0920-0004 Waterborne Diseases Outbreak 52.12

DEPARTMENT OF HEALTH
& HUMAN SERVICES

CDC USE ONLY

WATERBORNE DISEASES OUTBREAK REPORT

Centers for Disease Control
and Prevention
National Center for Infectious Diseases
Atlanta, GA 30333

This form should be used to report outbreaks of illness after consumption or
use of water intended for drinking, as well as outbreaks associated with
exposure (ingestion, contact or inhalation) to recreational water.

Form Approved
OMB No. 0920-0004

SUBMITTED COPIES OF THIS FORM SHOULD INCLUDE AS MUCH INFORMATION AS POSSIBLE; BUT THE COMPLETION OF EVERY ITEM IS NOT REQUIRED.

1. TYPE of EXPOSURE:

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■
■

Drinking water
Recreational water
Other:

____________________

2. LOCATION of OUTBREAK:

4. NUMBERS OF:

3. DATE of OUTBREAK:

Estimated

Persons ill:
Hospitalized:

County:

Mo.

5. HISTORY of EXPOSED PERSONS:

NO. OF PERSONS
INTERVIEWED:

Enter the no. of persons with the
following symptoms:

Diarrhea (≥3 stools/day):

Diarrhea (other):

Visible blood in stools:
Eye infections:

Nausea:
Ear
infections:

Respiratory symptoms:

Other, specify:

Day

Yr.

Fatalities:
6. INCUBATION
PERIOD:
Hrs. Days

NO. OF INTERVIEWED
PERSONS WHO WERE ILL:

/(Specify definition):

Shortest:

Fever:
Skin
infections:

Vomiting:

Cramps:

Longest:

Rash:

Dermatitis:

Median:
Mean:

8. SPECIMENS EXAMINED from PATIENTS: (stool, vomitus, serum, etc.)

EXAMPLE

Actual

Persons exposed:

(Date first case became ill):

State:
City or
Town:

SPECIMEN

No. PERSONS

Stool

11

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■
■
■

■
■
■
■

Shortest:
Longest:
Median:
Mean:

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■
■
■

9. ETIOLOGY of OUTBREAK:
Diagnostic Certainty
Agent
(If not known enter "Unk.")
Confirmed Suspected

FINDINGS

8 Giardia intestinalis

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■
■
■

7. DURATION of
ILLNESS:
Hrs. Days

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■
■

Pathogen:

3 negative

Chemical:
Other:

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■

Comments:
......................................................................................................

10a. EPIDEMIOLOGIC DATA: (e.g., vehicle/source - specific attack rates; dose-response curve, attach local and/or state report if available)
Number of Persons EXPOSED

EXPOSURE
(vehicle/source)

■

ILL

NOT ILL

TOTAL

% ILL

Number of Persons NOT EXPOSED
ILL

NOT ILL

TOTAL

% ILL

ODDS/RISK
RATIO
(If available)

p VALUE or
CONFIDENCE
INTERVAL
(If available)

No data were collected from comparison groups to estimate risk but water was the only common source shared by persons who were ill.

10b. Comments:
....................................................................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................................................................
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11. WATER SUPPLY CHARACTERISTICS:

(check all that apply for drinking water or recreational water)

a) TYPE OF DRINKING WATER SUPPLY:

■

■

■
■
■
■

Community or Municipal
City or County
(Name: _____________________________ )
■ Subdivision
■ Trailer Park

■

Noncommunity
(does not obtain water from a community water
system, but has developed/maintained its own
water supply)
■ Camp, Cabin, Recreational area
■ School
■ Restaurant
■ Hotel, Motel
■ Church
■ Other:________________________________
Individual household supply
Bottled water
Other: __________________________________
Unknown

CDC 52.12

REV. 01/2003

(Front)

b) WATER SOURCE OR SETTING:
■ Well
■ Spring/Hot spring
■ River, Stream
■ Lake, Pond, Reservoir
■ Ocean
■ Pool
■ Waterpark
■ Community/municipal
■ Subdivision/neighborhood apartment
■ Hotel/motel
■ Membership club
■ Private home
■ Kiddie/wading
■ Fountain
■ Interactive
■ Ornamental
■ Waterpark
■ Hot tub
■ Whirlpool/spa pool
■ Other: _____________________________
■ Unknown
WATERBORNE DISEASES OUTBREAK REPORT

*If recreational water outbreak, this refers
to recreational water treatment
c) WATER TREATMENT PROVIDED:*

■
■

■
■
■

■
■

No treatment
Disinfection
Chlorine
Chlorine and Ammonia (chloramine)
Bromine
Ozone
U.V.
Other: ________________________________
Unknown

■
■
■
■
■
■
■

Coagulation and/or Flocculation
Settling (sedimentation)
Filtration at purification plant
(don't include home filters) or pool
■ Rapid sand
■ Slow sand
■ Diatomaceous earth
■ Other: _______________________________
■ Unknown
Other: __________________________________
Unknown

IF RECREATIONAL EXPOSURE, PROCEED TO QUESTION (13), OTHERWISE PROCEED TO (12a).
12. FACTORS CONTRIBUTING TO DRINKING WATER CONTAMINATION: (check all that apply) *See 16
a) Contamination at the water source:
■ Flooding, heavy rains
■ Overflow of sewage
■ Use of a back-up source of water by a water utility
■ Underground seepage of sewage
■ Improper construction or location of well or spring
■ Septic system drainage
■ Contamination of wells through limestone or fissured rock
b) Water treatment deficiencies :
■ No disinfection
■ Temporary interruption of disinfection
■ Chronically inadequate disinfection

■
■
■

No filtration
Inadequate filtration
Deficiencies in other treatment processes

c) Contamination in the water distribution system or home plumbing:
■ Contamination of mains during construction or repair
■ Cross connection of potable and nonpotable water pipes resulting in back
■ Contamination of storage facility
siphonage (negative pressure or
■ Contamination in building/home
backflow)

■
■
■
■
■

Contamination from wild/domestic animals
Chemical pollution
Algal bloom
Other:
Unknown

■
■

Other:
Unknown

■
■

Other:
Unknown

d) OTHER REASONS/CONTRIBUTING FACTORS FOR CONTAMINATION OF WATER (eg. corrosive water):
....................................................................................................................................................................................................................................................................................................................................................................................

13. ROUTE OF ENTRY FOR RECREATIONAL EXPOSURE:

■

Accidental ingestion

■

■

Intentional ingestion

Contact

■

Inhalation

14. FACTORS CONTRIBUTING TO RECREATIONAL WATER CONTAMINATION : (check all that apply) *See 16
a) FRESH OR MARINE WATER (e.g. lakes, rivers, oceans):
■ High bather density/load
■ Flooding, heavy rains
■ Fecal accident by bather(s)
■ Stagnant water
■ Use by diaper/toddler aged children
■ Water Temperature >_ 30°C
■ Overflow or release of sewage
■ Chemical pollution

■
■

Other:
Unknown

■
■
■
■
■
■

Algal bloom
Animal feces observed near site
Agricultural/animal production in watershed
Unprotected watershed
Other:
Unknown

b) FILTERED AND/OR DISINFECTED SWIMMING VENUES (e.g. swimming pools, water parks, hot tubs, whirlpools/spa pools):
■ High bather density/load
■ Inadequate disinfection
■ No filtration
■ Fecal accident by bather(s)
■ Poor monitoring of disinfection levels
■ Inadequate filtration
■ Use by diaper/toddler aged children
■ Cross contamination (specify _____________________ ) ■ Other:
■ No disinfection
■ Combined adult/child pool filtration systems
■ Unknown
15. WATER SPECIMENS EXAMINED: (provide information for routine samples collected before and during the outbreak investigation as well as for any special lab studies)

■

NONE TESTED

LABORATORY RESULTS

ITEM

DATE

MICROBIOLOGY

DISINFECTANT
RESIDUAL

TURBIDITY

0.1 NTU

Tap Water

10/11/01

Total coliforms - none found in two 100ml samples; Giardia - 10 cysts/100L

0.5 mg/L

Untreated Raw Water

11/02/01

23 fecal coliforms per 100 ml

Not Done 10.0 NTU

EXAMPLES

System History

Prev. 3 mos MCL for total coliforms exceeded month before outbreak

NA

>MCL

Source Water

Prev. 2 wks Heavy runoff, high turbidity

NA

5.0 NTU

16. REMARKS: Clarify for sections 12 and 14 which checked items
are confirmed or are suspected factors

Briefly describe the unusual aspects of the outbreak and/or the outbreak investigation
not covered above. Attach epidemic curve and summary report, if available.

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Person to contact for information about
water quality or water system:

Person completing form:

(please print)
E-MAIL: _____________________________________

NAME:

TEL. NO: ( __ __ __ ) __ __ __ - __ __ __ __
area code

AGENCY:

DATE OF REPORT:

__ __ / __ __ / __ __
MO.

Note: Epidemic and laboratory assistance for the investigation of a waterborne outbreak is available
upon request by the State Health Department to the Centers for Disease Control and Prevention.
To improve national surveillance of outbreaks of waterborne diseases, please send a copy of this
report, your internal report, and the questionnaire used in the epidemiologic investigation (if available) to:

DAY

YR.

Date investigation
initiated:

__ __ / __ __ / __ __
MO.

DAY

YR.

Centers for Disease Control and Prevention
Division of Parasitic Diseases
Attention: Waterborne Disease Coordinator
4770 Buford Highway, NE, Mailstop F22
Atlanta, GA 30341-3724

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA
30333, ATTN: PRA (0920-0004). <–—DO NOT MAIL CASE REPORTS TO THIS ADDRESS–

CDC 52.12

REV.

01/2003 (Back)

WATERBORNE DISEASES OUTBREAK REPORT