Form 1 Form 1 NHGQ

Form Approved

OMB No: 0XXX-XXXX

Expires: XX/XX/20XX

Hypothesis Generating Questionnaire for [__________ __________] (enter pathogen)

PulseNet cluster code: [_____________] (enter Cluster Code)

e

Section 1: Interviewer & Patient Information – Complete Section 1 prior to interview
PulseNet ID #: ______________________ and/or WGS ID: _______________	State/Local/Other ID #: _______________________
Date of Interview: __ __ / __ __ / __ __ __ __ M M D D Y Y Y Y
Interviewer Information Name: ______________________________________ Agency or Organization: _______________________________
Respondent was: Self Parent Spouse Other (specify):_______________
State and county of residence? State _______ County ____________________
Age at time of illness _______ Days Months Years Unknown

Section 2: Clinical Information: Now I have a few questions about your (the patient’s) illness.
What date did you (the patient) first feel sick? __ __ / __ __ / __ __ __ __ Unknown M M D D Y Y Y Y If Unknown, please enter specimen collection date: __ __ / __ __ / __ __ __ __ Unknown M M D D Y Y Y Y
Yes	Maybe	No	Don’t Know	Did you (the patient)
				Get admitted overnight to a hospital for this illness? Refused
				Develop Hemolytic Uremic Syndrome, or HUS? Refused
				Have any diarrhea (defined as at least 3 loose stools in 24 hours) Refused
				Have any close contact with anyone with diarrhea or vomiting in the week before illness?
				a. When did this person first become ill less than 24 hours before you ≥ 24 hours before you After your (the patient’s) illness onset Unknown For interviewer only: b. If this person is part of the outbreak, what is their PulseNet or WGS ID? ______________________________

Section 3: Travel: Next I have a couple of questions about any travel you (the patient) might have done, either for work or for pleasure. As I read each question, please answer as yes, no, maybe, or can't remember in the 7 days before you (the patient) got sick.

• If the case spent the entire 7 days before illness onset outside the US, please be sure countries, travel dates, and hotel/resort names are noted and skip to the end of the interview.

• If the case spent only part of the 7 days before illness onset outside the US, please complete the remainder of the interview collecting only foods purchased or eaten in the US.

Yes

Maybe

No

Don’t Know

1. In the 7 days before illness, did you (the patient) travel to another country outside the U.S.?

City and Country	Date of Arrival	Date of Departure	Hotel/Resort Name

List all states that you traveled to where you (the patient) might have purchased or eaten foods. This would include foods eaten at airports, bus, or train stations.

2. In the 7 days before illness, did you (the patient) travel to another state in the U.S.?

List all countries outside the United States where you (the patient) might have purchased or eaten foods. This would include foods eaten at airports, bus, or train stations.

State	Date of Arrival	Date of Departure	Hotel/Resort Name

Section 3: Travel Comments. Please fill in any comments/notes from this section in the space provided below:

Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0XXX-XXXX

Section 4: Sources of food prepared at home: Now I have a few questions about where the sources of food you (the patient) prepared and ate at home in the 7 days before your illness began. First, I will ask you (the patient) about where any food prepared at home came from. This could include grocery stores, warehouse stores, farmers’ markets, home delivery, delis, swap meets, ethnic or specialty markets, butchers, live animal markets, food or meal subscription services, or groceries that were bought several weeks ago but consumed in the 7 days before you (the patient) got sick. I’m going to ask a few questions about stores you (the patient) may have shopped at, as well as any shopper card numbers or other store membership information you (the patient) may have. This could also include a shopper number from someone else in your household. Store shopper or membership information can help provide detailed information, such as brands, varieties, purchase date, that you may not know or remember. You (the patient) may also be able to access your own shopper history through an online account. Additionally, I’ll also ask a few questions about dietary practices and restrictions.

Optional prompt to further explain shopper card/purchase records: when you share your purchase histories with us, we can compare other people’s purchase histories to see if the same food is reported or identified. Your (the patient’s) purchase history will only be shared on a need-to-know basis with local, state, or federal staff during the investigation. This information could help solve the outbreak and prevent additional illnesses. Remember to collect all store shopper or membership information used for the household. Store shopper or membership information can be a shopper card or loyalty program number, phone number, or other identifier that an individual may use when making purchases that would allow for a record of their purchases to be obtained.

1. Do you (the patient) keep Halal? Yes No Unknown

2. Do you (the patient) keep Kosher? Yes No Unknown

3. Do you (the patient) follow any other type of diet or have other dietary restrictions such as vegan, vegetarian, dairy or gluten free, etc.?

Yes No (if yes, specify) ____________________________________________________________________________________________

4. Did you (the patient) consume groceries purchased online or through an app such as Instacart, Amazon, Whole Foods, etc.? Yes No (if yes, specify in the table below)

5. Did you (the patient) consume food provided by online meal kit or meal delivery services such as Hello Fresh, Blue Apron, etc.? Yes No (if yes, specify in the table below)

6. Please specify all other locations you (the patient) may have shopped or ate food from in the 7 days prior to illness (please list store names, address/location, and shopper card # (if applicable) mentioned by the interviewee below: Remember to collect all shopper cards, online records, or app orders used for the household. Sometimes shopper card numbers can be phone numbers.)

Store/Supermarket/ Subscription Services	Address/Location	Purchase/Shopping Method	Store Shopper or Membership Information	Records of Online/App Orders (if applicable)
		In-Person Online/App & Pick-Up or delivery		Yes No
		In-Person Online/App & Pick-Up or delivery		Yes No
		In-Person Online/App & Pick-Up or delivery		Yes No
		In-Person Online/App & Pick-Up or delivery		Yes No
		In-Person Online/App & Pick-Up or delivery		Yes No
		In-Person Online/App & Pick-Up or delivery		Yes No

7. May we have permission to retrieve purchase history based on your (the patient’s) store shopper or membership information and share with other public health officials to help with this outbreak investigation? Although we will collect your purchase history, we will not release any further information about you (the patient) or your (the patient’s) illness. Please modify wording to fit your state’s needs Yes No

Section 4: Additional Store/Retail Names and Locations.

Section 5: Sources of food prepared outside the home: Now I have a few questions about the food that you (the patient) ate outside your (the patient’s) home or that was prepared outside your home such as at restaurants, fast food chains, or take out. It could be helpful to check calendars, credit card statements or receipts, or phone photos to refresh your memory. I’m going to ask some specific questions about where food you (the patient) may have eaten was prepared. Please tell me the names of each place you (the patient) would have eaten food during the 7 days before your (the patient’s) illness began.

1. Please specify all restaurants/stores you (the patient) may have eaten (sit down and take out) (please list names, address/location, meal dates, and food ordered/eaten by the interviewee below)

2. Eat ready-to-eat foods from a grocery store salad bar, hot bar, or deli? Yes No (if yes, specify in table)

3. Eat foods from a food truck or food stand Yes No (if yes, specify in table)

4. Eat any food from catered events or potlucks such as a parties, conferences, weddings, etc.? Yes No (if yes, specify in table)

5. Eat any food items from a school, work, or hospital cafeteria? Yes No (if yes, specify in table)

6. For the restaurant and fast food locations identified, did you order from delivery service such as Uber Eats, Grub Hub, or Door Dash? Yes No (if yes, specify in table)

Location Name	Address/Location	Meal Date(s)	Food Ordered/Eaten

Section 5: List Additional Restaurant/Retail Names and Locations.

Section 6: Poultry, Meat, and Meat Alternatives: Now I have a few questions about meat, poultry, and meat alternatives (like tofu) that you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. This does not include canned items, but the meat and poultry could have been fresh, frozen, or could have been eaten as part of dish such as casseroles, soups, burgers, or sandwiches. You (the patient) may have eaten this at home or away from home, such as in a restaurant, takeout, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
First, I have questions about CHICKEN & OTHER POULTRY products.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Chicken prepared at home? If no, skip to question 5
				Whole chicken? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Chicken cut into parts or pieces, like breasts, drumsticks, thighs, or wings? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Ground chicken? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Frozen, stuffed chicken products like breaded chicken cordon bleu, chicken kiev, chicken broccoli and cheese, or other similar stuffed chicken products? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Frozen, breaded chicken products like chicken nuggets, strips, or tenders? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Chicken prepared outside the home? List name(s) and location(s): ___________________________________________________ Unknown Dish eaten: ________________________________________________________________ Unknown
				Rotisserie chicken, roasted chicken, or any chicken purchased precooked at a grocery store or deli? List name(s) and location(s): ___________________________________________________ Unknown
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Turkey prepared at home. If no, skip to question 14
				Whole turkey? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Cut turkey pieces or parts like turkey legs or breasts? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Ground turkey? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Other turkey? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Turkey prepared outside the home? List name(s) and location(s): ___________________________________________________ Unknown Dish eaten: ________________________________________________________________ Unknown
				Other poultry, like duck, game hen, or squab? Type, variety, brand: _________________________________________________________ Unknown
Section 6: Chicken/Poultry Comments. Please fill in any comments/notes from this section in the space provided below:

Now I have questions about BEEF products.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Beef prepared at home? This could include foods like hamburger patties, steaks, casseroles, tacos, soups, or pasta sauces. If no, skip to question 19
				Ground beef? This could include foods like hamburger patties, casseroles, tacos, soups, or pasta sauces Was it purchased: In a tray As a chub Pre-formed patties Other, specify ___________ Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown How was it consumed? Raw Pink/red inside Well-done, no pink inside Unknown
				Beef steak, roasts, carne asada, or other whole cuts of beef? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown How was it consumed? Raw Pink/red inside Well-done, no pink inside Unknown
				Beef prepared outside the home? This could include foods like hamburger patties, steaks, casseroles, tacos, soups, or pasta sauces. Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown How was it consumed? Raw Pink/red inside Well-done, no pink inside Unknown
				Veal? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown How was it consumed? Raw Pink/red inside Well-done, no pink inside Unknown
				Raw beef dishes such as kitfo or tartare? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
Section 6: Beef Comments. Please fill in any comments/notes from this section in the space provided below:

Now I have questions about PORK, LAMB, AND OTHER MEAT TYPES
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Pork prepared at home (like whole pig, chops, tenderloin, roast, shoulder, ground, etc.)? Type/cut: Ground Whole pig Pork chops Pork ribs Other, specify: ____________________________________ Unknown Brand(s): __________________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Pork prepared outside the home? This would include pig roasts, sit-down restaurants, fast food restaurants, take-out, food trucks, cafeterias, delivery from restaurants, etc. Place purchased from (names, locations): _______________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
				Other meat like lamb, goat, bison, or game meat? Type, variety, brand: _______________________________________________________ Unknown Place purchased from (names, locations): ______________________________________ Unknown
				Other meat and/or poultry products, including organ meats (like liver, heart, giblets, tongue, intestines, blood), not mentioned already? Type, variety, brand: ________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
Section 6 Pork, Lamb, and Other Meat Type Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about PROCESSED MEAT and POULTRY products.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Bacon? Type (beef, pork, turkey, etc.), variety, brand: _____________________________________ Unknown
				Sausage, like Polish sausage, kielbasa, Bratwurst, breakfast sausage, or other similar product? Type, variety, brand: _________________________________________________________ Unknown
				Hot dogs or corn dogs? Type, variety, brand: _________________________________________________________ Unknown
				Pepperoni? Including pepperoni on a sandwich or pizza
				Any Italian-style meats, like salami, prosciutto, or capicola? Type: Salami Prosciutto Capicola Other, specify: _______________________ Unknown Variety, brand: ______________________________________________________________ Unknown How were these purchased? Prepackaged At the deli In a snack plate/charcuterie board Salami sticks Other, specify: ____________________________________________ Unknown
				Store-bought, dried meat strips or jerky such as turkey, chicken, pork, or beef? Type, variety, brand: _________________________________________________________ Unknown
				Any deli meat or cold cuts? Was this sliced at the deli? Yes No Unknown Type: Turkey Ham Beef (like pastrami, roast beef) Italian meats (like salami, prosciutto) Other, specify: _________________________________________________ Unknown Variety, brand: ______________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Any liver pâté or foie gras (specify type: chicken, beef, duck, pork, etc.) Type, variety, brand: _________________________________________________________ Unknown
Section 6 Processed Meat and Poultry Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have a question about MEAT ALTERNATIVES.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Any plant-based meat substitutes like Impossible Meat, Beyond Meat, or Morningstar? Type, variety, brand: _________________________________________________________ Unknown
				Any tofu, tempeh, seitan, or other meat alternatives? Type, variety, brand: _________________________________________________________ Unknown
Section 6: Meat Alternatives Comments. Please fill in any comments/notes from this section in the space provided below:

Section 7: Fish and Seafood: Now I have some questions about fish and seafood you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) may have eaten this at home or away from home, such as in a restaurant, take-out, or at a catered event. This does not include canned items. The fish and seafood could have been fresh, frozen, or could have been eaten alone or as part of a dish, sauce, or dip. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Raw or undercooked fish or fish products, like sushi, sashimi, ceviche, or poke? Raw tuna? Yes No Maybe Don’t know Raw salmon? Yes No Maybe Don’t know Other raw fish, specify: _______________________________________________________ Unknown Describe the dish: ___________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Store-bought fish (not including shellfish) prepared at home? How was it purchased? Frozen Fresh Unknown How was it prepared? Raw Undercooked Fully cooked Unknown Type of fish eaten: ___________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Fish (not including shellfish) prepared outside the home? How was it prepared? Raw Undercooked Fully cooked Unknown Type of fish eaten: ___________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
				Smoked or dried fish, like smoked salmon, lox, bonito flakes, fish jerky? Type, variety, brand: _________________________________________________________ Unknown
				Shrimp or prawns? Frozen Fresh Unknown Type, variety, brand: _________________________________________________________ Unknown
				Crab, lobster, or crayfish/crawfish? Type, variety, brand: _________________________________________________________ Unknown
				Oysters? Were the oysters raw? Yes No Unknown Type, variety, brand: _________________________________________________________ Unknown
				Clams, mussels, scallops, or other shellfish? Type, variety, brand: _________________________________________________________ Unknown
				Any other fish or seafood? Type, variety, brand: _________________________________________________________ Unknown
Section 7: Fish and Seafood Comments. Please fill in any comments/notes from this section in the space provided below:

Section 8: Eggs, Dairy, and Cheese: Now I have a few questions about eggs, dairy, and cheese products you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) could have eaten these either in your home or away from home, such as in a restaurant, take-out, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Eggs or egg-containing dishes prepared at home? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Eggs or egg-containing dishes prepared outside the home? Place purchased from (names, locations): ________________________________________ Unknown Dish Eaten: _________________________________________________________________ Unknown
				Egg alternatives or vegan egg substitutions? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Anything made with raw eggs that was not fully cooked (cookie dough, cake batter, sauces, homemade ice cream, homemade mayo, homemade salad dressing etc.)? Please describe: _____________________________________________________________ Unknown
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Dairy milk from a cow or other animal source? Type (cow, goat, etc.), variety, brand: ___________________________________________ Unknown Raw or unpasteurized? Yes No Unknown
				Dairy milk alternatives, like almond, oat, hemp, coconut, cashew, rice, or soy milk? Type, variety, brand: _________________________________________________________ Unknown
				Any yogurt or yogurt product like kefir? Type, variety, brand: _________________________________________________________ Unknown
				Cheese made from unpasteurized or raw milk, including homemade, farm-fresh, and door-to-door cheeses? Type, variety, brand: _________________________________________________________ Unknown
				Fresh, soft cheeses? Queso fresco Cotija Feta Goat cheese Fresh mozzarella Other, specify: ___________________________________________________________ Unknown
				Blue-veined cheese like bleu, stilton, or gorgonzola? Type, variety, brand: _________________________________________________________ Unknown
				Brie or camembert? Type, variety, brand: _________________________________________________________ Unknown
				Other prepackaged, shredded, sliced, block, gourmet, or artisanal cheese? Type, variety, brand: _________________________________________________________ Unknown
				Dairy-alternative cheese products, like cashew cheese, vegan cheese? Type, variety, brand: _________________________________________________________ Unknown
Section 8: Eggs, Dairy, and Cheese Comments. Please fill in any comments/notes from this section in the space provided below:

Section 9: Vegetables: Now I have some questions about vegetables you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) could have eaten these either in your home or away from home, like in a restaurant, take-out, or at a catered event. This does not include canned items, but these foods could have been eaten alone or as part of a dish. I am not interested in vegetables grown at home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
First, I have questions about TOMATOES & LEAFY GREENS that are not homegrown.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Tomatoes at home? Type: Red Round Roma (oval-shaped) Small, bite-sized tomato, like grape or cherry Other, specify: ___________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Tomatoes outside the home, sometimes served as part of a sandwich, burger, or salad? Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
				Salsa or pico de gallo (not from a jar or can) prepared at home? List ingredients included: _____________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Salsa or pico de gallo prepared outside the home? List ingredients included: _____________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Avocado? Type, variety, brand: _________________________________________________________ Unknown
				Guacamole? Type, variety, brand: _________________________________________________________ Unknown
				Iceberg lettuce at home? Was it purchased Prepackaged Whole head/Loose Unknown Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations) _________________________________________ Unknown
				Iceberg lettuce prepared outside the home, sometimes served as part of a sandwich, burger, or salad? Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Romaine lettuce at home? Was it purchased: Prepackaged hearts Prepackaged chopped Whole head/loose Unknown Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Romaine lettuce prepared outside the home, sometimes served as part of a sandwich, burger, or salad? Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
				Spinach at home? Was it purchased Prepackaged Bundled/Loose Unknown Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations) _________________________________________ Unknown
				Spinach prepared outside the home, sometimes served as part of a sandwich, burger, or salad? Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
				Cabbage? Type, variety, brand: _________________________________________________________ Unknown
				Kale? Type, variety, brand: _________________________________________________________ Unknown
				Arugula? Type, variety, brand: _________________________________________________________ Unknown
				Spring mix/mixed greens or other lettuce blend? Type, variety, brand: _________________________________________________________ Unknown
				Prepackaged salad kits often sold in a bag or clamshell? Type, variety, brand: _________________________________________________________ Unknown
				Other leafy greens, like Swiss chard, mustard greens, dandelion, watercress? a. Type, variety, brand: ___________________________________________________________ Unknown
Section 9 – Tomatoes/Leafy Greens Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about fresh herbs and sprouts you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. Remember, these could have been part of a dish, like pesto, salsa, sauces, etc. We are not interested in dried or bottled herbs or herbs grown at home.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Basil, sometimes in pesto or as a garnish? Type, variety, brand: _________________________________________________________ Unknown
				Cilantro, sometimes in salsa, Mexican food, Asian food, or as a garnish? Type, variety, brand: _________________________________________________________ Unknown
				Other fresh herbs (parsley, chives, dill, sage, thyme, mint, etc.)? Type, variety, brand: _________________________________________________________ Unknown
				Bean sprouts, like mung bean or soybean, usually served in stir fries, Asian salads, or soups prepared at home? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Bean sprouts, like mung bean or soybean, usually served in stir fries, Asian salads, or soups prepared outside the home? Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
				Other microgreens/sprouts (like alfalfa, clover, daikon radish, microgreens, etc.) prepared at home? Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Other microgreens/sprouts (like alfalfa, clover, daikon radish, microgreens, etc.) prepared outside the home? Place purchased from (names, locations): ________________________________________ Unknown Dish eaten: _________________________________________________________________ Unknown
Section 9– Herbs/Sprouts Comments. Please fill in any comments/notes from this section in the space provided below:
Next, I have a few questions about other vegetables that you (the patient) may have eaten in the 7 days before your (the patient’s) illness.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Cucumbers prepared at home? Type, variety: Mini (like Persian) Large, wrapped in plastic (like English or European) “Regular” sold loose, not wrapped in plastic Other, specify: ___________________ Unknown Place purchased from (names, locations): _________________________________________ Unknown
				Cucumbers prepared outside the home? Place purchased from (names, locations): ________________________________________ Unknown Specify dish: ________________________________________________________________ Unknown
				Zucchini, summer squash, or other “soft” squash? Type, variety, brand: _________________________________________________________ Unknown
				Sweet or bell peppers (green, red, orange, or yellow)? Type, variety, brand: _________________________________________________________ Unknown
				Mini or snack-sized sweet peppers, usually sold in a bag or clamshell? Type, variety, brand: _________________________________________________________ Unknown
				Hot, spicy peppers, like jalapenos or serranos? These could be an ingredient in salsa, pico de gallo, pho, salad, or as a garnish Type, variety, brand: _________________________________________________________ Unknown
				Celery? a. Type, variety, brand: ___________________________________________________________ Unknown
				Carrots or mini carrots? Type, variety, brand: _________________________________________________________ Unknown
				Pea pods, snap peas, or snow peas? Type, variety, brand: _________________________________________________________ Unknown
				Broccoli? Type, variety, brand: _________________________________________________________ Unknown
				Cauliflower? Type, variety, brand: _________________________________________________________ Unknown
				Onions (white, yellow, or red/purple), including in salads, salsa, pico de gallo, sandwiches, burgers What color were the onions? White Red/Purple Yellow Other, specify: ________________________________________________________ Unknown
				Green onions/scallions?
				Mushrooms, including fresh or dried? Type: Button Portobellos Shiitake Enoki Wood ear (kikurage) Other, specify: ____________ Unknown Fresh Dried
				Prepackaged, precut vegetable mix such as a stir fry or grill kit?
				Fermented vegetables (like kimchi, sauerkraut)? Type, variety, brand: _________________________________________________________ Unknown Was this homemade? Yes No Don’t know
				Other vegetables (Brussels sprouts, radishes, beets, turnips, fennel, etc.)? Type, variety, brand: _________________________________________________________ Unknown
Section 9: Other Vegetable Comments. Please fill in any comments/notes from this section in the space provided below:

Section 10: fruits & Berries: Now I have some questions about fruits, not canned, cooked, or frozen, that you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. I will ask you about frozen fruits later. You (the patient) could have eaten these either in your home or away from home, like in a restaurant, take-out, or at a catered event. I am not interested in fruits and berries grown at home. As I read each food item, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Apples? Type, variety, brand: _______________________________________________________ Unknown
				Grapes? Type, variety, brand: _______________________________________________________ Unknown
				Pears?
				Peaches?
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Nectarines?
				Other stone fruit, like apricots, plums, or cherries? Type, variety, brand: _______________________________________________________ Unknown
				Citrus fruits, like lemons, limes, oranges, tangerines, grapefruit, mandarins, or clementines? Type, variety, brand: _______________________________________________________ Unknown
				Strawberries?
				Raspberries?
				Blueberries?
				Blackberries?
				Other berries? Type, variety, brand: _______________________________________________________ Unknown
				Cantaloupe, rock melon, or musk melon? Precut Yes No Unknown Type, variety, brand: _______________________________________________________ Unknown Place purchased from (names, locations): ______________________________________ Unknown
				Watermelon? Precut Yes No Unknown Type, variety, brand: _________________________________________________________ Unknown Place purchased from (names, locations): ________________________________________ Unknown
				Other melon, such as honeydew or galia melon? Precut Yes No Unknown Type, variety, brand: _______________________________________________________ Unknown Place purchased from (names, locations): ______________________________________ Unknown
				Pineapple?
				Mango?
				Papaya?
				Other fruit purchased sliced or pre-cut? Type, variety, brand: _______________________________________________________ Unknown
				Other fruit (banana, kiwi, guava, pomegranate, coconut, dragon fruit, etc.)? Type, variety, brand: _______________________________________________________ Unknown
				Juices or ciders? Raw or unpasteurized? Yes No Unknown Type, variety, brand: _______________________________________________________ Unknown
				Smoothies made with fresh or frozen fruit or produce, prepared at home or outside the home? Prepared at home Prepared outside the home, specify place of purchase __________________ Ingredients in smoothie: ____________________________________________________ Unknown
Section 10: Fruits and Berries Comments. Please fill in any comments/notes from this section in the space provided below:

Section 11: Frozen Foods: Now I have a few questions about frozen foods you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) may have purchased the food frozen (from a grocery store, restaurant, or specialty market) and prepared it at home. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Frozen vegetables? Type, variety, brand: ________________________________________________________ Unknown
				Frozen fruit or berries, including those used in a smoothie? Type, variety, brand: ________________________________________________________ Unknown
				Frozen pot pies? Type, variety, brand: ________________________________________________________ Unknown
				Frozen pizza? Type, variety, brand: ________________________________________________________ Unknown
				Frozen fish product (fish sticks, nuggets, etc.)? Type, variety, brand: ________________________________________________________ Unknown
				Frozen appetizers or snack foods like mozzarella sticks, jalapeno poppers, burritos, potato skins, or hot pockets? Type, variety, brand: ________________________________________________________ Unknown
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Frozen breakfast items (waffles, breakfast sandwiches, etc.)? Type, variety, brand: ________________________________________________________ Unknown
				Frozen vegetarian foods like a veggie burger? Type, variety, brand: ________________________________________________________ Unknown
				Frozen pre-mixed meals in a bag or box (stir fry, pasta meals, etc.)? Type, variety, brand: ________________________________________________________ Unknown
				Frozen dinners or box entrees? Type, variety, brand: ________________________________________________________ Unknown
				Other frozen, prepackaged product not mentioned previously? Type, variety, brand: ________________________________________________________ Unknown
				Ice cream, ice cream products, frozen yogurt, or non-dairy frozen desserts? Type or brand (bar, tub, carton, etc.): __________________________________________ Unknown Variety or flavor: __________________________________________________________ Unknown Place purchased from (names, locations): ______________________________________ Unknown
Section 11: Frozen Foods Comments. Please fill in any comments/notes from this section in the space provided below:

Section 12: Nuts, Cereal, Processed, and Dried Foods: Now I have some questions about nuts, cereals, and processed foods you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) could have eaten these either in your home or away from home, like in a restaurant, take-out, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Peanut butter eaten at home? What was the brand: Jif Skippy Peter Pan Other, specify: ______________ Unknown
				Peanut butter eaten outside the home? Place purchased from (names, locations): ________________________________________ Unknown
				Peanut butter containing foods (cookies, crackers, candies, ice cream, etc.)? Type, variety, brand: ________________________________________________________ Unknown
				Ground nut/seed butter or other spreads (like Nutella, cookie butter, almond butter)? Type(s): Almond Hazelnut Sunflower Cookie/Speculoos Unknown Cashew Nutella Other, specify: __________________ Brand: ___________________________________________________________________ Unknown
Next, I have questions about dried fruits, nuts, and seeds you (the patient) might have eaten. Remember that these may be used as toppings or mixed into many foods. If you (the patient) ate any of the nuts below as part of another food, please answer "yes".
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Dried fruit, including dried whole fruit and fruit leathers? Type, variety, brand: ________________________________________________________ Unknown
				Peanuts?
				Almonds (whole, sliced, chopped, etc.)?
				Walnuts?
				Cashews?
				Pistachios?
				Hazelnuts or filberts?
				Pecans?
				Pine nuts, including in pesto?
				Sunflower seeds?
				Chia, flaxseed, or hemp? Type, variety, brand: ________________________________________________________ Unknown
				Sesame seeds or other products made from sesame seeds, like tahini or halva?
				Other nuts, mixed nuts, or seeds? Type, variety, brand: ________________________________________________________ Unknown
				Dips or spreads, like hummus, baba ghanoush, bean dips? Type, variety, brand: ________________________________________________________ Unknown
Section 12: Peanut Butter/Nuts/Seeds Comments. Please fill in any comments/notes from this section in the space provided below:
Now I have questions about uncooked dough or batter, pre-packaged snack foods and cereals you (the patient) might have had in the 7 days before your (the patient’s) illness began.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Eat, taste, or lick any uncooked or unbaked dough or batter (such as cookie, cake, biscuit, muffin batter)? From scratch: type, variety, brand of flour: ___________________________________ Unknown Premade dough: type, variety, brand: _______________________________________ Unknown Prepackaged dry mix (such as cake): type, variety, brand: _______________________ Unknown
				Did anyone in your household do any baking with flour, premade dough, or prepackaged dry mix? From scratch: type, variety, brand of flour: ___________________________________ Unknown Premade dough: type, variety, brand: _______________________________________ Unknown Prepackaged dry mix (such as cake): type, variety, brand: _______________________ Unknown
				Granola, breakfast, power, or protein bars? Type, variety, brand: ________________________________________________________ Unknown
				Trail mix (or similar product)? Type, variety, brand: ________________________________________________________ Unknown
				Salty/savory snacks, like chips, corn puffs, seaweed snacks, or pretzels? Type, variety, brand: ________________________________________________________ Unknown
				Sweet snacks, like cookies or snack cakes? Type, variety, brand: ________________________________________________________ Unknown
				Chocolate or chocolate-containing candy? Type, variety, brand: ________________________________________________________ Unknown
				Cold breakfast cereals? Type, variety, brand: ________________________________________________________ Unknown
				Breakfast cereals like oatmeal, cream of wheat, overnight oats, etc.? Type, variety, brand: ________________________________________________________ Unknown
Section 12: Snack foods/Cereal Comments. Please fill in any comments/notes from this section in the space provided below:
And finally, I have questions about a few other products you (the patient) might have had in the 7 days before your (the patient’s) illness began.
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
				Bottled, pre-made smoothies?
				Flavored milk powder (such as chocolate, vanilla, Carnation, or Ovaltine)?
				Recently purchased or newly opened spices, spice blends, or dried herbs? Type, variety, brand: ________________________________________________________ Unknown
				Nutritional products, such as whey, protein powders, meal replacement powders, probiotics, vitamin boosters, etc.? Type, variety, brand: ________________________________________________________ Unknown
				Herbal products, such as powdered greens, kratom, herbal teas, or other natural remedies? Type, variety, brand: _______________________________________________________ Unknown
				Bottled, pre-made health drinks, like Kombucha or coconut water? Type, variety, brand: ________________________________________________________ Unknown
Section 12: Other foods Comments. Please fill in any comments/notes from this section in the space provided below:

Section 13: We have covered a wide variety of foods, drinks, etc. After answering all these questions are there any other things you (the patient) ate or drank in the 7 days before becoming ill that have not been mentioned?
Please describe any other foods, drinks, etc. including as much detail as possible regarding type, variety, or brand.

Section 14: Animal Contact and Pet Food: Now I have some questions about contact with pets or other animals in the 7 days before your (the patient’s) illness began. Contact is defined as: you (the patient) or someone in the household handling, touching, petting, or otherwise interacting with an animal or the areas where the animal lives/roams. This could have been at your home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location. As I read each exposure, please answer as yes, no, may have had, or can't remember having contact in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	Did you (the patient) or anyone in the household have contact with any of the following types of animals or the areas where the animal lives/roams?
				Chickens/chicks, ducks/ducklings, turkeys, or other backyard poultry? Chickens/Chicks Ducks/Ducklings Turkeys Other, specify: ___________________ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ Unknown
				Turtles or tortoises? If yes/maybe, was the shell <4 inches in diameter (smaller than the palm of an adult hand)? Yes No Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ Unknown
				Other reptiles (such as snakes, lizards, geckos, bearded dragons), amphibians (frogs, toads, salamanders), fish or other aquatic animals? If yes or maybe, please specify the type: ________________________________________ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: ___________________________________________________ Unknown Was it fed: Live mice/rat Frozen mice/rat Live chick Frozen chick Other feeder animal, specify: ___________________ Not fed feeder animal Unknown
				Small mammalian household pet, such as hamster, rat, mouse, guinea pig, gerbil, ferret, sugar glider, or hedgehog (excluding feeder rodents used as pet food for reptiles, see #3c)? If yes or maybe, please specify the type: ________________________________________ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ Unknown
				Any other type of pets (dogs, cats, birds (not poultry) etc.) If yes or maybe, please specify the type: ________________________________________ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ Unknown
				Any other animal (such as farm animals or wildlife)? If yes or maybe, please specify the type: ________________________________________ Unknown If yes or maybe, where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify: __________________________________________________ Unknown
				Did you (the patient) or anyone in the household have contact with animal food, animal treats, animal feeding bowls or equipment, or the area where animal food/treats are stored or where animals are fed? What type of animal food: Dry Canned Fresh Raw Other, specify: ________ Unknown Animal food brand: ___________________________________________________________ Unknown Purchase location: ___________________________________________________________ Unknown Animal treat type: Pig ear Pizzle/bully stick Raw hide Hooves Jerky-style treat Biscuit-style treats Freeze-dried treats Other, specify: ___________________ Unknown Animal treat brand: ___________________________________________________________ Unknown Purchase location: ___________________________________________________________ Unknown
Section 14: Animal Contact and Pet Food Comments. Please fill in any comments/notes from this section in the space provided below:

Section 15: Race, Ethnicity, and Sex: In this section, we will ask questions about your (the patient’s) race, ethnicity, and sex. We are collecting this information from all ill people. By knowing more about your (the patient’s) race, ethnicity, and sex we can get a better idea of health risks you (the patient) may have and foods you might eat, that might help us identify what caused you to become sick. You (the patient) may belong to more than just one race or ethnicity; please check all that apply to you (the patient). These questions are optional, and you may choose not to answer them.

1. What is your race and/or ethnicity? (Select all that apply and enter additional details in the spaces below)

American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc. _________________________________	Asian Chinese Asian Indian Filipino Vietnamese Korean Japanese Enter, for example, Pakistani, Hmong, Afghan, etc. _________________________________	Black or African American African American Jamaican Haitian Nigerian Ethiopian Somali Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congalese, etc. _________________________________
Hispanic or Latino Mexican Puerto Rican Salvadoran Cuban Dominican Guatemalan Enter, for example, Colombian, Honduran, Spaniard, etc. _________________________________	Middle Eastern or North African Lebanese Iranian Egyptian Syrian Iraqi Israeli Enter, for example, Moroccan, Yemeni, Kurdish, etc. _________________________________	Native Hawaiian or Pacific Islander Native Hawaiian Samoan Chamorro Tongan Fijian Marshallese Enter, for example, Chuukese, Palauan, Tahitian, etc. _________________________________
White English German Irish Italian Polish Scottish Enter, for example, French, Swedish, Norwegian, etc. _________________________________

2. What languages are spoken at home? ________________________________________________________________________ Declined to answer

3. Sex: Male Female

That completes the interview. Thank you for taking the time to answer these questions. Your responses may be helpful in preventing others from becoming sick.

National Hypothesis Generating Questionnaire v2, OMB No. 0XXX-XXXX, Page 20 of 20