 4 days (7 days for S. dysenteriae) 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.

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 the question was not asked.

Yes	– Indicates case ate the food	Prob	– Indicates the case probably ate the food
No	– Indicates case did not eat the food	DK	– Indicates case doesn’t know if they ate the food

	Yes	Prob	No	DK	IMPORTANT. Please complete in as much detail as possible Type / Variety / Brand	Where purchased or eaten: Specify grocery store or restaurant name
VEGETABLES Include raw or cooked vegetables (exclude vegetables purchased canned)
Any tomatoes, including any in a dish or meal such as a salad, sandwich, burger or taco If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
Cherry or grape	☐Y	☐P	☐N	☐DK
Any lettuce or leafy greens, including in a dish or meal such as a salad, sandwich, burger or taco If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
Iceberg ☐ prepackaged ☐ loose/head	☐Y	☐P	☐N	☐DK
Romaine ☐ prepackaged ☐ loose/head	☐Y	☐P	☐N	☐DK
Spinach ☐ prepackaged ☐ loose	☐Y	☐P	☐N	☐DK
Mesclun lettuce/spring mix ☐ prepackaged ☐ loose	☐Y	☐P	☐N	☐DK
Kale ☐ prepackaged ☐ loose	☐Y	☐P	☐N	☐DK
Arugula ☐ prepackaged ☐ loose	☐Y	☐P	☐N	☐DK
Other lettuce/leafy greens If yes, specify:___________________ ☐ prepackaged ☐ loose/head	☐Y	☐P	☐N	☐DK
Any commercially pre-packaged salad kits (e.g. in a bag or container, may include dressing, toppings), excluding prepared or ready to eat salads If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Any store-bought prepared or ready to eat green salads (e.g. prepared Caesar, kale, garden, chef’s spinach) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Store-bought potato salad	☐Y	☐P	☐N	☐DK
Store-bought pasta salad	☐Y	☐P	☐N	☐DK
Store-bought other salad (e.g. Greek, quinoa, bean)	☐Y	☐P	☐N	☐DK
Any cabbage (e.g. whole, shredded cabbage, coleslaw) ☐ prepackaged ☐ loose/head	☐Y	☐P	☐N	☐DK
Coleslaw ☐ prepackaged ☐ homemade	☐Y	☐P	☐N	☐DK
Any microgreens or sprouts including in a dish or meal such as on a sandwich or salad (e.g, bean or alfalfa sprouts, broccoli microgreens) If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
Microgreens	☐Y	☐P	☐N	☐DK
Alfalfa sprouts	☐Y	☐P	☐N	☐DK
Bean sprouts	☐Y	☐P	☐N	☐DK
Other sprouts If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Cucumbers ☐ English ☐ Field ☐ Mini	☐Y	☐P	☐N	☐DK
Bell peppers (e.g. red, green, yellow peppers) If yes, specify:______________	☐Y	☐P	☐N	☐DK
Hot peppers (e.g. jalapeno, serrano, habanero) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Celery	☐Y	☐P	☐N	☐DK
Carrots (not mini)	☐Y	☐P	☐N	☐DK
Mini/baby carrots	☐Y	☐P	☐N	☐DK
Peas (fresh, raw pea pods, snap peas, snow peas)	☐Y	☐P	☐N	☐DK
Green or yellow beans	☐Y	☐P	☐N	☐DK
Broccoli	☐Y	☐P	☐N	☐DK
Cauliflower	☐Y	☐P	☐N	☐DK
Radishes	☐Y	☐P	☐N	☐DK
Onions If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
White/yellow onions	☐Y	☐P	☐N	☐DK
Green onions	☐Y	☐P	☐N	☐DK
Red onions	☐Y	☐P	☐N	☐DK
Other onions If yes, specify: __________________	☐Y	☐P	☐N	☐DK
Leeks	☐Y	☐P	☐N	☐DK
Fresh garlic (not powdered)	☐Y	☐P	☐N	☐DK
Fresh ginger (not ground)	☐Y	☐P	☐N	☐DK
Mushrooms	☐Y	☐P	☐N	☐DK
Zucchini	☐Y	☐P	☐N	☐DK
Other vegetables If yes, specify: _____________________	☐Y	☐P	☐N	☐DK
Frozen vegetables	☐Y	☐P	☐N	☐DK
Vegetable juices (e.g. tomato juice, carrot juice) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
FRUIT Include raw or cooked fruits (exclude fruits purchased canned)
Fruit salad/pre-cut fruit or fruit platter	☐Y	☐P	☐N	☐DK
Melon If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
Cantaloupe ☐ Fresh ☐ Frozen	☐Y	☐P	☐N	☐DK
Honeydew melon ☐ Fresh ☐ Frozen	☐Y	☐P	☐N	☐DK
Watermelon ☐ Fresh ☐ Frozen	☐Y	☐P	☐N	☐DK
Other melons If yes, specify : _____________________	☐Y	☐P	☐N	☐DK
Apples	☐Y	☐P	☐N	☐DK
Pears	☐Y	☐P	☐N	☐DK
Peaches ☐ Fresh ☐ Frozen	☐Y	☐P	☐N	☐DK
Nectarines ☐ Fresh ☐ Frozen	☐Y	☐P	☐N	☐DK
Apricots	☐Y	☐P	☐N	☐DK
Plums	☐Y	☐P	☐N	☐DK
Citrus fruits (e.g. oranges, grapefruit, lemons, limes) If yes, specify : ______________________	☐Y	☐P	☐N	☐DK
Berries If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
Strawberries ☐ Fresh ☐ Frozen ☐ Dried	☐Y	☐P	☐N	☐DK
Raspberries ☐ Fresh ☐ Frozen ☐ Dried	☐Y	☐P	☐N	☐DK
Blueberries ☐ Fresh ☐ Frozen ☐ Dried	☐Y	☐P	☐N	☐DK
Blackberries ☐ Fresh ☐ Frozen ☐ Dried	☐Y	☐P	☐N	☐DK
Other berries (e.g. cranberries, gooseberries, tayberries) If yes, specify : ______________________	☐Y	☐P	☐N	☐DK
Bag of mixed frozen fruit or berries	☐Y	☐P	☐N	☐DK
Cherries	☐Y	☐P	☐N	☐DK
Grapes	☐Y	☐P	☐N	☐DK
Bananas	☐Y	☐P	☐N	☐DK
Mangos ☐ Fresh ☐ Frozen ☐ Dried	☐Y	☐P	☐N	☐DK
Papaya ☐ Fresh ☐ Frozen ☐ Dried	☐Y	☐P	☐N	☐DK
Kiwi	☐Y	☐P	☐N	☐DK
Pomegranate ☐ Fresh (including ready-to-eat seeds) ☐ Frozen	☐Y	☐P	☐N	☐DK
Pineapple	☐Y	☐P	☐N	☐DK
Coconut ☐ Fresh ☐ Frozen ☐ Dried/shredded	☐Y	☐P	☐N	☐DK
Avocado (including guacamole) ☐ Fresh ☐ Frozen	☐Y	☐P	☐N	☐DK
Olives	☐Y	☐P	☐N	☐DK
Other fruit If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Unpasteurized apple cider or fruit juice If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Smoothies made with fresh or frozen fruit or produce, made at home or purchased fresh-made from a store, restaurant, or café	☐Y	☐P	☐N	☐DK
Bottled, pre-made smoothie	☐Y	☐P	☐N	☐DK
HERBS AND SPICES
Fresh basil ☐ Thai ☐ Conventional	☐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, 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
Salsa ☐ Fresh (e.g. pico de gallo) ☐ In a jar or can	☐Y	☐P	☐N	☐DK
Hummus purchased from a store or a restaurant (excluding home-made)	☐Y	☐P	☐N	☐DK
Any other dip If yes, specify:___________________	☐Y	☐P	☐N	☐DK
POULTRY
Any chicken (not including deli meat) If yes, please specify type(s) below	☐Y	☐P	☐N	☐DK
Store-bought breaded chicken (e.g. nuggets, strips, burgers)	☐Y	☐P	☐N	☐DK
Store-bought stuffed chicken products (e.g. chicken Kiev, chicken Cordon Bleu)	☐Y	☐P	☐N	☐DK
Ground chicken	☐Y	☐P	☐N	☐DK
Any chicken pieces or parts (e.g. roasted whole chicken, breasts, wings, thighs, in soups, or as part of a dish, not including deli meat) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Other chicken (not including deli meat, e.g. chicken salad) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Any turkey (not including deli meat) If yes, please specify type(s) below	☐Y	☐P	☐N	☐DK
Ground turkey	☐Y	☐P	☐N	☐DK
Any turkey pieces or parts (e.g. roasted whole turkey, breasts, wings, thighs, in soups, or as part of a dish, not including deli meat) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Other turkey (not including deli meat) (e.g. turkey bacon) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Other poultry (not including deli meat e.g. Cornish hen, duck) If yes, specify: ___________________	☐Y	☐P	☐N	☐DK
EGGS AND EGG-CONTAINING DISHES
Eggs (e.g. scrambled eggs, omelets) If yes, specify ____________	☐Y	☐P	☐N	☐DK
Eggs consumed raw or undercooked (e.g. “runny” or “over-easy”), anything made with raw eggs (e.g. raw cookie dough, cake batter, sauces, homemade ice cream, mayo, salad dressing, or in a drink) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
PORK
Any pork (not including deli meat) If yes, please specify type(s) below	☐Y	☐P	☐N	☐DK
Ham (not including deli meat)	☐Y	☐P	☐N	☐DK
Bacon	☐Y	☐P	☐N	☐DK
Ground pork	☐Y	☐P	☐N	☐DK
Any pork pieces or parts (e.g. pork roasts, ribs, chops, in soups, or as part of a dish, not including deli meat or ham) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Other pork (not including deli meat) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
BEEF
Any beef (not including deli meat) If yes, please specify type(s) below	☐Y	☐P	☐N	☐DK
Any ground beef (e.g. hamburgers, lasagna, chili) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Ground beef consumed raw or undercooked (e.g. undercooked hamburgers or kibbeh)	☐Y	☐P	☐N	☐DK
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
Veal	☐Y	☐P	☐N	☐DK
Other beef (not including deli meat) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
OTHER MEAT/ANIMAL PRODUCTS
Any deli meats/cold cuts (e.g. Bologna, salami, pepperoni, turkey, ham) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Pre-packaged deli meat If yes, specify: ___________________	☐Y	☐P	☐N	☐DK
Deli meat sliced at the deli counter If yes, specify: ___________________	☐Y	☐P	☐N	☐DK
Sausage If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Dried/cured meat products (e.g. beef jerky, dried sausage, summer sausage) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Pâté/meat spread If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Lamb	☐Y	☐P	☐N	☐DK
Goat	☐Y	☐P	☐N	☐DK
Any kind of game/country food (e.g. venison, pheasant, rabbit, caribou, seal, quail, moose, bison) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Any organ meats (e.g. liver, kidney, heart) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Shawarma/donair/gyro	☐Y	☐P	☐N	☐DK
Other meat, excluding fish/seafood If yes, specify:___________________	☐Y	☐P	☐N	☐DK
FISH AND SEAFOOD
Any fish (including fresh, canned, jarred, frozen) If yes, please specify type(s) below	☐Y	☐P	☐N	☐DK
Smoked fish (e.g. smoked salmon) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Fish – eaten raw (e.g. sushi, tartare, sashimi, ceviche) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Other fish (e.g. fresh, frozen, cooked, dried) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Any shellfish If yes, please specify type(s) below	☐Y	☐P	☐N	☐DK
Mussels If yes, was it eaten raw ☐Y ☐N ☐DK	☐Y	☐P	☐N	☐DK
Clams If yes, was it eaten raw ☐Y ☐N ☐DK	☐Y	☐P	☐N	☐DK
Shrimp/Prawns If yes, specify:___________________ If yes, was it eaten raw ☐Y ☐N ☐DK	☐Y	☐P	☐N	☐DK
Any oysters If yes, was it eaten raw ☐Y ☐N ☐DK	☐Y	☐P	☐N	☐DK
Any other shellfish (e.g. scallops, cockles, crab, crayfish, lobster) If yes, specify:___________________ If yes, was it eaten raw ☐Y ☐N ☐DK	☐Y	☐P	☐N	☐DK
Other seafood or seaweed products If yes, specify:___________________	☐Y	☐P	☐N	☐DK
DAIRY and DAIRY SUBSTITUTES
Pasteurized dairy milk If yes, specify: _____________________	☐Y	☐P	☐N	☐DK
Unpasteurized (raw) milk If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Non-dairy milk (e.g. soy, almond, coconut, rice, cashew, oat) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Powdered milk products (e.g. powdered milk, Carnation, Ovaltine)	☐Y	☐P	☐N	☐DK
Whipped/whipping cream	☐Y	☐P	☐N	☐DK
Sour cream	☐Y	☐P	☐N	☐DK
Ice cream/gelato If yes, specify: ______________________	☐Y	☐P	☐N	☐DK
Desserts containing milk or cream (e.g. cream filled pies/pastries, pudding) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
Yogurt	☐Y	☐P	☐N	☐DK
Other dairy products If yes, specify:___________________	☐Y	☐P	☐N	☐DK
CHEESE
Any cheese	☐Y	☐P	☐N	☐DK
Cheddar cheese	☐Y	☐P	☐N	☐DK
Mozzarella cheese	☐Y	☐P	☐N	☐DK
Parmesan cheese	☐Y	☐P	☐N	☐DK
Gouda	☐Y	☐P	☐N	☐DK
Feta cheese	☐Y	☐P	☐N	☐DK
Any Brie, camembert or other soft cheeses If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Any blue-veined cheese such as blue cheese or gorgonzola If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Any cottage, ricotta or other fresh cheese If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Any cheese made from goat/sheep milk If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Any other cheese that is typically sold as a block or cut from solid blocks or wheels (e.g. Emmental, jarlsberg, monterey jack, havarti, colby, oka) If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Processed cheese (e.g. sliced cheese, cheese string/tubes, from a jar) If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Any cheese made with unpasteurized (raw) milk If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Non-dairy cheese alternatives If yes, specify : __________________	☐Y	☐P	☐N	☐DK
FROZEN FOODS
Frozen pizza	☐Y	☐P	☐N	☐DK
Frozen pot pies	☐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
Any nuts on their own, mixed, as a butter/spread or home made nut milk, in granola bar, as a garnish or as part of a dish If yes, please specify type(s) below:	☐Y	☐P	☐N	☐DK
Peanuts (excluding peanut butter/spread)	☐Y	☐P	☐N	☐DK
Almonds (excluding almond butter/spread)	☐Y	☐P	☐N	☐DK
Walnuts	☐Y	☐P	☐N	☐DK
Hazelnuts/filberts (excluding hazelnut butter/spread)	☐Y	☐P	☐N	☐DK
Cashews (excluding cashew butter/spread)	☐Y	☐P	☐N	☐DK
Pecans	☐Y	☐P	☐N	☐DK
Other nuts (e.g. macadamia, brazil nuts, pistachios, pine nuts) If yes, specify:___________________	☐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, including homemade hummus	☐Y	☐P	☐N	☐DK
Other seeds (e.g. chia/chia powder, flax, hemp) If yes, specify:___________________	☐Y	☐P	☐N	☐DK
DRIED/PROCESSED/OTHER FOODS
Any plant-based meat substitutes (e.g. tofu, veggie burgers or hotdogs) If yes, specify : __________________	☐Y	☐P	☐N	☐DK
Dried fruits (e.g. raisins, cranberries, apricots) 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
Any food or drinks containing cannabis as an ingredient (e.g. brownies or other baked goods, gummies or candies, chocolate, oils, teas, juices or sodas, etc.) 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 12. Demographics:

My final question asks about your race or racial background. In our society, people are often described by their race and consider themselves to be “White” or “Black” or “South Asian”. This information is being collected to understand who is being infected with Shigella to help guide our investigation.

(Interviewer note: if a case is uncomfortable with answering, skip the question).

Which race category best describes you? Select all that apply from the options:

☐ Black (e.g. African, Afro-Caribbean, African Canadian descent)

☐ East/Southeast Asian (e.g. Chinese, Korean, Japanese, Taiwanese, Filipino, Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian descent)

☐ Indigenous (e.g. First Nations, Inuk/Inuit, Métis descent): ☐ First Nations ☐ Inuk/Inuit ☐ Métis

☐ Latino (e.g. Latin American, Hispanic descent)

☐ Middle Eastern (e.g. Arab, Persian, West Asian descent – for example, Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish)

☐ South Asian (e.g. South Asian descent-for example, East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)