NORS Reporting Form

General

National Outbreak Reporting System

Foodborne Disease Transmission, Person-to-Person Disease Transmission, Animal Contact
This form is used to report enteric foodborne, person-to-person, and animal contact-related disease outbreak investigations. This form has 5 sections, General, Laboratory, Person to
Person, Animal contact, and Food, as indicated by tabs at the top of each page. Complete the General and Laboratory tabs for all modes of transmission and complete additional
sections as indicated by the mode of transmission. Please complete as much of all sections as possible.
CDC USE ONLY

CDC Report ID

State Report ID

General Section
Primary Mode of Transmission

Form Approved
OMB No. 0000-0000

(check one)

Food (Complete General, Lab, and Food tabs)

Person-to-person (Complete General, Lab, and Person-to-Person tabs)

Water (Complete CDC 52.12)

Environmental contamination other than food/water

Animal contact (Complete General, Lab, and Animal Contact tabs)

Indeterminate/Other/Unknown (Complete General and Lab tabs)

Investigation Methods

(Complete General and Lab tabs)

(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

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
Reporting state:
Exposure occurred in multiple states
Exposure occurred in a single state but cases resided in multiple states
Other states:
Reporting county:
Exposure occurred in multiple counties in reporting state
Exposure occurred in a single county but cases resided in multiple counties in reporting state
Other counties:
City/Town/Place of exposure:
Do not include proprietary or private facility names

Primary Cases
Sex (estimated percent of the primary cases)

Number of Primary Cases
# Lab-confirmed cases

(A)

# Probable cases

(B)

# Estimated total primary ill (if greater than sum A+B)
# Cases

Total # of cases for whom
info is available

Male

%

Female

%

Approximate percent of primary cases in each age group

# Died

<1 year

%

20–49 years

%

# Hospitalized

1–4 years

%

50–74 years

%

# Visited Emergency Room

5–9 years

%

≥ 75 years

%

10–19 years

%

Unknown

# Visited health care provider (excluding ER visits)
CDC 52.13 Rev. 03 2008

National Outbreak Reporting System

%
CS115923

1

General

Incubation Period, Duration of Illness, Signs or Symptoms for Primary Cases only
Incubation Period (circle appropriate units)
Duration of Illness (among recovered cases-circle appropriate units)
Shortest

Min, Hours, Days Shortest

Min, Hours, Days

Median

Min, Hours, Days Median

Longest
Total # of cases for whom info is available

Min, Hours, Days Longest
Total # of cases for whom info is available

Min, Hours, Days
Min, Hours, Days

Unknown incubation period

Signs or Symptoms

Unknown duration of illness

(*refer to terms from appendix, if appropriate, to describe other common characteristics of cases)

Feature
Vomiting
Diarrhea
Bloody stools
Fever

# Cases with signs or symptoms

Total # cases for whom info available

Abdominal cramps
HUS
Asymptomatic
*
*
*

Secondary Cases
Mode of Secondary Transmission (check one)

Number of Secondary Cases

Food
Water
Animal contact
Person-to-person
Environmental contamination other than food/water
Indeterminate/Other/Unknown

# Lab-confirmed secondary cases

(A)

# Probable secondary cases

(B)

Total # of secondary cases (if greater than sum A+B)
Total # of cases (Primary + Secondary)

Environmental Health Specialists Network (if applicable)
EHS-Net Evaluation ID: 1.)

2.)

3.)

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

Comments

Country

Recall
Please check if any food or bottled water product was recalled
Type of item recalled:
Comments:

Reporting Agency
Agency name:

E-mail:

Contact name:

Contact title:

Phone no.:

Fax no.:

Remarks

CDC 52.13 Rev. 03 2008

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)

National Outbreak Reporting System

CS115923

2

Laboratory

Person-to-Person

Animal Contact

Laboratory Section
Etiology known?

Yes

No
Yes

If etiology is unknown, were patient specimens collected?

No

Unknown

If yes, how many specimens collected? (provide numeric value)
What were they tested for? (check all that apply)

Etiology

Bacteria

Chemicals/Toxins

Viruses

Parasites

(Name the bacterium, chemical/toxin, virus, or parasite. If available, include the serotype and other characteristics such as phage type,
virulence factors, and metabolic profile. Confirmation criteria available at http://www.cdc.gov/foodborneoutbreaks/guide_fd.htm or
MMWR2000/Vol. 49/SS-1/App. B)

Genus

Species

Serotype

Confirmed outbreak
etiology

Other
Characteristics

Detected in*

# Lab-confirmed
cases

yes
yes
yes
yes

*Detected in (choose all that apply): 1 - patient specimen 2 - food specimen 3 - environment specimen 4 - food worker specimen

Isolates

(For bacterial pathogens, provide a representative for each distinct pattern; provide lab ID for all specimens submitted for
viral sequencing)

State Lab ID

PulseNet Outbreak
Code

CDC PulseNet
Pattern Designation for
Enzyme 1

CDC PulseNet
Pattern Designation for
Enzyme 2

Other Molecular
Designation

Other Molecular
Designation

Person to Person
Major setting of exposure (choose one)
Camp
Child day care
Community-wide
Hospital

Hotel
Nursing home
Prison or detention facility
Other, please specify:

Private setting (residential home)
Religious facility
Restaurant

School
Ship
Workplace

Attack rates for major settings of exposure
Group (based on setting)

Estimated exposed in
major setting*

Estimated ill in
major setting

Crude attack
rate [(estimated ill /

estimated exposed) x 100]

residents, guests, passengers, patients, etc.
staff, crew, etc.
*e.g., number of persons on ship, number of residents in nursing home or affected ward

Other settings of exposure
Camp
Child day care
Community-wide
Hospital

(choose all that apply)

Hotel
Nursing home
Prison or detention facility
Other, please specify:

Private setting (residential home)
Religious facility
Restaurant

School
Ship
Workplace

Animals and their environment
Setting of exposure

CDC 52.13 Rev. 03 2008

Type of animal

Remarks

National Outbreak Reporting System

CS115923

3

Food

Food-specific data
Food vehicle undetermined

Total # of cases exposed to implicated food

Food

1

2

3

Yes, Country
Yes, Unknown
No

Yes, Country
Yes, Unknown
No

Yes, Country
Yes, Unknown
No

Yes
No
Unknown

Yes
No
Unknown

Yes
No
Unknown

Name of food
(excluding any preparation)

Ingredient(s)
(enter all that apply)

Contaminated ingredients
(enter all that apply)

Reason(s) suspected (enter all that
apply from list in appendix)

Method of processing (enter all that
apply from list in appendix)

Method of preparation (enter all from list in
appendix)

Level of preparation
(select from list in appendix)

Contaminated food imported to US?
Was product both produced under
domestic regulatory oversight and sold?

Location where food was prepared (Check all that apply)

Location of exposure (where food was eaten)
(Check all that apply)

Restaurant – ‘Fast-food’ (drive
up service or pay at counter)

Nursing home, assisted
living facility, home care

Restaurant – ‘Fast-food’ (drive
up service or pay at counter)

Nursing home, assisted
living facility, home care

Restaurant – Sit-down dining

Hospital

Restaurant – Sit-down dining

Hospital

Restaurant – Other or
unknown type

Child day care center

Restaurant – Other or
unknown type

Child day care center

Private home

School

Private home

School

Banquet Facility (food
prepared and served
on-site)

Prison, jail

Banquet Facility (food
prepared and served
on-site)

Prison, jail

Carterer (food prepared
off-site from where served)

Church, temple, religious
location

Carterer (food prepared
off-site from where served)

Church, temple, religious
location

Fair, festival, other temporary
or mobile services

Camp

Fair, festival, other temporary
or mobile services

Camp

Grocery store

Picnic

Grocery store

Picnic

Workplace, not cafeteria

Other (describe in remarks)

Workplace, not cafeteria

Other (describe in remarks)

Workplace cafeteria

Unknown

Workplace cafeteria

Unknown

Remarks:

CDC 52.13 Rev. 03 2008

Remarks:

National Outbreak Reporting System

CS115923

4

Food

Contributing Factors (Check all that contributed to this outbreak)
Contributing factors unknown
Contamination Factor

C1

C2

C3

C4

C5

C6

C7

C8

C9

C10

C11

C12

C13

P8

P9

P10

P11

P12

N/A

C14

C15

N/A

Proliferation/Amplification Factor (bacterial outbreaks only)

P1

P2

P3

P4

P5

P6

S3

S4

S5

N/A

P7

Survival Factor

S1

S2

The confirmed or suspected point of contamination (Check one)
Before preparation
If ‘before preparation’:

Preparation
Pre-Harvest

Processing

Unknown

Reason suspected (Check all that apply)
Environmental evidence

Laboratory evidence

Epidemiologic evidence

Prior experience makes this a likely source

Was food-worker implicated as the source of contamination?

If yes, please check only one of the following
Laboratory and epidemiologic evidence
Epidemiologic evidence
Laboratory evidence
Prior experience makes this a likely source

Yes

No

School Questions
(Complete this section only if school is checked in either sections “Location where food was prepared” or “Location of exposure (where food prepared)”)

1. Did the outbreak involve a single or multiple schools?
Single
Multiple (If yes, number of schools____)
2. School characteristics (for all involved students in all involved schools)
a. Total approximate enrollment
(number of students)
Unknown or undetermined
b. Grade level(s)
Preschool
Grade school (grades K-12)
Please check all grades affected:
College/university/technical school
Unknown or Undetermined
c. Primary funding of involved schools
Public
Private
Unknown

K

1st

3. Describe the preparation of the implicated item:
(check all that apply)
Heat and serve (item mostly prepared or cooked
off site, reheated on-site)
Served a-la-carte
Serve only (preheated or served cold)
Cooked on-site using primary ingredients
Provided by a food service management company
Provided by a fast-food vendor
Provided by a pre-plate company
Part of a club or fundraising event
Made in the classroom
Brought by a student/teacher/parent
Other ___________________
Unknown or Undetermined
CDC 52.13 Rev. 03 2008

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

12th

11th

4. How many times has the state, county or local health department inspected this school cafeteria or kitchen in the 12 months
before the outbreak?*
Once
Twice
More than two times
Not inspected
Unknown or Undetermined
5. Does the school have a HACCP plan in place for the
school feeding program?*
Yes
No
Unknown or Undetermined
*If multiple schools are involved, please answer according to the most affected school
National Outbreak Reporting System

CS115923

5

Food
6. Was implicated food item provided to the school through the
National School Lunch/Breakfast Program?

If yes, was the implicated food item donated/purchased by:

Yes
No
Unknown or Undetermined

USDA through the Commodity Distribution Program
The state/school authority
Other
Unknown or Undetermined

Ground Beef
1. What percentage of ill persons (for whom information is available) ate ground beef raw or undercooked?

%

2. Was ground beef case-ready? Yes
No
Unknown
(Case-ready ground beef is meat that comes from a manufacturer packaged for sale that is not altered or repackaged by the retailer)
3. Was the beef ground or reground by the retailer?
Yes
No
Unknown
If yes, was anything added to the beef during grinding (such as shop trim or any product to alter the fat content)?:

Additional Salmonella Questions
(Complete this section for Salmonella outbreaks)

1. Phage type(s) of patient isolates:
if RDNC* then include #
if RDNC* then include #
if RDNC* then include #
if RDNC* then include #
* Reacts, Does Not Conform

Eggs
1. Were eggs (check all that apply)
in shell, unpasteurized?
in shell, pasteurized?
packaged liquid or dry?
stored with inadequate refrigeration during or after sale?
consumed raw?
consumed undercooked?
pooled?
2. Was SE found on the farm?

Yes

No

Unknown

Comment (e.g. eggs and patients isolates matched by phage type):

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 (xxxx-xxxx) <--DO NOT MAIL CASE REPORTS TO THIS ADDRESSCDC 52.13 Rev. 03 2008

National Outbreak Reporting System

CS115923

6