Form Approved
OMB No. 0920-xxxx
Exp xx/xx/xx
FoodNet Non-O157 STEC Case-Control Study
Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
Date of interview:___mm/___dd/20___ Day of week:_______________ Time of interview:__________
Interviewer:_______________
Matched-Case Person ID Number (FoodNet site-specific)_________________
Matched-Case Study ID Number____________________
Matched-Case State Lab ID Number__________________
Control: 1 2 3
-- Date Matched CASE’S SYMPTOMS Began: ____mm/_____dd/20____
--Date 7 days before Matched CASE’S SYMPTOMS began: __mm/_____dd/20____
--Date one month before Matched CASE’S SYMPTOMS began: ____mm/_____dd/20____
These dates will be used to ascertain the control’s exposure history so it can be matched with the history of the case.
___________________________________________________________________________________________
START HERE AFTER OBTAINING CONSENT
Age Strata of matched case-patient: |
0 to <2 years |
2 to <6 years |
6 to <18 years |
18 to <40 years |
40 to <60 years |
60 or older years |
1. What is your/your child’s age? _______Years______months
2. What is your/your child’s gender?
Gender: F M Refused
3. In what county do you/your child live? ___________________
Section 1: Health Questions
I will be asking you some questions about specific dates so it may be helpful to have a calendar in front of you. Do you need a few minutes to get one?
First, I would like to ask you some health related questions. The following questions refer to the four week time period from___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) to ___/___/___ (Date one day before CASE’S SYMPTOMS began).
4. During this four week time frame, did you/your child have any diarrhea?
Yes................…………….…………….…..................................................... 1
No................…………….......Go to Q5.…. …………….................................... 2
Don't know/Not sure………...Go to Q5..… …......................................…… 7
Refused................. ………….Go to Q5...........…...............................……………...9
4a. When you/your child had this diarrhea, what was the maximum number of stools you/your child had in a 24 hour period? _______ Don’t know/not sure Refused
5. Were you/ Was your child diagnosed with an E. coli infection any time between ___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) and ___/___/___ (Date one day before CASE’S SYMPTOMS began)?
Yes................…………………………..…..................................................... 1
No................…………….....Go to Q6....…. …………….................................... 2
Don't know/Not sure..….…. …………………......................................…… 7
Refused................. ……………………............….............................……… 9
IF YES/DON’T KNOW/NOT SURE/REFUSED,
Sorry, but we need to do this interview with someone who definitely did not have an E. coli infection within the past month. Thank you for your time. END.
6. Did you/your child take an antibiotic for any reason between ___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) and ___/___/___ (Date one day before CASE’S SYMPTOMS began)?
Yes................…………….. ………….……………............................................. 1
No................…………….... Go to Q7....…. …………….................................... 2
Don't know/Not sure..….… Go to Q7...........… …......................................…… 7
Refused................. ……….. Go to Q7..……...........….............................……… 9
6a. What was the name of the antibiotic? Interviewer: refer to appendix 1, list all.
Specify:____________________________________
6b. When did you/your child start taking that antibiotic?
Start __/__/__
Don't know/Not sure..….… Go to Q6d...........… …......................................…… 7
Refused................. ……….. Go to Q6d..……...........….............................……… 9
6c. When did you/your child stop taking that antibiotic?
End__/__/__
Don't know/Not sure..….… Go to Q6d...........… …......................................…… 7
Refused................. ……….. Go to Q6d..……...........….............................………9
6d. if unsure of dates, for how many days? ____
Don't know/Not sure..……………...........… …......................................…… 7
Refused................. ………………..……...........….............................……… 9
7. Were you/Was your child taking any stomach acid-reducing medications between ___/___/___ (Date 4 weeks before CASE’S SYMPTOMS began) and ___/___/___ (Date one day before CASE’S SYMPTOMS began)? Such medications might include Tums, Rolaids, Maalox, Zantac, or Prilosec and many others.
Yes................…………….. ………………..…..................................................... 1
No................…………….......Go to Q8....…. …………….................................... 2
Don't know/Not sure..….……Go to Q8...........… …......................................…… 7
Refused................. ………….Go to Q8.……...........….............................……… 9
7a. What was the brand or name of that medication? Interviewer: refer to appendix 2, list all
Specify: ____________________________________________________________
Section 2: Exposures
Up until this point, we have been talking about your/your child’s health and medications you/your child may have taken. Now I will be asking you question about a certain 7 day period of time. ). The period about which I am now going to ask you questions is the seven days from ___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___(day before case’s onset)
PART 1. TRAVEL AND SOCIAL CONTACTS
I’d now like to ask you about travel and settings where you/your child may have come in contact with other people during the time period of interest. Just a reminder that the 7 days of interest are___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___ (DAY BEFORE case’s onset).
8. Did you/your child go camping during the 7 days of interest? Yes..................................................................................................... 1
No...............................................……….......................................... 2
Don't know/Not sure.............. ………….......................................... 7
Refused.................................. …………......................................... 9
9. Did you/your child travel to another city, but within your state during the 7 days of interest (do not include travel associated with your regular commute to home or school)?
Yes..................................................................................................... 1
No...............................................……….......................................... 2
Don't know/Not sure.......................................................................... 7
Refused...............................................………................................... 9
10. Did you/your child travel out-of-state, but within the United States during the 7 days of interest?
Yes..................................................................................................... 1
No.......................................... Go to Q11........................................ 2
Don't know/Not sure.............. Go to Q11........................................ 7
Refused.................................. Go to Q11....................................... 9
10a. What cities and states did you/your child visit? ______________________ ________________________________________________________________
10b.When did you/your child leave? _____/_____/_____
10c.When did you/your child return from your/his/her trip? _____/_____/______
11. Did you/your child travel to another country during the 7 days of interest?
Yes..................................................................................................... 1
No.......................................... Go to Q12........................................ 2
Don't know/Not sure.............. Go to Q12........................................ 7
Refused.................................. Go to Q12....................................... 9
11a. What country(s) did you/your child visit? _________________________ ______________________________________________________________
11b. When did you/your child leave the U.S.? _____/_____/_____
11c. When did you/your child return from your/his/her trip? _____/_____/______
12. For adult control: In the 7 days of interest between, ___/___/___ and ___/___/__, did you work or volunteer at a child care center/setting where there were children under 5 years of age? A child care setting is defined as a place where there are 2 or more children from different households under the care of a person or persons.
For child control: In the 7 days of interest, between, ___/___/___ and ___/___/__, did your child attend a child care center/setting where there were children under 5 years of age? A child care setting is defined as a place where there are 2 or more children from different households under the care of a person or persons.
Yes............................................................................................... 1
No................................................................................................ 2
Don't know/Not sure.............. ……............................................. 7
Refused.................................. ..................................................... 9
13. If control’s age is 5 years of age or older: Were there any children under five in your household during the 7 days of interest?
If control is under 5 years of age: Were there any other children under five in your child’s household during the 7 days of interest?
Yes..................................................................................................... 1
No.......................................... Go to Q14........................................ 2
Don't know/Not sure.............. Go to Q14........................................ 7
Refused.................................. Go to Q14....................................... 9
13a. Did the child/children attend a childcare setting or center?
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
14. During the 7 days of interest, did you/your child live, work, volunteer or spend time in a residential facility like a nursing home, hospital, summer camp, dorm, or jail?
Yes..................................................................................................... 1
No.......................................... Go to Q15........................................ 2
Don't know/Not sure.............. Go to Q15........................................ 7
Refused.................................. Go to Q15....................................... 9
14a. What type of facility or setting was it?
Specify______________________________________
15. During the 7 days of interest, did you/your child come in contact with anyone else with a diarrheal illness?
Yes..................................................................................................... 1
No.......................................... Go to Part 2.......................................2
Don't know/Not sure.............. Go to Part 2.................................. 7
Refused.................................. Go to Part 2................................ 9
15a. Where? Mark all that apply.
Home ……………………………………………………………… 1
Daycare ……………………………………………………………. 2
Other setting, specify_________________________________..... 3
PART 2. WATER
If participant traveled, read the following:
During the 7 days of interest, what were the sources of your/your child’s drinking water? For each source I will be asking whether you/your child drank the water at home or outside the home. This includes water used to wash vegetables, and to mix drinks and baby formula. Water outside of the home includes water drank while at school, work, or any other place you were outside of your own home, including ____________,_____________,___________which you previously told us you traveled to (In order to capture all water consumed away from home, please prompt participant of all places that he or she reported travelling to in questions 8-10).
If participant did NOT, travel read the following:
During the 7 days of interest, what were the sources of your/your child’s drinking water? For each source I will be asking whether you/your child drank the water at home or outside the home. This includes water used to wash vegetables, and to mix drinks and baby formula. Water outside of the home includes water drank while at school, work, or any other place you were outside of your own home.
Again, the period we are interested in is:
___/___/___(SEVEN DAYS BEFORE case’s onset) to ___/___/___ (day before case’s onset).
Did you drink any |
|
At home |
At places other than home |
|
16a |
Municipal water, that is, water that is provided by the city or town? |
Y |
N U R |
Y N U R |
16b |
Tap water from a private well (a well on the premises)? |
Y |
N U R |
Y N U R |
|
If N/U/R to well water at home Go to Q16f |
|||
16c |
Was it treated with a whole-house point-of- entry device: a device installed by some homeowners to treat all water when it first enters the house; for example, a reverse osmosis unit? do not include water softeners. |
Y |
N U R |
|
16d |
Was it treated by some other method, for example, boiled, filtered, UV light, distilled? do not include water softeners. |
Y |
N U R |
|
16e |
Do cattle sometimes go near the well? For example, within 50 feet |
Y |
N U R |
|
16f |
Tap water that came from a spring? |
Y |
N U R |
Y N U R |
|
If N/U/R to spring water at home Go to Q16j |
|||
16g |
Was it treated with a whole-house point-of- entry device: a device installed by some homeowners to treat all water is treated when it first enters the house; for example, a reverse osmosis unit? do not include water softeners. |
Y |
N U R |
|
16h |
Was it treated by some other method, for example, boiled, filtered, UV light, distilled? do not include water softeners. |
Y |
N U R |
|
16i |
Do cattle sometimes go near the spring? For example, within 50 feet |
Y |
N U R |
|
Did you drink any |
At home or outside the home |
|||
16j |
Bottled water? Specify brand_____________ |
Y N U R |
17. Did you/your child drink any untreated water from a pond, lake, river, stream or another source not already mentioned during the 7 days of interest? Specify_________________
Yes.............................................................................................. 1
No............................................................................................ 2
Don't know/Not sure............................................................... 7
Refused.................................. ................................................ 9
18. Did you/your child go swimming or play in water during the 7 days of interest?
Yes.............................................................................................. 1
No.......................................... Go to Part 3...................................... 2
Don't know/Not sure.............. Go to Part 3...................................... 7
Refused.................................. Go to Part 3..................................... 9
Did you/your child swim or play in: |
|
If YES |
Did you/your child put your/their face in the water or swallow any water? |
||
18a |
The ocean? |
Y |
N U R |
|
Y N U R |
18b |
A swimming pool? |
Y |
N U R |
|
Y N U R |
18c |
A wading pool? |
Y |
N U R |
|
Y N U R |
18d |
A splash pad or fountain? |
Y |
N U R |
|
Y N U R |
18e |
A water park? |
Y |
N U R |
|
Y N U R |
18f |
An irrigation ditch? |
Y |
N U R |
|
Y N U R |
|
Go to Q18h |
||||
18g |
Were there cattle nearby? For example, within 50 feet |
Y |
N U R |
|
|
18h |
In a lake, river, or stream (body of fresh water)? |
Y |
N U R |
|
Y N U R |
|
Go to Part 3 |
||||
18i |
Were there cattle nearby? For example, within 50 feet |
Y |
N U R |
|
|
PART 3. ANIMALS
I’d now like to ask you about some animals you/your child may have come into contact with in the 7 days of interest. These may be animals you own, animals your neighbors own, or any other animals.
Again, the period of interest is
___/___/___(SEVEN DAYS BEFORE case’s onset) to ___/___/___ (day before case’s onset).
19. During the 7 days of interest, did you/your child have contact with any pets or backyard animals, including fish or reptiles?
Yes......................................... ………….......................................... 1
No.......................................... Go to Q20......................................... 2
Don't know/Not sure.............. Go to Q20......................................... 7
Refused.................................. Go to Q20....................................... 9
19a. Which of these pets or backyard animals did you/your child have contact with?
|
|
|
|
If YES |
Did you/your child have contact with the animal’s treats, food or feed? |
|
19b |
A dog |
Y |
N U R |
|
Y N U R |
|
Go to Q19d |
||||||
19c |
Did you/your child feed the dog(s) animal- based products such as rawhides, pig’s ears or cow hooves?
|
Y |
N U R
|
|
|
|
19d |
A cat |
Y |
N U R |
|
Y N U R |
|
19e |
A bird |
Y |
N U R |
|
Y N U R |
|
19f |
Reptiles or amphibians like a turtle, snake, iguana or frog |
Y |
N U R |
|
Y N U R |
|
Go to Q19h |
||||||
19g |
What type of reptile or amphibian? |
Specify:_______ |
|
|
||
19h |
Fish |
Y |
N U R |
|
Y N U R |
|
19i |
Chickens |
Y |
N U R |
|
Y N U R |
|
19j |
A goat |
Y |
N U R |
|
Y N U R |
|
19k |
Another pet or backyard animal |
Y |
N U R |
|
Y N U R |
|
Go to Q20 |
||||||
19l |
What type of animal? |
Specify_______
|
|
|
20. During the 7 days of interest, did you/your child live on a farm?
Yes.................................................................................................. 1
No.......................................... Go to Q21........................................ 2
Don't know/Not sure.............. Go to Q21........................................ 7
Refused.................................. Go to Q21....................................... 9
Were any of the following animals present on the farm?
|
If YES |
Did you/your child have contact with the animal? |
Did you/your child have contact with the animal’s manure or go into the animal’s living area? |
Did you/your child have contact with animal’s food or feed? |
||
20a |
Cattle/Cows |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20b |
Calves |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20c |
Chickens |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20d |
Turkeys |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20e |
Pigs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20f |
Goats |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20g |
Sheep/lambs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20h |
Horse |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20i |
Deer or elk |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20j |
Other?________ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
20k |
Other?________ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21. During the 7 days of interest, did you/your child work on a farm?
Yes..................................................................................................... 1
No.......................................... Go to Q22........................................ 2
Don't know/Not sure.............. Go to Q22........................................ 7
Refused.................................. Go to Q22....................................... 9
Were any of the following animals present on the farm? |
If YES |
Did you/your child have contact with the animal? |
Did you/your child have contact with the animal’s manure or go into the animal’s living area? |
Did you/your child have contact with animal’s food or feed? |
||
21a |
Cattle/Cows |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21b |
Calves |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21c |
Chickens |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21d |
Turkeys |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21e |
Pigs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21f |
Goats |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21g |
Sheep/lambs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21h |
Horse |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21i |
Deer or elk |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21j |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
21k |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22. During the 7 days of interest, did you/your child visit a farm?
Yes..................................................................................................... 1
No.......................................... Go to Q23........................................ 2
Don't know/Not sure.............. Go to Q23........................................ 7
Refused.................................. Go to Q23....................................... 9
Were any of the following animals present on the farm? |
If YES |
Did you/your child have direct contact with the animal? |
Did you/your child have contact with the animal’s manure or go into the animal’s living area? |
Did you/your child have contact with animal’s food or feed? |
||
22a |
Cattle/Cows |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22b |
Calves |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22c |
Chickens |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22d |
Turkeys |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22e |
Pigs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22f |
Goats |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22g |
Sheep/lambs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22h |
Horse |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22i |
Deer or elk |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22j |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
22k |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23. During the 7 days of interest, did you/your child visit a petting zoo or petting zoo-like setting, like a birthday party, camp, or any other venue or setting where farm animals were present?
Yes..................................................................................................... 1
No.......................................... Go to Q24........................................ 2
Don't know/Not sure.............. Go to Q24......................................... 7
Refused.................................. Go to Q24…..................................... 9
Were any of the following animals present? |
If YES |
Did you/your child have direct contact with the animal? |
Did you/your child have contact with the animal’s manure or go into the animal’s living area? |
Did you/your child have contact with animal’s food or feed? |
||
23a |
Cattle/Cows |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23b |
Calves |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23c |
Chickens |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23d |
Turkeys |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23e |
Pigs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23f |
Goats |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23g |
Sheep/lambs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23h |
Horse |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23i |
Deer or elk |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23j |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23k |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
23l. Was that place a
Petting zoo?……………………………………………………….. 1
Camp?……………………………………………………………... 2
Birthday party with animals?……………………………………… 3
Other, specify____________________________________............ 4
24. Did you/your child visit a state or county fair, during the 7 days of interest?
Yes..................................................................................................... 1
No.......................................... Go to Q25........................................ 2
Don't know/Not sure.............. Go to Q25........................................ 7
Refused.................................. Go to Q25....................................... 9
Were any of the following animals present at the fair? |
If YES |
Did you/your child have direct contact with the animal? |
Did you/your child have contact with the animal’s manure or go into the animal’s living area? |
Did you/your child have contact with animal’s food or feed? |
||
24a |
Cattle/Cows |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24b |
Calves |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24c |
Chickens |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24d |
Turkeys |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24e |
Pigs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24f |
Goats |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24g |
Sheep/ lambs |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24h |
Horse |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24i |
Deer or elk |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24j |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
24k |
Other?______ |
Y N U R |
|
Y N U R |
Y N U R |
Y N U R |
25. Aside from anything you already may have mentioned, does your/your child’s work during the 7 days of interest, result in contact with live animals or animal carcasses (e.g., veterinarian, food production, slaughter, rendering, or other work)?
Yes..................................................................................................... 1
No.......................................... Go to Q26........................................ 2
Don't know/Not sure.............. Go to Q26........................................ 7
Refused.................................. Go to Q26....................................... 9
25a. What type of work do you do? __________________________
25b. What type of animal?_________________________________
26. During the 7 days of interest, did anyone else in your/your child’s household work on or visit a farm, petting zoo, or state or county fair, or engage in any work that resulted in contact with live animals or animal carcasses?
Yes..................................................................................................... 1
No.......................................... Go to Q27........................................ 2
Don't know/Not sure.............. Go to Q27........................................ 7
Refused.................................. Go to Q27....................................... 9
26a. What type of activity, setting or work? __________________________
26b. Were any of the following animals present?
26c |
Cattle, cows or calves |
Y N U R |
26d |
Goats |
Y N U R |
26e |
Sheep or lambs |
Y N U R |
26f |
Other, specify____________________________ |
Y N U R |
27. Did you/your child have contact with any wild animals or their droppings or feces during outdoor activities such as spending time in your back yard, hunting, hiking or other activities during the 7 days of interest?
Yes..................................................................................................... 1
No.......................................... Go to Q28........................................ 2
Don't know/Not sure.............. Go to Q28........................................ 7
Refused.................................. Go to Q28....................................... 9
27a. Did you/your child have contact with deer, elk or their droppings or feces during the 7 days of interest?
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
27b. During the 7 days of interest, did you/your child have contact with any other wild animal or wild animal droppings or feces?
Yes..................................................................................................... 1
No.......................................... Go to Q28........................................ 2
Don't know/Not sure.............. Go to Q28........................................ 7
Refused.................................. Go to Q28....................................... 9
27c.what type of wild animal or wild animal droppings or feces?
Specify: ________________________________
Don't know/Not sure.................................................. 7
Refused.......................................................................9
28. For adult cases: Did you garden during the 7 days of interest?
For pediatric cases: Did your child play or help in the garden during the 7 days of interest?
Yes.................................................................................................... 1
No.......................................... Go to Part 4.......................................2
Don't know/Not sure.............. Go to Part 4....................................... 7
Refused.................................. Go to Part 4....................................... 9
29. Was animal manure or compost applied to your garden anytime in the 12 months before ___/___/___ (DAY BEFORE case’s onset)?
Yes..................................................................................................... 1
No.......................................... Go to Part 4....................................... 2
Don't know/Not sure.............. Go to Part 4....................................... 7
Refused.................................. Go to Part 4....................................... 9
29a. Compost
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
29b. Manure
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
29c. Type of manure (cow, sheep, etc.)__________________________
29d. When did you apply the compost or manure?_____________________________
29e. Was the compost or manure pre-packaged?
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
PART 4. FOOD SECTION
If control is younger than 12 months, go to Q30; otherwise, go to Q31:
30. Does your child eat any foods or drinks other than formula or breast milk?
Yes.................................................................................................1
No.......................................... Go to Demographics....................2
Don't know/Not sure.............. Go to Demographics....................7
Refused.................................. Go to Demographics................... 9
31. In the past 3 months, did you/your child eat or handle any meats, such as beef, pork, poultry or fish?
Yes...........................................................................................1
No.......................................... Go to Vegetables.....................2
Don't know/Not sure................................................................7
Refused.................................. …………………..................... 9
I am now going to ask you about foods you/your child may have eaten during the 7 days of interest. As a reminder, I am referring to the 7 days of interest are:
___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___ (DAY BEFORE case’s onset).
BEEF:
32. Did you/your child eat any of the following foods containing beef in your home or someone else’s home (not including at a restaurant, we will ask you about this later)?
* Location code |
6. Private slaughter 7. “Cow share” or community supported agriculture (CSA) program 8. Other, specify |
1. Grocery store 2. Warehouse style market like Sam’s Club, Costco 3. Butcher 4. Farmer’s market |
|
5. Small, local or independent market, like a specialty food market; for example, an Asian or a Latino market |
U. Unknown R. Refused |
|
|
|
If YES |
Was any of it pink when you ate it? |
Where was the beef obtained? Interviewer: use location code * |
32a |
Hamburgers made in a home from fresh or frozen ground beef? |
Y N U R |
|
Y N U R |
1 2 3 4 5 6 7 8 U R __________ |
32b |
Pre-made, frozen hamburger patties? |
Y N U R |
|
Y N U R |
1 2 3 4 5 6 7 8 U R __________ |
32c |
Any other foods that contained ground beef as an ingredient like tacos, or lasagna? |
Y N U R |
|
Y N U R |
1 2 3 4 5 6 7 8 U R __________ |
32d |
Any steak? |
Y N U R |
|
Y N U R |
1 2 3 4 5 6 7 8 U R __________ |
32e |
Other intact, not ground, cuts of beef. For example stew meat, roast beef, pot roast? What type or cut?_____________ |
Y N U R |
|
Y N U R |
1 2 3 4 5 6 7 8 U R __________ |
33. Did you/your child handle any raw ground beef in your home?
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
34. Did you/your child handle any raw steaks or intact cuts of beef in your home?
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
35. Did anyone else in your household handle any raw beef (ground or intact cuts)?
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
36. Did you/your child eat at a fast food restaurant during the 7 days of interest? We define a fast-food restaurant as any place where you order and pay for your food at the counter or a drive through; for example, McDonald’s, a cafeteria, or a burger stand at a fair?
Yes..................................................................................................... 1
No.......................................... Go to Q38........................................ 2
Don't know/Not sure.............. Go to Q38........................................ 7
Refused.................................. Go to Q38....................................... 9
37. Did you/your child eat any of the following:
|
|
|
If YES |
Was any of it pink when you ate it? |
37a |
Hamburgers made from ground beef? |
Y N U R |
|
Y N U R |
37b |
Any other forms of ground beef (tacos)? |
Y N U R |
|
Y N U R |
38. Did you/your child eat at a sit down or table service restaurant during the 7 days of interest?
Yes..................................................................................................... 1
No.......................................... Go to OTHER MEAT.................... 2
Don't know/Not sure.............. Go to OTHER MEAT..................... 7
Refused.................................. Go to OTHER MEAT..................... 9
39. Did you/he/she eat any of the following at a restaurant:
|
|
|
If YES |
Was any of it pink when you ate it? |
39a |
Hamburgers made from ground beef? |
Y N U R |
|
Y N U R |
39b |
Any other foods that contained ground beef as an ingredient like tacos, or lasagna? |
Y N U R |
|
Y N U R |
39c |
Any steaks? |
Y N U R |
|
Y N U R |
39d |
Other intact (not ground) cuts of beef (for example stew meat, roast beef, pot roast)? What type or cut?___________________ |
Y N U R |
|
Y N U R |
OTHER MEAT / POULTRY / FISH:
From here to the end of the interview, I’m going to ask you questions about other meats, vegetables and fruits. For each food you/your child ate, I’ll be asking you where it was prepared:
-at a private home, such as your own home or someone else’s home,
-outside the home, meaning a restaurant or commercial food establishment,
-or both.
For example, if you ate something at home that you bought pre-made at a deli or take out from a restaurant, I’d record it as prepared outside the home.
All food questions are in regards to the specific 7 days of interest between ___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began)
40. I’m going start with questions about other meat poultry or fish. During the 7 days of interest, did you/your child eat____
* Interviewer: Take-out is considered as prepared outside the home
|
|
|
If YES |
Where was it prepared*? at Home (any private home), Outside (restaurant or commercial food establishment), or Both |
40a |
Chicken? |
Y N U R |
|
H O B U R |
40b |
Turkey? |
Y N U R |
|
H O B U R |
40c |
Pork? |
Y N U R |
|
H O B U R |
40d |
Lamb? |
Y N U R |
|
H O B U R |
40e |
Veal? |
Y N U R |
|
H O B U R |
40f |
Jerky? What type of jerky? Specify:_______________ |
Y N U R |
|
H O B U R |
40g |
Venison (deer meat)? |
Y N U R |
|
H O B U R |
40h |
Elk? |
Y N U R |
|
H O B U R |
40i |
Goat? |
Y N U R |
|
H O B U R |
40j |
Bison? |
Y N U R |
|
H O B U R |
40k |
Salami? |
Y N U R |
|
H O B U R |
40l |
Pepperoni? |
Y N U R |
|
H O B U R |
40m |
Summer sausage? |
Y N U R |
|
H O B U R |
40n |
Other Sausage? What type of sausage? Specify:_______________ |
Y N U R |
|
H O B U R |
40o |
Shrimp? |
Y N U R |
|
H O B U R |
40p |
Other Shellfish? |
Y N U R |
|
H O B U R |
40q |
Raw Fish/sushi? |
Y N U R |
|
H O B U R |
40r |
Other meat, poultry, or fish? Specify______________ |
Y N U R |
|
H O B U R |
41. Were any of the any meats, such as beef, pork, poultry or fish, organic?
Yes..................................................................................................... 1
No.......................................... Go to Vegetables............................... 2
Don't know/Not sure.............. Go to Vegetables............................ 7
Refused.................................. Go to Vegetables........................... 9
42a. Which meats were organic? Mark all that apply
Ground beef……………………………………………………… 1
Other beef………………………………………………………… 2
Pork ……………………………………………………………… 3
Poultry……………………………………………………………. 4
Fish……………………………………………………………….. 5
V EGETABLES:
I am now going to ask you about foods you/your child may have eaten in the seven days of interest. As a reminder, I am referring to the 7-day time period from: ___/___/___ (SEVEN DAYS BEFORE case’s onset) to ___/___/___ (DAY BEFORE case’s onset).
I’m going to ask you about RAW vegetables that you/your child may have eaten during the 7 days of interest. Please include any vegetables that you consumed as a smoothie or blended or puréed.
43. Did you/your child eat any lettuce?
Yes..................................................................................................... 1
No.......................................... Go to Q45........................................ 2
Don't know/Not sure.............. Go to Q45........................................ 7
Refused.................................. Go to Q45....................................... 9
44. What type of lettuce?
|
If YES |
Where was it prepared? Home, Outside, Both |
If prepared at HOME
|
Was it prepackaged? Interviewer: Read the first time you ask this question: By “prepackaged” I mean in a bag or a clamshell or clear plastic box. |
||
44a |
Iceberg? |
Y N U R |
|
H O B U R |
|
Y N U R |
44b |
Romaine? |
Y N U R |
|
H O B U R |
|
Y N U R |
44c |
Other lettuce? specify_______ |
Y N U R |
|
H O B U R |
|
Y N U R |
45. Did you/your child eat any of the following fresh greens?
|
|
|
If YES |
Where was it prepared? Home, Outside, Both |
If prepared at HOME
|
Was it prepackaged? |
45a |
Raw Spinach? |
Y N U R |
|
H O B U R |
|
Y N U R |
45b |
Mixed Greens, such as spring mix or swiss chard? |
Y N U R |
|
H O B U R |
|
Y N U R |
46. The following questions refer to RAW vegetables that you/your child were prepared at your/your child’s home, someone else’s home, or outside the home during the 7 days of interest. Please include any vegetables that you/your child ate from a salad bar, as a smoothie, blended, puréed or in home-squeezed juice.
|
|
|
If YES |
Where was it prepared? Home, Outside, or Both |
46a |
Did you eat raw cabbage (including cole slaw)? |
Y N U R |
|
H O B U R |
46b |
Tomatoes? |
Y N U R |
|
H O B U R |
46c |
Cucumbers? |
Y N U R |
|
H O B U R |
46d |
Peppers? Specify____________ |
Y N U R |
|
H O B U R |
46e |
Celery? |
Y N U R |
|
H O B U R |
46f |
Carrots? |
Y N U R |
|
H O B U R |
46g |
Radishes? |
Y N U R |
|
H O B U R |
46h |
Pea pods? |
Y N U R |
|
H O B U R |
46i |
Green onions/ scallions? |
Y N U R |
|
H O B U R |
46j |
Other onions (white, red)? Specify:____________ |
Y N U R |
|
H O B U R |
46k |
Broccoli? |
Y N U R |
|
H O B U R |
46l |
Alfalfa sprouts? |
Y N U R |
|
H O B U R |
46m |
Bean sprouts? |
Y N U R |
|
H O B U R |
46n |
Other sprouts? Specify:___________ |
Y N U R |
|
H O B U R |
46o |
Parsley? |
Y N U R |
|
H O B U R |
46p |
Cilantro? |
Y N U R |
|
H O B U R |
46q |
Any other fresh herbs? Specify:____________ |
Y N U R |
|
H O B U R |
46r |
Fresh salsa? |
Y N U R |
|
H O B U R |
FRUITS:
47. The following questions refer to RAW fruits. Please remember to include any fruits that you ate from a salad bar, as a smoothie, blended, puréed or in home-squeezed juice during the 7 days of interest, between ___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began) (One week period before the matched CASE’S SYMPTOMS began)
|
|
|
If YES |
Where was it prepared? Home, Outside, or Both |
47a |
Oranges? |
Y N U R |
|
H O B U R |
47b |
Other citrus? Specify:_________ |
Y N U R |
|
H O B U R |
47c |
Pears? |
Y N U R |
|
H O B U R |
47d |
Apples? |
Y N U R |
|
H O B U R |
47e |
Other tree fruit, for example: apricot, nectarine, peach, plum? |
Y N U R |
|
H O B U R |
47f |
Strawberries? |
Y N U R |
|
H O B U R |
47g |
Raspberries? |
Y N U R |
|
H O B U R |
47h |
Blueberries? |
Y N U R |
|
H O B U R |
47i |
Grapes? |
Y N U R |
|
H O B U R |
47j |
Bananas? |
Y N U R |
|
H O B U R |
47k |
Cantaloupe? |
Y N U R |
|
H O B U R |
47l |
Watermelon? |
Y N U R |
|
H O B U R |
47m |
Honeydew? |
Y N U R |
|
H O B U R |
47n |
Pineapple? |
Y N U R |
|
H O B U R |
47o |
Exotic fruits like kiwi, avocado, mango? Specify:____________
|
Y N U R |
|
H O B U R |
47p |
Other fruit? Specify:____________ |
Y N U R |
|
H O B U R |
48. Were any of the leafy greens, vegetables or fruits that you/your child ate organic?
Yes..................................................................................................... 1
No.......................................... Go to Q49........................................ 2
Don't know/Not sure.............. Go to Q49........................................ 7
Refused.................................. Go to Q49....................................... 9
48a. Which ones were organic?
_____________________________________________________________________
_____________________________________________________________________
49. Were any of the leafy greens, vegetables or fruits that you/your child ate home grown?
Yes..................................................................................................... 1
No.......................................... Go to Q50........................................ 2
Don't know/Not sure.............. Go to Q50........................................ 7
Refused.................................. Go to Q50....................................... 9
49a. Which ones were home grown?
_____________________________________________________________________
_____________________________________________________________________
50. During the 7 days of interest did you consume any unpasteurized apple cider or apple juice?
Unpasteurized juices are usually labeled as such, but might be sold at road side stands without
such labels.
Yes............................................................................. 1
No.............................................................................. 2
Don't know/Not sure.................................................. 7
Refused.......................................................................9
51. During those seven days did you consume any other unpasteurized juice?
Yes..................................................................................................... 1
No.......................................... Go to DAIRY.................................. 2
Don't know/Not sure.............. Go to DAIRY................................... 7
Refused.................................. Go to DAIRY................................... 9
51a. What type of juice? ________________________________________
DAIRY:
52. The following questions refer to dairy products that you may have eaten during the 7 days interest, between ___/___/___ and ___/___/___ (One week period before the matched CASE’S SYMPTOMS began) (One week period before the matched CASE’S SYMPTOMS began)
In that time, did you/your child eat or drink any of the following?
|
|
|
If YES |
Where was it served or consumed? Home, Outside, or Both |
52a |
Unpasteurized or raw milk? |
Y N U R |
|
H O B U R |
52b |
Pasteurized milk? |
Y N U R |
|
H O B U R |
52c |
Hard cheese, for example, Gouda, Cheddar? Specify: ______________ |
Y N U R |
|
H O B U R |
52d |
Soft cheese, for example, Feta, Brie or Camembert? Specify: ______________ |
Y N U R |
|
H O B U R |
52e |
Queso fresco or Mexican style cheese? |
Y N U R |
|
H O B U R |
52f |
Cheese curds? |
Y N U R |
|
H O B U R |
52g |
Any other cheese? Specify___________________ |
Y N U R |
|
H O B U R |
52h |
Were any of the cheeses you/your child ate unpasteurized? Specify: __________________ |
Y N U R |
|
H O B U R |
52i |
Ice cream? |
Y N U R |
|
H O B U R |
52j |
Yogurt? |
Y N U R |
|
H O B U R |
Section 3: Demographics
Now I would like to ask you a few questions about your/your child’s community and family. Some of these questions may be personal but they help us figure out how to prevent these infections. You may refuse to answer any of these questions.
53. What is your occupation? Specify_________________________________
54. What type of phone are we speaking to you on now? Choose one, circle answer:
What type of phone are we speaking to you on now? Choose one, circle answer:
Landline (traditional home or house) phone………………….…………1
Cell or mobile phone …………………………………….……………...2
Other type of phone…………………………………….………………..3
Specify _________________________
55. Is there a working landline (traditional home or house) phone in your home?
Yes……………………………………………………………………….1
No…………………………………………………………………..……2
Unknown…………………………………….…………………………..7
Refused………………..………………………………………...……….9
56. On what type of phone do you make or receive the majority of your personal (non-work) phone calls? Choose one, circle answer:
Landline (traditional home or house) phone………………………….... 1
Cell or mobile phone …………………………………………………....2
Equally split between landline & cell……………………………………3
Other……………………………………………………………………..4
Specify____________________________
57. Are you/Is your child of Hispanic or Latino origin?
Yes.......................................................................................... 1
No........................................................................................... 2
Don't know/Not sure............................................. ................. 7
Refused.................................................................................... 9
58. What is your/your child’s race? Read only if necessary, respondent may choose more than one race
American Indian or Alaskan Native ................................... 1
Asian………………….................................................……. 2
Black or African American .………………….…………….3
White………………….………………………………….....4
Native Hawaiian or Other Pacific Islander….………….…..5
Do not read Don't know/Not sure..............................................................6
Do not read Refused..................................................................................9
59. What is your/your child’s zip code? ___ ___ ___ ___ ___
Don't know/Not sure.................................................... 7 7 7 7 7
Refused......................................................................... 9 9 9 9 9
END CALL HERE
___________________________________________________________________________________
12/30/08**
Section 4: Control/Interviewer Information
60. Who completed the interview?
Control…………………………………………..1
Spouse/Partner………………………………… 2
Parent………………………………………… 3 CIRCLE: FATHER OR MOTHER
Guardian…….………………………………… 4
Other Relative………………………………… 5
Other……………………………………………6SPECIFY______________________
Don’t Know/Not Sure………………………… 9
APPENDIX 1: ANTIBIOTICS LIST
Antibiotic Name |
Antibiotic Name |
||
Don’t Remember Name |
99 |
Fosfomycin |
33 |
Amoxicillin |
1 |
Keflex |
34 |
Amoxicillin/Clavulanate |
2 |
Keftab |
35 |
Ampicillin |
3 |
Ketek |
36 |
Ancef |
4 |
Levofloxacin |
37 |
Augmentin |
5 |
Levoquin |
38 |
Avelox |
6 |
Linezolid |
39 |
Azithromycin |
7 |
Macrobid |
40 |
Bactrim |
8 |
Metronidazole |
41 |
Biaxin |
9 |
Minocin |
42 |
Ceclor |
10 |
Minocycline |
43 |
Cefaclor |
11 |
Monurol |
44 |
Cefadroxil |
12 |
Moxifloxacin |
45 |
Cefdinir |
13 |
Nitrofurantoin |
46 |
Cefixime |
14 |
Norfloxacin or Norflox |
47 |
Cefprozil |
15 |
Omnicef |
48 |
Ceftin |
16 |
Pediazole |
49 |
Ceftriaxone |
17 |
Penicillin or Pen VK |
50 |
Cefuorixime |
18 |
Rifaximin |
51 |
Cefzil |
19 |
Rocephin |
52 |
Cephalexin |
20 |
Septra |
53 |
Cephradine |
21 |
Suprax |
54 |
Ciprofloxacin or Cipro |
22 |
Telithromycin |
55 |
Clarithromycin |
23 |
Tetracycline |
56 |
Cleocin |
24 |
Trimethoprim/Sulfa |
57 |
Clindamycin |
25 |
Trimox |
58 |
Dicloxacillin |
26 |
Vibramycin |
59 |
Doxycycline |
27 |
Xifaxan |
60 |
Duricef |
28 |
Zithromax or Z-Pak |
61 |
Erythromycin |
29 |
Zyvox |
62 |
Erythromycin/sulfa |
30 |
OTHER – SPECIFY ____________________ |
77 |
Flagyl |
31 |
REFUSED |
88 |
Floxin |
32 |
UNKNOWN |
99 |
APPENDIX 2: ANTIACIDS LIST
Medication Name |
|
Medication Name |
|
Don’t Remember Name |
99 |
Novo-Ranidine |
35 |
Aciphex |
1 |
Nu-Cimet |
36 |
Alternagel |
2 |
Nu-Famotidine |
37 |
Alti-Ranitidine |
3 |
Nu-Ranit |
38 |
Aluminum hydroxide |
4 |
Omepral |
39 |
Amphgel |
5 |
Omeprazole |
40 |
Antra |
6 |
Pantoloc |
41 |
Apo-Cimetidine |
7 |
Pantoprazole |
42 |
Apo-Famotidine |
8 |
Pariet |
43 |
Apo-Ranitidine |
9 |
Pepcid (all varieties) |
44 |
Axid |
10 |
Pepto |
45 |
Calcium carbonate |
11 |
Phllips Chewables |
46 |
Carafate |
12 |
PMS-Cimetidine |
47 |
Cimetidine |
13 |
PMS-Ranitidine |
48 |
Cytotec |
14 |
Prevacid (all varieties) |
49 |
Dexlansoprazole |
15 |
Prevpac |
50 |
Esomeprazole |
16 |
Priolsec (all varieties) |
51 |
Fluxid |
18 |
Protonix |
52 |
Famotidine |
17 |
Proton-pump inhibitor (PPI) |
53 |
Gas-X |
19 |
Rabeprazole |
54 |
Gen-Cimetidine |
20 |
Ranitidine |
55 |
Gen-Famotidine |
21 |
ratio-Famotidine |
56 |
Gen-Ranidine |
22 |
Rhoxal-famotidine |
57 |
H2-blocker |
23 |
Rhoxal-ranitidine |
58 |
Kapidex |
24 |
Riva-Famotidine |
59 |
Lansoprazole |
25 |
Rolaids (all varieties) |
60 |
Losec |
26 |
Sodium bicarbonate |
61 |
Maalox (all varieties) |
27 |
Sucralfate |
62 |
Misoprostol |
28 |
Tagamet |
63 |
Mopral |
29 |
Tums (all varieties) |
64 |
Mylanta (all varieties) |
30 |
Zantac |
65 |
Nexium |
31 |
Zegerid |
66 |
Nizatidine |
32 |
OTHER – SPECIFY ____________________ |
77 |
Novo-Cimetidine |
33 |
REFUSED |
88 |
Novo-Famotidine |
34 |
UNKNOWN |
99 |
File Type | application/msword |
File Title | FoodNet Case-Control Study of Non-O157 Shiga Toxin-Producing E |
Author | crz5 |
Last Modified By | Sharon Harrison |
File Modified | 2011-11-02 |
File Created | 2011-11-02 |