Foodnet Case Report - Tennessee Department Of Health
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2Please fill this form out as complete as possible. Anything that appears in
is not available for
Tennessee Department of Health
red
data entry into NEDSS. However, you may find those fields helpful in your investigation. Do not
FoodNet Case Report
forget to complete the appropriate disease-specific supplement form.
D
EMOGRAPHICS
Last Name: ___________________________ First: ___________________________ Middle: ____________ DOB: ____/____/________
□ Days
□ Months
□ Years
□ Male
□ Female
□ Unknown
Reported Age:
________
Sex:
Street Address: ____________________________________________________________________________________________________
City: ___________________________
County: ________________________
State: __________________
Zip: _________
Home Phone: ______________________________ Work: ______________________________ Cell: ______________________________
□ Hispanic
□ American Indian / Alaskan
□ Asian
□ Black / African American
Ethnicity:
Race:
□ Not Hispanic
□ Hawaiian / Pacific Islander
□ White
□ Other
(________________)
Employer/School/Daycare: _____________________________________________________
Occupation: _______________________
L
R
AB
EPORT
Reporting Facility: _______________________________________
Ordering Facility: _______________________________________
Ordering Provider: _______________________________________
Phone Number:
_______________________________________
Jurisdiction: □ East Tennessee
□ Mid-Cumberland
□ Northeast
□ South Central
□ Southeast
□ West Tennessee
□ Upper Cumberland
□ Nashville/Davidson
□ Chattanooga/Hamilton
□ Knoxville/Knox
□ Jackson/Madison
□ Memphis/Shelby
□ Sullivan
□ Out of Tennessee
□ Unassigned
□ Blood
□ CSF
□ Stool
Lab Report Date:
____/____/_______
Specimen Source:
□ Urine
□ Other _______________
Date Received by Public Health:
____/____/_______
□ Unknown
____________________
Date Specimen Collected:
____/____/_______
□ Campylobacter sp identified
□ E. coli identified
□ Shigella sp identified
□ Cryptosporidium sp
□ Listeria sp identified
□ Yersinia identified
□ Cyclospora identified
□ Salmonella sp identified
□ Vibrio sp identified
□ Campylobacter test, EIA
□ Cryptosporidium
□ E. coli Shiga toxin test, PCR
□ positive
□ indeterminate
□ acid-fast stain □ DFA
□ EIA
□ stx1
□ stx1 & stx2
□ negative
□ rapid cartridge □ PCR
□ Other
□ stx2
□ undifferentiated
□ Campylobacter test, PCR
□ E. coli Shiga toxin test, EIA
□ Microorganism identified, by PCR
□ positive
□ indeterminate
□ stx1
□ stx1 & stx2
O
RGANISM
□ negative
□ stx2
□ undifferentiated
I
NVESTIGATION
Investigation Start Date: ____/____/_______
Date of Report: ____/____/_______
□ Open
□ Closed
Investigation Status:
Reporting Source: __________________________________
Investigator: _______________________________________
Earliest Date Reported to County: ____/____/_______
Date Assigned to Investigation: ____/____/_______
Reporter: __________________________________________
Physician: _______________________________________
Physician’s Phone: ________________________________________
Was the patient □ Yes
Hospital: _______________________________________________________________________
hospitalized for □ No
Admission Date: ____/____/_______
Discharge Date: ____/____/_______
□ Unknown
this illness?:
If patient not hospitalized, Diagnosis Date: ____/____/_______
Is the patient pregnant?: □ Yes □ No □ Unknown
Did the patient die from this illness?: □ Yes □ No □ Unknown
□ Yes
□ Yes
□ Yes
Is this patient
Is this patient
Is this case
□ No
□ No
□ No
associated with
a food handler?:
part of an
□ Unknown
□ Unknown
□ Unknown
a daycare facility?:
outbreak?:
If yes, name
If yes, name of
If part of a multistate cluster or
of daycare: ______________________
restaurant/facility: ______________________
outbreak, list CDC cluster code:
________________________________
______________________________________
_____________________________
□ Foodborne
□ Indeterminate
□ Confirmed
Transmission Mode:
Case Status:
□ Waterborne
□ Other ________________________
□ Probable
□ Zoonotic
_____________________________
□ Suspect
D
U
01/2014
F
C
Q
(F
A
U
O
):
RAFT
PDATED
OOD
ORE
UESTIONS
OR
DMINISTRATIVE
SE
NLY
Was the case interviewed by public health? □ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
Was a food history obtained?
□ Yes
□ No
□ Unknown
□ Yes
□ No
□ Unknown
If no, was an attempt made?
Was the case entered into NEDSS?
Date of first
Date of
Date entered into NEDSS: ____/____/_______
interview attempt: ____/____/_______
interview: ____/____/_______
Data Entry Person’s Name: _______________________________________
Interviewer’s Name: _____________________________________________
Other Notes: ___________________________________________________
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