Case Report Form - U.s. Department Of Health And Human Services (Page 6 of 13) in pdf

CDC Listeria Initiative Case Report Form

PulseNet ID or state public health lab isolate ID ____________________________

Interviewer: In the question stems and interviewee instructions, the text “<case>” is used in place of “you/he/she,” and “<case’s>” is used in place of “your/his/

1. Patient Interview

her.” For pregnancy-associated cases, the mother is the case-patient and she should be asked about her food history during the 4 weeks before delivery.

1. Date of interview

2. Respondent was £ Case-patient £ Surrogate £ Unknown £ None available (chart review only)

If surrogate, relationship to patient: £ Parent £ Child £ Sibling £ Spouse £ Other, Specify _____________________

3. When did <case’s> illness begin? (Onset of illness)

£ Not applicable (e.g. pregnant woman without clinical illness)

4. During the 4 weeks before <case’s> illness/delivery date, was <case> admitted

5. During the 4 weeks before <case’s> illness/delivery date, was <case> a resident

to a hospital (i.e., stayed at least overnight)?

£ Yes £ No £ DK

in a nursing home or other long term care facility? £ Yes £ No £ DK

If yes, Hospital name ________________________________________

If yes, Facility name ________________________________________

Admission date:

Discharge date:

or £ Still hospitalized

Discharge date:

or £ Still residing in facility

6. During the 4 weeks before <case’s> illness/delivery date, did <case> travel to a

7. During the 4 weeks before <case’s> illness/delivery date, did <case> travel

state outside of <case’s> state of residence?

£ Yes £ No £ DK

outside the U.S.?

£ Yes £ No £ DK

If yes, please list states visited ____________________________

If yes, Names of countries visited ___________________________________

If yes, Date of departure from U.S.

Date of return to U.S.

8. Which of the following symptoms were associated with illness? (read each) (ask mother for her symptoms if case was pregnancy-associated or in infant < 60 days old)

Preterm labor

Fever

£ Yes £ No £ DK

Stiff Neck

£ Yes £ No £ DK

Chills

£ Yes £ No £ DK

£ Yes £ No £ DK £ N/A

Altered mental status £ Yes £ No £ DK

Diarrhea (>3loose stools/day) £ Yes £ No £ DK

Muscle Aches

£ Yes £ No £ DK

Other (specify) ____________________________

Vomiting

£ Yes £ No £ DK

Headache

£ Yes £ No £ DK

Other (specify) ____________________________

2. Food History

Interviewer: In this section, “case” refers to patient except when patient is infant ≤60 days old, when questions apply to mother.

“I am interested in the foods <case> ate during the 4 weeks before <case’s> illness/delivery, which I see was on ____/____/____. For most of the interview, I will be asking you questions about

the 4 weeks before this date, starting ____/____/____ (date 4 weeks before) through ____/____/____. It might be helpful to look at a calendar available for reference, if possible.”

1.Did <case> have any allergies that prevented <case> from eating certain foods? £ Yes £ No £ DK

2. Did <case> have a vegetarian or vegan diet?

1a. If yes: What foods? £ Milk £ Eggs £ Peanuts £ Tree nuts £ Fish £ Soy £ Wheat £ Shellfish

£ Yes £ No £ DK

£ Other (specify) ____________________________________

2a. If yes, Which one? £ Vegetarian £ Vegan

3.Did <case> have a special or restricted diet (medical, weight-loss, religious, cultural) or are there any types of foods <case> didn’t eat? £ Yes £ No £ DK

3a. If yes: Please Describe: ____________________________________________________________________________

Food Purchase History (the lists of store and restaurant types below are meant to prompt the respondent)

A. Sources of food at home: “Now I have a few questions about where the food came from that <case> ate at home in the 4 weeks before <case’s> illness began. I’m going to list several types of

stores. For each type, please tell me the names of each store <case> would have eaten food from during the 4 weeks before <case> was sick. Did <case> eat foods from?”

• Grocery stores or supermarkets

• Ethnic specialty markets (e.g., Mexican, Asian)

• Did <case> eat food at home from any other place during

• Warehouse stores, such as Costco or Sam’s Club

• Farmer’s markets

the 4 weeks before illness began?

• Small markets (convenience stores, gas stations, etc.)

• Online stores or foods received by mail

Store Name

Location (address, city, state)

Would you be willing to release your shopper card information so we can get an

Store name: __________________ Shopper card #: _____________________

exact list of your foods and when they were purchased?

Store name: __________________ Shopper card #: _____________________

£ Yes £ No £ None available

Store name: __________________ Shopper card #: _____________________

B. Restaurants: “Now I have a few questions about restaurants where <case> might have eaten. For each type of restaurant, please tell me the names of every restaurant <case> ate food from

during the 4 weeks before <case> was sick. Did <case> eat foods from…?” (interviewer name all types)

• Buffet-style (where you serve yourself)

• Sandwich shops or delis

• Any other type of restaurant

• Ethnic restaurants that are not fast-food, such as Mexican, Italian, Chinese

• Fast-food (drive up or pay at counter)

Restaurant Name

Location (address, city, state)

What foods did <case> eat?

Date(s)