Form Doh 210-040 - Shellfish Poisoning: Paralytic, Domoic Acid Page 2
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1
2Washington State Department of Health
Case Name: _________________________
INFECTION TIMELINE
Exposure period
o
n
Enter onset date/time
Hours from
s
(first sx) in heavy
onset:
- 4 or longer
- minutes
Note: Exposure period for domoic acid
e
box. Count backward
may be up o 38 hours
t
to figure probable
exposure period
Calendar dates/times:
EXPOSURE (Refer to dates above)
Y N DK NA
Y N DK NA
Shellfish or seafood
Travel out of the state, out of the country, or
outside of usual routine
County or location shellfish collected: ________
_
Out of:
County
State
Country
_______________________________________
Dates/Locations: ________________________
Known contaminated food product
______________________________________
Food from restaurants
______________________________________
Restaurant name/location: ____________
______
______________________________________
Y N DK NA
_
Case knows anyone with similar symptoms
____________________________________________
Epidemiologic link to a confirmed human case
Where did exposure probably occur?
In WA (County: ___________________)
US but not WA
Not in US
Unk
Exposure details: ___________________________________________________________________________________________
No risk factors or exposures could be identified
Patient could not be interviewed
PUBLIC HEALTH ISSUES
PUBLIC HEALTH ACTIONS
Notify others sharing exposure
Notify shellfish program
Initiate trace-back investigation
Other, specify: _____________________
NOTES
Investigator
Investigation complete date ___/___/___
Record complete date ___/___/___
Local health jurisdiction _______________________________
Shellfish Poisoning: case defining variables are in bold. Answers are: Yes, No, Unknown to case, Not asked /Not answered
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