Nors 52.12

General

National Outbreak Reporting System
Waterborne Disease Transmission

This form is used to report waterborne disease outbreaks. Pages 1-5 ask for the minimum or basic information about the outbreak investigation, epidemiological data, and clinical specimen and water test
results. These are followed by sections specific to the type of water exposure. Only 1 of the 5 water exposure sections should be completed.

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-XXXX) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESS
CDC USE ONLY

CDC ID

Form Approved
OMB No. 0920-XXXX

State ID

General Section
Primary Mode of Transmission (Check one)
■ Food (Complete CDC 52.13)
¨¨Water (Complete the tabs for General, Water-General, Water-Etiology &
Lab, Water Samples and the type of water exposure)
■ Animal contact (Complete CDC 52.13)
Investigation Methods (Check all that apply)
¨¨Interviews only of ill persons
¨¨Case-control study
¨¨Cohort study
¨¨Food preparation review
¨¨Water system assessment: Drinking water
¨¨Water system assessment: Nonpotable water

■ Person-to-person (Complete CDC 52.13)
■ Environmental contamination other than food/water
(Complete CDC 52.13)
■ Other/Unknown (Complete CDC 52.13)
¨¨Treated or untreated recreational water venue assessment
¨¨Investigation at factory/production/treatment plant
¨¨Investigation at original source (e.g., farm, water source, etc.)
¨¨Food product or bottled water traceback
¨¨Environment/food/water sample testing
¨¨Other

Comments
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Dates (mm/dd/yyyy)
Date first case became ill (required) ____________________

Date last case became ill ____________________

Date of initial exposure ____________________

Date of last exposure ____________________

Date of report to CDC (other than this form) ____________________
Date of notification to State/Territory or Local/Tribal Health Authorities _____________________
Geographic Location

Exposure state: ___________________________________________________________________________________________
¨¨Exposure occurred in multiple states
¨¨Exposure occurred in a single state, but cases resided in another state or multiple states
Other states: _______________________________________________________________________________________
(For multistate exposure or multistate residency outbreaks, enter the case count for each state)

Exposure county: _________________________________________________________________________________________
¨¨Exposure occurred in multiple counties in exposure state
¨¨Exposure occurred in a single county, but cases resided in another county or multiple counties
Other counties: _____________________________________________________________________________________

City/Town/Place of exposure: ____________________________________________________________________________
(Do not include proprietary or private facility names)

Primary Cases
Number of primary cases
Lab-confirmed primary cases

Sex (Number or percent of the primary cases)
# Male
#

%

Probable primary cases

# Female

#

%

Estimated total primary cases

# Unknown

#

%

Primary case outcomes
Died
Hospitalized
Visited Emergency Room
Visited health care provider
(excluding ER visits)

CDC 52.12 Rev. 03 2017

# Cases
#
#
#
#

Total # of cases
for whom info is
available

Age (Number or percent of the primary cases)
#
<1 year
#
% 20–49 years
#
1–4 years
#
% 50–74 years
> 75 years
#
5–9 years
#
%

#
#
#

%
%
%

# 10–19 years

#

%

National Outbreak Reporting System

#

%

Unknown

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General

Incubation Period, Duration of Illness, Signs or Symptoms for Primary Cases Only
Incubation Period (Select appropriate units)
Shortest

Min, Hours, Days

Duration of Illness (Among recovered cases-select appropriate units)
Shortest
Min, Hours, Days

Median

Min, Hours, Days

Median

Min, Hours, Days

Longest

Min, Hours, Days

Longest

Min, Hours, Days

Total # of cases for whom info is available

Total # of cases for whom info is available

¨¨Unknown incubation period
Signs or Symptoms
Sign or symptom
Vomiting

¨¨Unknown duration of illness
# Cases with signs or symptoms

Total # cases for whom info available

Diarrhea
Bloody stools
Fever
Abdominal cramps
HUS

Secondary Cases
Mode of secondary transmission (Check all that apply)
¨¨Food
¨¨Water
¨¨Animal contact
¨¨Person-to-person
¨¨Environmental contamination other than food/water
¨¨Other/Unknown

Number of secondary cases
Lab-confirmed secondary cases

#

Probable secondary cases

#

Estimated total secondary cases

#

Estimated total cases (Primary + Secondary)

#

Other CDC System IDs (If applicable)
NEARS ID: 1)________________________ 2)________________________ 3)________________________ 4)_______________________
OHHABS ID: 1)________________________ 2)________________________
Traceback (For food and bottled water only, not public water)
¨¨Please check if traceback conducted
Source name

(if publicly available)

Source type (e.g. poultry farm, tomato
processing plant, bottled water factory)

Location of source
State

Traceback comments

Country

Recall
¨¨Please check if any food or bottled water product was recalled
Type of item recalled: _________________________________________________________________________________________
Comments: _________________________________________________________________________________________________
Reporting Agency
Reporting site: ________________________________________
E-mail: __________________________________________
Agency name: _________________________________________
Phone #: _______________________________________
Contact name: ________________________________________
Fax #: __________________________________________
Contact title: _________________________________________
General Remarks

Briefly describe important aspects of the outbreak not covered above. Please indicate if any adverse outcomes occurred
in special populations (e.g., pregnant women, immunocompromised persons)

_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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Water-General

Water - General Section
Type of Water Exposure (Check ONE box)
¨¨Treated recreational water (e.g., in manufactured venues such as pools, spas/whirlpools, hot tubs, spray pads, at-home kiddie pools)
¨¨Untreated recreational water (e.g., water in natural venues such as freshwater lakes, hot springs, marine beaches/oceans)
¨¨Drinking water in public or individual water systems (e.g., municipal system, private well, commercially-bottled water, water kiosk), regardless of the
exposure pathway (i.e., not limited to ingestion).
¨¨Other water (e.g., cooling/industrial, water reuse, irrigation, occupational, decorative/display; includes water consumed from sources such as backcountry streams)
¨¨Unknown water uses (i.e., the intended purpose or use of the water is unknown or the water exposure category could not be determined)
Epidemiologic Data
1. Estimated total number of persons with primary water exposure: ______________
2. Were data collected from comparison groups to estimate risk?

If NO or UNKNOWN, was water the common source
shared by persons who were ill?

Exposure in epidemiologic investigation Total #
(e.g., pool, waterpark, hot spring,
exposed
well water)
(A)

# ill
exposed
(B)

Total
# not
exposed

Attack rate for residents of reporting state: _________ %

£ Yes (specify in table below)

£ No

£ Unknown

£ Yes £ No

£ Unknown

# ill not
exposed

Attack
rate (%)
(B/A)

Odds
ratio

Relative
risk

p-Value

(provide
exact value)

95%
confidence
interval

Attack rate for non-residents of reporting state: _________ %

Geographic Location
Percent of ill persons (primary cases) living in reporting state: ______________%
Associated Events
Was exposure associated with a specific event or gathering?
£ Yes
£ No
£ Unknown
If YES, what type of event or gathering was involved?
_______________________________________________________________
If outbreak occurred during a defined event, dates of event:
Start date:________________ End date: ________________
(mm/dd/yyyy) (mm/dd/yyyy)
Route of Entry
£ Ingestion
CDC 52.12 Rev. 03 2017

£ Contact

£ Inhalation
National Outbreak Reporting System

£ Other (specify in remarks)

£ Unknown
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Water-Etiology & Lab
Outbreak Etiology (Report the confirmed and/or suspected etiological agent(s) here, even if no clinical specimens were tested)
Confirmed as Genus/Chemical/Toxin
Species
Serotype/Serogroup/ Genotype/
Detected
etiology?
Serovar
Subtype
in*
(list all
that apply)

Total #
tested
primary
cases

Total #
positive
primary
cases

¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
¨¨ Confirmed
¨¨ Suspected
* 1-Clinical Specimens, 2-Water Samples, 3-Clinical Specimens & Water Samples, 4-Other (describe in the general remarks), 5-Unknown, 6-None

Outbreak Isolates (Links data about molecular characterization across multiple systems. For each pathogen, provide a representative for each distinct molecular
designation)

Which CDC system contains this
isolate profile? (e.g., PulseNet, CaliciNet)

CDC lab system outbreak #
(e.g., PulseNet tracking number)

State lab ID

(i.e., Lab tracking number)

Molecular
designation 1

Molecular
designation 2

Clinical Specimens
1. Were clinical diagnostic specimens taken from persons?
£ Yes
£ No
£ Unknown
If YES, from how many persons were specimens taken? _______________________________
Specimen type†

Specimen subtype§

Tested for¶ (list all that apply)

Specimen Type: 1- Autopsy Specimen (specify subtype), 2-Biopsy (specify subtype), 3-Blood, 4-Bronchial Alveolar Lavage (BAL), 5-Cerebrospinal Fluid (CSF), 6-Conjunctiva/Eye Swab, 7-Ear Swab, 8-Endotracheal
Aspirate, 9-Saliva, 10-Serum, 11-Skin Swab, 12-Sputum, 13-Stool, 14-Urine, 15-Vomitus, 16-Wound Swab, 17-Other (describe in the general remarks), 18-Unknown
§
Specimen Subtype: 1-Bladder, 2-Brain, 3-Dura, 4-Hair, 5-Intestine, 6-Kidney, 7-Liver, 8-Lung, 9-Nails, 10-Skin, 11-Stomach, 12-Wound, 13-Other, 14-Unknown
¶
Tested for: 1-Bacteria, 2-Chemicals/Toxins, 3-Fungi, 4-Parasites, 5-Viruses, 6-Other (describe in general remarks), 7-Unknown
†

Testing Information
1. Test types (select all test types used for clinical specimens)
£ Chemical Testing
£ Culture
£ DNA or RNA Amplication/Detection
(e.g. PCR, RT-PCR)

£ Microscopy (e.g., fluorescent, EM)
CDC 52.12 Rev. 03 2017

£ Serological/Immunological Test
(e.g., EIA, ELISA)

£ Tissue culture infectivity assay
£ Other (specify in the general remarks)
£ Unknown

2. Was Antimicrobial Susceptibility Testing (AST) performed?
£ Yes £ No £ Unknown
If yes, where was AST performed?
£ Clinical Lab £ Public Health Lab £ CDC-NARMS
£ Other
£ Unknown
If yes, were any antimicrobial resistant isolates associated with the
outbreak? £ Yes £ No £ Unknown

National Outbreak Reporting System

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Water Samples
Water Samples (Provide representative data about water quality testing, chemical or pathogen testing. Additional sample data can be described in the remarks
or attached)

Was water tested?
Results
Sample number

£ Yes (specify in table below)
1

£ No

£ Unknown
2

3

4

5

Source of sample

(e.g., swimming pool, lake)

Additional description
(e.g., time of day, location
of sample collection)

Date (mm/dd/yyyy)
Volume tested, (number, unit)
Temperature (number, unit)
Residual/Free disinfectant level -

number, unit (if total and combined disinfectant
levels given, total - combined = free)

Combined disinfectant level -

number, unit (if total and free disinfectant
levels given, total - free = combined)

pH
Turbidity (NTU)
Water Samples - Water Quality Indicators (Might not be applicable for treated recreational water samples)
Sample
number

Type (e.g., fecal coliforms)

Concentration (numerical
value)

Water Samples - Microbiology or Chemical/Toxin Analysis (Provide both positive and negative test results)
Sample
Genus/Chemical/Toxin
Species
Serotype/Serogroup/
Genotype/Subtype
number
Serovar

Sample
number

Test results positive?
£ Yes

£ No

£ Yes

£ No

£ Yes

£ No

£ Yes

£ No

£ Yes

£ No

£ Yes

£ No

Concentration

(numerical value)

Unit

Test type*

Unit

PFGE pattern

Test method (reference: National

Environmental Methods Index: http://www.nemi.
gov)

* Test type: 1-Culture, 2-DNA or RNA Amplification/Detection (e.g., PCR, RT-PCR), 3-Microscopy (e.g., fluorescent, EM), 4-Serological/Immunological Test (e.g., EIA, ELISA), 5-Phage Typing, 6-Chemical Testing,
7-Tissue Culture Infectivity Assay, 8-Other (describe in the general remarks), 9-Unknown

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Rec Water-Treated

Recreational Water - Treated Venue
Implicated Water - Recreational Water Venue Description
Venue number
Water venue
(use this number to link the
venue with water treatment
or fill water data below)

(e.g., spa/whirlpool/hot tub; pool-swimming pool;
pool-waterpark)

Water venue subtype

Setting of exposure

Venue treatment subtype

Chlorination subtype

If public water supply, USUAL
water treatment provided before
coming to the venue

If public water supply, fill water
treatment subtype

(select indoor, outdoor, or unknown)

(e.g., club, requiring membership;
hotel/motel/lodge/inn; waterpark)

1
2
3
4
5

Implicated Water - Water Treatment Description
Venue number

(reference the appropriate
Venue number from above)

USUAL water treatment provided at venue

(e.g., no treatment; coagulation; disinfection; flocculation;
filtration [pool]; unknown)

Implicated Water - Fill Treatment Description
Venue number
Fill water type
(reference the appropriate
Venue number from above)

(e.g., public water supply; sea water; untreated ground or surface
water; unknown)

(disinfection or pool filtration: e.g., UV;
chlorine dioxide; bag filter; cartridge
filter; unknown)

(chlorine disinfection only: e.g., gaseous;
sodium hypochlorite; cyanurates/
stabilized chlorine)

(disinfection or filtration: e.g., UV;
chlorine dioxide; bag filter; cartridge
filter; unknown)

(e.g., no treatment; disinfection; filtration
[treatment plant]; unknown)

Recreational Water Quality

Did the venue meet state or local recreational water quality regulations?

£ Yes

£ No

£ Unknown

£ Not applicable

If NO, explain: ___________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Was there a pool operator on the payroll with state-approved training or certification?

CDC 52.12 Rev. 03 2017

National Outbreak Reporting System

£ Yes

£ No

£ Unknown

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Rec Water-Treated
Factors Contributing to Recreational Water Contamination and/or Increased Exposure in Treated Venues

Policy and Management

Maintenance

Facility
Design

People

Contributing factors (Check all that apply)*
Exceeded maximum bather load
Primary intended use of water is by diaper/toddler-aged children (e.g., kiddie pool)
Heavy use by child care center groups
Fecal/vomitus accident
Patrons continued to swim when ill with diarrhea
Operator error
Intentional contamination (explain in remarks)
Combined pool filtration/recirculation systems led to cross-contamination
Hygiene facilities (e.g., toilets, diaper changing facilities) inadequate or distant
Some spray feature water bypasses filtration/treatment system and returns to feature unfiltered/untreated
No supplemental disinfection installed that would have inactivated pathogen (e.g., Cryptosporidium)
Water temperature ≥30°C (≥86°F)
Cross-connection with wastewater or non-potable water
Disinfectant control system malfunctioning, inadequate, or lacking (e.g., hand feed chemicals)
Incorrect settings on disinfectant control system
pH control system malfunctioning, inadequate, or lacking (e.g., hand feed chemicals)
Incorrect settings on pH control system
Filtration system malfunctioning or inadequate (e.g., low flow rate)
Supplemental disinfection system malfunctioning or inadequate (e.g., ultraviolet light, ozone)
Insufficient system checks so breakdown detection delayed
No preventive equipment maintenance programs to reduce breakdowns
Ventilation insufficient for indoor aquatic facilities
Chemical handling error (e.g., chemical hookup, improper mixing or application)
Maintenance chemicals not flushed from system before opening to swimmers
Recirculation pump off or restarted with swimmers in water
Low or zero water flow combined with continuous feed of chemicals resulted in excess chemicals in water
Extensive slime/biofilm formation
Recent construction
Cyanurate level excessive
Lack of draining/cleaning
Stagnant water in spa piping was aerosolized
No aquatics operators on payroll who have completed state/local training
Untrained/inadequately trained staff on duty
Remote monitoring system replaces on-site water quality testing
Unclear communication chain for reporting problems
Inadequate water quality monitoring (e.g., inadequate test kit, inadequate testing frequency)
Employee illness policies absent or not enforced
No or inadequate policies on good chemical handling and storage practices
No operator on duty at the time of incident
Facility falls outside aquatic health code
No shock/hyperchlorination policy
Other, specify:
Unknown

Documented/
Observed†

Suspected†

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* Only check off what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no documentation
(as defined previously) is available.

Remarks

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Rec Water-Untreated

Recreational Water - Untreated Venue
Implicated Water - Recreational Water Venue Description
Water venue
IF SPRING OR HOT SPRING, water venue subtype
(e.g., canal; lake; river/stream; ocean)

(select indoor, outdoor or unknown)

Recreational Water Quality
Did the venue meet state or local recreational water quality regulations?

Setting of exposure

(e.g., beach-public; camp/cabin/recreational area)

If NO, explain: _______________________________________________

Did the venue meet Environmental Protection Agency (EPA) recreational
water quality standards?
£ Yes
£ No
£ Unknown
£ Not applicable
If NO, explain: ______________________________________________

___________________________________________________________

__________________________________________________________

£ Yes

£ No

£ Unknown

£ Not applicable

Factors Contributing to Recreational Water Contamination and/or Increased Exposure in Untreated Venues

Policy and
Management

Water Quality

Swim Area
Design

People

Contributing factors (Check all that apply)*
Exceeded maximum bather load
Primary intended use of water is by diaper/toddler-aged children (e.g., kiddie pool)
Heavy use by child care center groups
Fecal/vomitus accident
Patrons continued to swim when ill with diarrhea
Staff error
Intentional contamination (explain in remarks)
Hygiene facilities (e.g., toilets, diaper changing facilities) inadequate or distant
Malfunctioning or inadequate on-site wastewater treatment system§¶
Poor siting/design of on-site wastewater treatment system§¶
Stagnant or poorly circulating water in swim area
Heavy rainfall and runoff
Sanitary sewer overflow (SSO) impact§
Combined sewer overflow (CSO) impact§
Domestic animal contamination (e.g., livestock, pets)
Wildlife contamination - Birds
Wildlife contamination - Mammals
Wildlife contamination - Fish kill
Wastewater treatment plant effluent flows past swim area
Wastewater treatment plant malfunction§
Sewer line break§
Nearby biosolid/land application site (e.g., human or animal waste application)
Contamination from agricultural chemical application (e.g., fertilizer, pesticides)
Contamination from chemical pollution not related to agricultural application
Water temperature ≥30°C (≥86°F)
Seasonal variation in water quality (e.g., lake/reservoir turnover events)
Inappropriate dumping of sewage into water body (e.g., from boat, RV)
Algal bloom
Dumping of ballast water
Tidal wash (i.e., tide exchange or influence by inland water)
No or inadequate monitoring of water quality
No managers have completed state/local required training
Untrained/inadequately trained staff on duty
Unclear communication chain for reporting problems
Employee illness policies absent or not enforced
Other, specify:
Unknown

Documented/
Observed†

Suspected†

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* Only check off what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no documentation
(as defined previously) is available.
§
The release of sewage does not have to occur at the property/venue/setting where the people were exposed. The sewage may have occurred at a distant site but still affected the property/venue/setting in
question.
¶
“On-site wastewater treatment system” refers to a system designed to treat and dispose of wastewater at the point of generation, generally on the property where the wastewater is generated (e.g., septic
systems or other advanced on-site systems). However, contamination that originates from these systems can still occur off the property where treatment and disposal takes place due to migration of
contaminants from malfunctioning systems or poor siting and design.

Remarks

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Drinking Water

Drinking Water
Implicated Water - Drinking Water System Description
Water system*
Public water Water source
(e.g., commercially-bottled
(select ground water,
system EPA
water, community water
surface water or
†
ID
number
system, individual water
unknown)
system)

Water source
description
(e.g. spring;
well; lake)

Setting
of exposure

(e.g., airport, mobile
home park)

USUAL water
treatment provided
(e.g.,no treatment,
disinfection,
home filtration)

Water treatment
subtype (disinfection

or filtration: e.g., boiling;
chlorine; rapid sand filter;
reserve osmosis)

* Water system definitions: Community and noncommunity water systems are public water systems that have ≥ 15 service connections or serve an average of ≥ 25 residents for ≥ 60 days/year. A community
water system serves year-round residents of a community, subdivision, or mobile home park. A noncommunity water system serves an institution, industry, camp, park, hotel, or business and can
be nontransient or transient. Nontransient systems serve ≥ 25 of the same persons for > 6 months of the year but not year-round (e.g., factories and schools), whereas transient systems provide water
to places in which persons do not remain for long periods (e.g., restaurants, highway rest stations, and parks). Individual water systems are small systems not owned or operated by a water utility that have
< 15 connections or serve < 25 persons.
†
Number used for EPA reporting that uniquely identifies the public water system within a specific state. The water system ID number can be found by searching the Safe Drinking Water Information System
(SDWIS) online at https://ofmpub.epa.gov/apex/sfdw/f?p=108:200.

Drinking Water Quality
Did the drinking water system have any monitoring violations in the 1 month prior to the outbreak?
£ Yes
£ No
£ Unknown
£ Not applicable
If Yes, explain: _________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Did the drinking water system have any maximum contaminant level (MCL) violations in the 1 month prior to the outbreak?
£ Yes
£ No
£ Unknown
£ Not applicable
If Yes, explain: _________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Did the drinking water system have any violations in the 12 months prior to the outbreak?§
£ Yes
£ No
£ Unknown
£ Not applicable
If Yes, explain: _________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Sources of information about past violations can be obtained from utility records, consumer confidence reports (water quality reports), or violation records from state or local health departments

§

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Drinking Water
Factors Contributing to Drinking Water Contamination and/or Increased Exposure to Contamination Drinking Water
1. Did a problem with the source water (i.e., ground water or surface water) contribute to the disease or outbreak?
£ Yes (specify in the table below)
£ No
£ Unknown
Source water contributing factors (Check all that apply)*

Documented/
Observed†

Suspected†

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Observed†

Suspected†

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Sanitary sewer overflow (SSO)§
Combined sewer overflow (CSO)§
Malfunctioning on-site wastewater treatment system§¶
Sewage treatment plant malfunction§
Sewer line break§
Poor siting/design of on-site wastewater treatment system§¶
Nearby biosolid/land application site (e.g., human or animal waste application)
Contamination from agricultural chemical application (e.g., fertilizer, pesticides)
Contamination from chemical pollution not related to agricultural application
Contamination by a chemical that the current treatment methods were not designed to remove
Domestic animal contamination (e.g., livestock, concentrated feeding operations, pets)
Wildlife contamination - Birds
Wildlife contamination - Mammals
Wildlife contamination - Fish kill
Flooding/heavy rains
Algal bloom
Seasonal variation in water quality (e.g., lake/reservoir turnover events, resort community with seasonal loading)
Low water table (e.g., drought, over-pumping)
Ground water under direct influence of surface water (e.g., shallow well)**
Contamination through limestone or fissured rock (e.g., karst)
Contaminated recharge water
Use of an alternate source of water by a water utility
Mixing of raw water from different sources
Improper construction or location of a well or spring
Water system intake failure (e.g., cracked well casing, cracked intake pipe)
Intentional contamination (explain in remarks)
Other, specify:
Unknown
2. Did a problem with the water treatment prior to entry into a house or building contribute to the disease or outbreak?
£ Yes (specify in the table below)
£ No
£ Unknown
Treatment contributing factors (Check all that apply)*
Change in treatment process (specify in remarks)
No disinfection
Temporary interruption of disinfection
Chronically inadequate disinfection
No filtration
Inadequate filtration
Deficiencies in other treatment processes
Corrosion in or leaching from pipes or storage tanks
Pipe/component failure or break (e.g., pipes, tanks, valves)
Contamination during construction or repair of pipes/components
Construction or repair of pipes/components without evidence of contamination
Operator error
Other, specify:
Unknown

* Only check off what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no documentation
(as defined previously) is available.
§
The release of sewage does not have to occur on the property in which persons have become ill. The sewage release may have occurred at a distant site but still affected the property in question.
¶
“On-site wastewater treatment system” refers to a system designed to treat and dispose of wastewater at the point of generation, generally on the property where the wastewater is generated (e.g., septic
systems or other advanced on-site systems). However, contamination that originates from these systems can still occur off the property where treatment and disposal takes place due to migration of
contaminants from malfunctioning systems or poor siting and design.
** Any water beneath the surface of the ground with substantial occurrence of insects or other macroorganisms, algae, or large-diameter pathogens (e.g., Giardia intestinalis or Cryptosporidium), or substantial
and relatively rapid shifts in water characteristics (e.g., turbidity, temperature, conductivity, or pH) that closely correlate with climatologic or surface water conditions. Direct influence must be determined for
individual sources in accordance with criteria established by the state.

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Drinking Water
3. Did a problem with the distribution system contribute to the disease or outbreak? (NOTE: For a community water system, the distribution system refers to the

pipes and storage infrastructure under the jurisdiction of the water utility prior to the water meter (or property line if the system is not metered). For noncommunity and nonpublic
water systems, the distribution system refers to the pipes and storage infrastructure prior to entry into a building or house)

£ Yes (specify in the table below)

£ No

£ Unknown

Distribution and storage contributing factors (Check all that apply)*
Cross-connection of potable and nonpotable water pipes resulting in backflow
Low pressure or change in water pressure in the distribution system
Change in water flow direction in the distribution system
Mixing of treated water from different sources
Pipe/component failure or break (e.g., pipes, tanks, valves)
Corrosion in or leaching from pipes or storage tanks
Contamination of mains during construction or repair
Construction or repair of mains without evidence of contamination
Scheduled flushing of the distribution system
Contamination of storage facility
Aging water distribution components (e.g., pipes, tanks, valves)
Water temperature ≥30°C (≥86°F)
Intentional contamination (specify in remarks)
Other, specify:
Unknown

Documented/
Observed†

Suspected†

£
£
£
£
£
£
£
£
£
£
£
£
£
£
£

£
£
£
£
£
£
£
£
£
£
£
£
£
£
£

4. Did a problem occur after the water meter or outside the jurisdiction of a water utility that contributed to the disease or outbreak?

(e.g., in a service line leading to a house/building, in the plumbing inside a house/building, during shipping/hauling, during storage other than in the distribution system, at the point
of use, involving commercially-bottled water)

£ Yes (specify in the table below)

£ No

£ Unknown

Factors not under the jurisdiction of a water utility or contributing factors at the point of use
(Check all that apply)*

Legionella species in water system
Cross-connection of potable and nonpotable water pipes resulting in backflow
Lack of backflow prevention in plumbing
Low pressure or change in water pressure in the plumbing
Change in water flow direction in the plumbing
Corrosion in or leaching from pipes or storage tanks
Pipe/component failure or break (e.g., pipes, tanks, valves)
Aging plumbing components (e.g., pipes, tanks, valves)
Contamination of plumbing during construction or repair
Construction or repair of plumbing without evidence of contamination
Deficiency in building/home-specific water treatment after the water meter or property line
Deficiency or contamination of equipment/devices using or distributing water
Contamination during commercial bottling
Contamination during shipping, hauling, or storage
Contamination at point of use – Tap
Contamination at point of use – Hose
Contamination at point of use – Commercially-bottled water
Contamination at point of use – Container, bottle, or pitcher
Contamination at point of use – Unknown
Water temperature ≥30°C (≥86°F)
Intentional contamination (specify in remarks)
Other, specify:
Unknown

Documented/
Observed†

Suspected†

£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
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£

£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£
£

* Only check off what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no documentation
(as defined previously) is available.

Remarks

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Other or Unknown Water

Other or Unknown Water
Intent for Use
What was the intended use for the implicated water? (check all that apply)
¨¨Cooling/Air Conditioning (e.g., cooling tower, swamp cooler)
¨¨Mister (e.g., produce in grocery store, public cooling system)
¨¨Ornamental (e.g., a decorative non-interactive fountain intended for public display and
not designed for swimming or recreational use)

¨¨Industrial/Occupational (e.g., steam cleaner)
Implicated Water - Water Description
Water type
Setting of exposure
(e.g., cooling tower; drainage ditch;
fountain - ornamental)

(e.g, airport; hospital/health care facility;
nursing home; park-state park)

¨¨Agricultural Irrigation
¨¨Waste water
¨¨Other (specify) : ________________________________________
¨¨Unknown

Usual water treatment provided

(e.g., no treatment; disinfection; settling/
sedimentation)

Factors Contributing to Contamination and/or Increased Exposure to Contaminated Water
Contributing factors (Check all that apply)*

Ornamental
fountain

Cooling tower/
Evaporative condenser

Shutdown for >3 days without draining to waste
Lack of a maintenance program
Lack of a qualified water quality specialist
Presence of scale or corrosion
Presence of dirt, organic matter, or other debris in the cold water basin
Absence of drift eliminators
Presence of damaged drift eliminators
History of recent repairs to the device
Siting of device near building air intakes
Siting of device near windows that can be opened
Siting of device in immediate area of kitchen exhaust fans, live plants, truck bays, or other sources
of organic matter
Construction on the premises of the device within 6 months before the index case
Construction within 100 meters of the premises of the device within 6 months before the index case
Intended as an ornamental fountain but utilized as an interactive fountain
Inadequate disinfection for recreational use
Inadequate filtration for recreational use
Presence of submerged lighting
Lack of a written cleaning and maintenance program
Presence of dirt, organic matter, or other debris in the water basin
Broken/damaged sewer pipe
Recycling of water
Water temperature ≥30˚C (≥86˚F)
Other, specify:
Unknown

Water treatment subtype

(disinfection or filtration: e.g., boiling;
chlorine; rapid sand filter; reverse osmosis)

Documented/
Observed†

Suspected†

£
£
£
£
£
£
£
£
£
£

£
£
£
£
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£
£
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£

£

£

£
£
£
£
£
£
£
£
£
£
£
£
£

£
£
£
£
£
£
£
£
£
£
£
£
£

* Only check off what was found during investigation.
†
“Documented/Observed” refers to information gathered through document reviews, direct observations, and/or interviews. “Suspected” refers to factors that probably occurred but for which no documentation
(as defined previously) is available.

Remarks

CDC 52.12 Rev. 03 2017

National Outbreak Reporting System

CS262092-A

12