Form assigned Cyclosporiasis

CYCLOSPORIASIS SURVEILLANCE CASE REPORT FORM

Form Approved

OMB NO. 0920-0009

Demographic Data:

Patient’s name: __________________________________________________________________________________

Last First

State of residence: ______________________________________ County: ______________________________

Sex: Male Female Age:______ Date of birth (mm/dd/yy):____/____/____

Race/Ethnicity (select one or more):

American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander

Asian Hispanic or Latino White

Unknown

Physician’s Name:___________________________________________ Phone:__ __ __-__ __ __-__ __ __ __

Physician’s Email: ___________________________________________

Clinical Data: (NOTE: for dates, be as specific as possible. However, approximations (e.g., mm/yy) are okay.)

Date of illness onset (mm/dd/yy): ___/___/____ Unknown

Signs and symptoms:

Diarrhea: Yes No Unknown Fatigue: Yes No Unknown

Maximum number stools per day:__________ Anorexia: Yes No Unknown

(unknown = 999) Nausea: Yes No Unknown

Weight loss: Yes No Unknown Vomiting: Yes No Unknown

Baseline weight: __ __ __ lbs. (unknown = 999) Abdominal cramps: Yes No Unknown

Number of pounds lost: ___________ Other symptoms (specify): _________________

Fever: Yes No Unknown _______________________________________

Temperature (if measured):_______degrees F (unknown = 999)

Hospitalized (at least overnight): Yes No Unknown

If yes, list name of hospital: _________________________________ Date of admission: ___/___/___

Stool collection date: ___/___/___ Results: Positive Negative Unknown

Confirmed by state lab? Yes No Unknown Confirmed by CDC lab? Yes No Unknown

Was the case-patient treated for cyclosporiasis? Yes No Unknown

If yes, what medication was provided? trimethoprim/sulfamethoxazole (e.g., Bactrim, Septra, Cotrim)

Other (specify): _________________________ Unknown

Is case-patient sulfa-allergic? Yes No Unknown

Epidemiologic Data: (NOTE: for dates, be as specific as possible. However, approximations (e.g., mm/yy) are okay.)

Public reporting burden of this collection of information is estimated to average 15 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).

History of Travel (during the 2 weeks before onset of illness):  Yes  No  Unknown

International travel (country):  Unknown dates (check here if dates are unknown)

(1)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___

(2)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___

(3)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___

Travel in the United States (state):  Unknown dates (check here if dates are unknown)

(1)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___

(2)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___

(3)______________________ Departure date (mm/dd/yy) ___/___/___ Return date (mm/dd/yy) ___/___/___

Exposures (during the 2 weeks before onset of illness):

Ate fresh berries: Yes (if yes, specify types below; check all that apply) No Unknown

Strawberries Blackberries Blueberries

Raspberries Black raspberries Golden raspberries Unknown type of berry

Other type of berry (specify):_________________________________

Ate fresh herbs: Yes (if yes, specify types below; check all that apply) No Unknown

Cilantro Oregano Thyme Mint Dill Parsley Rosemary

Basil (specify types): Sweet basil Thai basil (i.e., green leaves and purple stems)

Purple basil (i.e., purple leaves and stems)

Other type of herb (specify): ___________________________________________________________

Unknown type of herb

Ate lettuce: Yes (if yes, specify types below; check all that apply) No Unknown

Mesclun (a.k.a., spring mix, field greens, baby greens, & gourmet salad mix)

Arugula

Other type of lettuce (specify): ____________________________________________________________

Unknown type of lettuce

Ate other types of fresh produce: Yes (if yes, specify types below; check all that apply) No Unknown

Fruit, other than berries (specify types): _______________________________________________________

Unknown type of fruit

Other type(s) of fresh produce (specify): _____________________________________________________

___________________________________________________________________________________

Unknown type of fresh produce

Did the case-patient attend any events (e.g., wedding reception) during the 2 weeks before symptom onset?  Yes  No  Unknown

If yes, specify type of event: ___________________________________________________________________

Event date: ___/___/___

Does the case-patient know of any other ill persons?  Yes  No  Unknown

If yes, did health department collect contact information about other ill persons and investigate further (provide comments below)?

 Yes  No  Unknown

Comments and additional data:

Name (person filling out form):______________________________________ Title:____________________________

Phone: __ __ __-__ __ __-__ __ __ __ FAX: __ __ __-__ __ __-__ __ __ __

Email: ____________________________________________

Name of investigating health department: ____________________________________________________________

Date form completed: ___/___/___

Revised 9/3/02