Case Report Form - U.s. Department Of Health And Human Services Page 7
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13CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
C. Other locations: “Did <case> eat food purchased or obtained from any other locations, such as salad bars (including at grocery stores), cafeterias, food trucks, picnics, potlucks, concession
stands, institutions (e.g. hospital food), local farms or dairies, or special events like weddings or parties during the 4 week period?”
Location Name
Location (address, city, state)
What foods did <case> eat?
Date(s)
1.
2.
3.
3 . Food Consumption History
“Now I’ d like to ask you about the foods that <case> ate during that same 4 week period. For each food item, please give me your best guess as to whether <case> ate the food. If you’re not sure, you
can tell me whether <case> likely ate or likely did NOT eat the food. If you have no idea, please say ‘don’t know.’ I’ll start by asking about cheeses.”
A. Cheese
Ate
Likely
Likely
Did NOT
Don’t
Details
Made from
Place of purchase or
(e.g., type, variety, brand, packaging, shape/size, how
ate
did NOT
eat
know
(=1)
prepared)
raw milk?
consumption
(=2)
eat (=3)
(=4)
(=99)
(circle one)
Feta
1
2
3
4
99
Y N DK
Goat cheese
1
2
3
4
99
Y N DK
Blue-veined cheese
1
2
3
4
99
Y N DK
(gorgonzola, bleu)
Brie or camembert
1
2
3
4
99
Y N DK
Gouda
1
2
3
4
99
Y N DK
Prepackaged, shredded cheese
1
2
3
4
99
Y N DK
Fresh mozzarella, sold in water
1
2
3
4
99
Y N DK
Cottage cheese
1
2
3
4
99
Y N DK
Ricotta cheese
1
2
3
4
99
Y N DK
Other gourmet, fancy, or
1
2
3
4
99
Y N DK
artisanal cheese
Any cheese sliced at a deli
1
2
3
4
99
Y N DK
counter
Middle Eastern-style cheese
1
2
3
4
99
Y N DK
(e.g., akawi, nabulsi)
Mexican- or Latin-style
1
2
3
4
99
Y N DK
cheese
(e.g., queso fresco)
If ate or likely ate Mexican- or Latin-style cheese, what type(s)?
- Queso fresco
1
2
3
4
99
Y N DK
- Queso blanco
1
2
3
4
99
Y N DK
- Queso casero
1
2
3
4
99
Y N DK
- Cuajada
1
2
3
4
99
Y N DK
- Asadero
1
2
3
4
99
Y N DK
- Cotija
1
2
3
4
99
Y N DK
- Panella
1
2
3
4
99
Y N DK
- Queso ranchero
1
2
3
4
99
Y N DK
- Requeson
1
2
3
4
99
Y N DK
- Oaxaca
1
2
3
4
99
Y N DK
- Other Mexican- or Latin-
style cheese
1
2
3
4
99
Y N DK
(specify)
______________
Other soft cheese (not cream,
cottage, or ricotta) — specify
1
2
3
4
99
Y N DK
type ______________
Any cheese from raw/
1
2
3
4
99
Y N DK
unpasteurized milk
Any other cheeses
1
2
3
4
99
Y N DK
(specify)____________
7
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