Form 2 Form 2 Foodborne Focus Questionnaire

Form Approved

OMB No: 0XXX-XXXX

Expires: XX/XX/20XX

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

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

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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0XXX-XXXX

Section 1: Chicken: Now I have a few questions about chicken that you (the patient) might have eaten in the X days before your (the patient’s) illness began. This does not include canned items, but the chicken 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.

Main Question: Did you (the patient) eat any chicken? If yes, maybe, ate, or likely ate, please proceed to the chicken-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Chicken-specific Food Questions If yes, maybe, ate, or likely ate to chicken-specific food items, please ask the following questions:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:
								If prepared at home: How was it purchased? ☐ Raw, fresh ☐ Raw, frozen ☐ Already cooked ☐ Unknown Type, variety: _____________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Was it organic? ☐ Yes ☐ Maybe ☐ No ☐ Unknown Place purchased from (names, locations): _______ ☐ Unknown Purchase date: _____/_____/_____ ☐ Unknown If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: _____/_____/_____ USDA Establishment # P___________________ (the establishment # starts with “P”) Is a receipt available from this purchase? ☐ Yes ☐ No ☐ Unknown Is any of the product purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Unknown If yes, Is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Unknown (Regardless of packaging) Would you be willing to have the leftover product collected by health officials for testing if needed? ☐ Yes ☐ Maybe ☐ No ☐ Unknown Did you handle the product after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Unknown Are others who ate the chicken also sick? ☐ Yes ☐ No If prepared outside the home: List name(s) and location(s): ___________________________ Meal date: ___/___/____ ☐ Unknown Describe the dish: ___________________________________ Do you have leftovers? ☐ Yes ☐ No Are others who ate the chicken sick? ☐ Yes ☐ No ☐ Unknown What other items were served that you ate? _______________ Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Whole chicken Chicken cut into parts or pieces Chicken breasts Chicken drumsticks Chicken thighs Chicken wings Ground chicken Frozen, stuffed chicken products Breaded chicken Chicken cordon bleu Chicken kiev Chicken broccoli and cheese Bacon wrapped chicken Frozen, breaded chicken products like chicken nuggets, strips, or tenders Rotisserie chicken, roasted chicken or any chicken purchased precooked at a grocery store or deli? Other chicken products Chicken sausage Chicken meatballs Chicken deli meat Chicken patties Chicken livers Chicken hearts Chicken feet Organ meat Chicken necks Chicken Intestines Chicken Blood Chicken gizzards/giblets Did you touch, handle, or prepare chicken? Any Kosher chicken/chicken product
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 2: Beef: Now I have a few questions about beef that you (the patient) might have eaten in the X days before your (the patient’s) illness began. This does not include canned items, but the beef 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.

Main Question: Did you (the patient) eat any beef? If yes, maybe, ate, or likely ate, please proceed to the beef-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Beef-specific Food Questions If yes, maybe, ate, or likely ate to beef-specific food items, please ask the following questions:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ______ ☐ Unknown How was the ground beef packaged? ☐ In a tray/bulk ☐ Bulk tube or chub ☐ Pre-formed patties ☐ Other, specify _______ ☐ Unknown How was the ground beef purchased? ☐ Raw, fresh ☐ Raw, frozen ☐ Already cooked ☐ Unknown If fresh, did you freeze the raw ground beef before cooking it? ☐ Yes ☐ No ☐ Unknown If yes, did you: ☐ freeze in original, unopened package ☐ repackage and then freeze ☐ Unknown If frozen or frozen at home, how was the ground beef defrosted? ☐ On counter ☐ Microwave ☐ Refrigerator ☐ Unknown Did you freeze the ground beef after cooking it? ☐ Yes ☐ No ☐ Unknown Brand: ___________________________________ ☐ Unknown What size was the package? ______lbs ☐ Unknown Was it organic? ☐ Yes ☐ Maybe ☐ No ☐ Unknown What was the percent lean/fat? _____% lean ☐ Unknown If known, what was the “Best If Used By/Expiration” date on that package: Best if used by date: ____/____/______ USDA Establishment # ______________________ (the establishment number is either located in the USDA mark of inspection or printed on the package and begins with “M” or “EST”.) Is a receipt or other proof of purchase available from this purchase? ☐ Yes ☐ No ☐ Unknown If yes, would you be willing to share a picture of the receipt with health officials? ☐ Yes ☐ No ☐ Unknown Purchase date: ____/____/_______ ☐ Unknown How was the ground beef prepared? ☐ Hamburger ☐ Meatballs ☐ Meatloaf ☐ Tacos ☐ In a dish (pasta/casserole) ☐ Other, specify _____________________ How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Unknown Is any of the ground beef purchased still in your home? ☐ Yes ☐ Maybe ☐ No ☐ Unknown If yes, Is it in its original packaging? ☐ Yes ☐ Maybe ☐ No ☐ Unknown (Regardless of packaging) Would you be willing to have the leftover product collected by health officials for testing if needed? ☐ Yes ☐ No ☐ Unknown Did you handle the leftover ground beef after illness began? ☐ Yes ☐ Maybe ☐ No ☐ Unknown Are others who ate the ground beef also sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______ ☐ Unknown Meal date: _____/_____/______ ☐ Unknown What type of beef product was this? ☐ Steak ☐ Stew ☐ Roast ☐ Hamburger ☐ Meatballs ☐ Meatloaf ☐ Tacos ☐ In a dish (pasta/casserole) ☐ Other, specify ___________ ☐ Unknown Describe dish eaten: _______________________ ☐ Unknown How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Unknown Are others who ate the beef also sick? ☐ Yes ☐ No
Yes		Maybe		No		Don’t Know	Ground beef Hamburger patties Casseroles Tacos Soups Pasta sauce Beef steaks Roasts Stews Carne asada Whole cuts of beef Carne mechada Carne menudo (beef tripe) Cabeza (beef cheeks) Lengua (beef tongue) Veal Raw beef dishes Kitfo Tartare Other beef products Corned beef Dried meats Beef jerky Organ meat Liver Heart Giblets Tongue Intestines Blood Did you handle or prepare any raw beef?
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 3: Pork: Now I have a few questions about pork that you (the patient) might have eaten in the X days before your (the patient’s) illness began. This does not include canned items, but the pork 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.

Main Question: Did you (the patient) eat any pork? If yes, maybe, ate, or likely ate, please proceed to the pork-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Pork-specific Food Questions If response is yes, maybe, ate, or likely ate to pork-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type/cut: ☐ Ground ☐ Whole pig ☐ Pork chops ☐ Pork ribs ☐ Tenderloin ☐ Shoulder ☐ Butt ☐ Carnitas ☐ Pulled ☐ Other, specify: _________________________ ☐ Unknown Was it: ☐ Fresh ☐ Frozen Brand(s): _____________________________ ☐ Unknown Place purchased from (names, locations): ________________ ☐ Unknown Location type: ☐ Supermarket/grocery store ☐ Ethnic market ☐ Live animal market ☐ Slaughterhouse/butcher shop ☐ Other, specify _____________________ ☐ Unknown Was the pork: ☐ Prepackaged ☐ Bulk Purchase date: ____/____/_______ ☐ Unknown Did you (your child) participate in cooking? ☐ Yes ☐ No If yes, what was the cooking method (ground, spit, oven, etc.)? _______________________ Do you have leftovers? ☐ Yes ☐ No Who purchased/cooked/handled the pork? _______________ Are others who ate the pork sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Type/cut: ☐ Ground ☐ Whole pig ☐ Pork chops ☐ Pork ribs ☐ Tenderloin ☐ Shoulder ☐ Butt ☐ Carnitas ☐ Pulled ☐ Other, specify _____________________________ ☐ Unknown Where was the pork consumed? (names, locations): ________________________________________ ☐ Unknown Dish eaten: ______________________________ ☐ Unknown Did you (your child) participate in cooking? ☐ Yes ☐ No If yes, what was the cooking method (ground, spit, oven, etc.)? ________________________ Do you know where the pork was obtained from (store, farm, market, etc)? ☐ Yes ☐ No If yes, name/location: _____________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Is a receipt or invoice available? ☐ Yes ☐ No Do you have leftovers? ☐ Yes ☐ No Are others who ate the pork sick? ☐ Yes ☐ No ☐ Unknown What other items were served that you ate? ______________
Yes		Maybe		No		Don’t Know	Whole pig Pork chops Pork Tenderloin Pork roast Pork shoulder Ground pork Attend a hog/pig roast Pork carnitas Chorizo Buche (pork stomach) Costilla (pork ribs) Pastor (marinated pork) Pozole (pork stew) Chitterlings/Chitlins (pork intestine) Other meals containing pork such as egg rolls, fried rice, dumplings, tamales, soup, and or pork rinds Lamb Goat (birria) Bison Game meat Organ meat Liver Heart Giblets Tongue Intestines Blood Other pork products
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 4: Processed Meat and Meat Alternatives: Now I have a few questions about processed meat and meat alternatives (like tofu) that you (the patient) might have eaten in the X days before your (the patient’s) illness began. This does not include canned items, but the processed meat and meat alternatives 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.

Main Question: Did you (the patient) eat any processed meats or meat alternatives? If yes, maybe, ate, or likely ate, please proceed to the processed meat/meat alternative-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Processed Meats/Meat Alternative-specific Food Questions If response is yes, maybe, ate, or likely ate to processed meat/meat alternative-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type, variety/style:______________________ ☐ Unknown Brand:__________________________________ ☐ Unknown Turkey bacon? ☐ Yes ☐ No ☐ Unknown Place purchased (name, location): ____________ ☐ Unknown Purchase date: ___/___/______ Receipt available?  ☐ Yes ☐ No ☐ Unknown Any product leftover?    ☐ Yes ☐ No ☐ Unknown Use-By/Best-By Date: ____/_____/_____ Lot code:________ USDA Establishment Number (may be in a circle seal on the packaging):_____________ Was it purchased: ☐ Raw ☐ Precooked ☐ Unknown Was it made from: ☐ Chicken ☐ Turkey ☐ Pork ☐ Beef ☐ Other, specify___________________ Was it: ☐ Cured ☐ Uncured ☐ Unknown How was it purchased? ☐ Sliced, in sealed package (size:______oz) ☐ Sliced at deli counter ☐ On pizza ☐ Chub/Log ☐ Other:_________________ ☐ Unknown Any product leftover?  ☐ Yes ☐ No ☐ Unknown Are others who ate the product sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ________________ ☐ Unknown Meal date: _____/_____/______ ☐ Unknown Describe dish eaten: _______________________ ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No Do you have leftovers? ☐ Yes ☐ No What other items were served that you ate? ______________ Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Bacon or Pancetta Sausage Polish sausage Kielbasa Bratwurst Breakfast sausage Italian sausage Dried sausage Summer sausage Chorizo Other processed meat products Hot dogs Corn dogs Pepperoni Antipasto/antipasti Salami (genoa, parma, peppered) Prosciutto/speck Sopressata Porchetta Bresaola Calbrese Coppa Capocollo/capicola Calabrese salami Mortadella salami Pistachio di Prato Amatrice di Cavallo Charcuterie Pancetta Serdelki Deli ham Deli turkey Deli chicken Deli roast beef Deli pastrami Any other deli meats or cold cuts Liver pate Foie gras Plant based meat substitutes Impossible meat Beyond meat Morningstar Tofu Tempeh Seitan Other meat alternatives
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 5: Sushi and Sashimi: Now I have some questions about sushi or sashimi you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any sushi/sashimi? If yes, maybe, ate, or likely ate, please proceed to the sushi/sashimi-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Sushi/sashimi-specific Food Questions If response is yes, maybe, ate, or likely ate to sushi/sashimi-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	Place purchased from (names, locations): ________________ Meal/purchase date: ­­­____/_____/________ ☐ Unknown How was it prepared? ☐ Raw ☐ Undercooked ☐ Fully cooked ☐ Unknown What were the types of sushi you ate (Did your meal include:)? ☐ Special Roll (ex. California or Dragon Roll) : _____________ ☐ Spicy Tuna Roll ☐ Nigiri (small clump of rice with piece of seafood on top) ☐ Maki (smaller roll usually with seaweed) ☐ Inari (pouch of fried tofu filled with rice) ☐ Sashimi (raw fish without rice) ☐ Other, specify ___________ ☐ Unknown What were the types of sushi you ate (Did your meal include:)? ☐ Special Roll (ex. California or Dragon Roll) : _____________ ☐ Spicy Tuna Roll ☐ Nigiri (small clump of rice with piece of seafood on top) ☐ Maki (smaller roll usually with seaweed) ☐ Inari (pouch of fried tofu filled with rice) ☐ Sashimi (raw fish without rice) ☐ Other, specify: __________ ☐ Unknown What were the seafood ingredients in the Sushi/Sashimi? ☐ Spicy Tuna ☐ Raw Tuna (Maguro) ☐ Smoked Tuna ☐ Yellowtail (Hamachi) ☐ Raw Salmon ☐ Smoked Salmon ☐ Shrimp (Ebi) ☐ Eel (Unagi) ☐ Squid (Ika) ☐ Crab stick (Imitation Crab) ☐ Alaskan/Real Crab ☐ Roe/caviar (fish eggs) ☐ Scallop ☐ Other White Fish, specify: ___________ ☐ Other Seafood, specify: ________________ ☐ Unknown What were the other ingredients in the sushi? ☐ Rice ☐ Seaweed (Nori) ☐ Cucumber ☐ Avocado ☐ Egg ☐ Mushroom ☐ Sprouts ☐ Ume (Pickled Plum) ☐ Asparagus ☐ Carrots ☐ Green onions or scallions ☐ Cream cheese ☐ Habanero cream cheese ☐ Tofu ☐ Spicy aioli ☐ Black Sesame seeds ☐ White sesame seeds ☐ Other Vegetables, specify ___________________ ☐ Other, specify: _______________________ ☐ Unknown What were the sides/garnishes eaten with your sushi/sashimi? ☐ Wasabi ☐ Soy sauce ☐ White/yellow ginger ☐ Pink ginger ☐ Ginger, color unknown ☐ Eel sauce ☐ Ponzu sauce ☐ Mayo ☐ Tempura flakes ☐ Spicy mayo ☐ Sriracha ☐ Radish sprouts ☐ Sprouts (other) ☐ Sesame seeds ☐ Shiso leaves ☐ Masago (orange-red, about the size of a pencil tip and a big crunchy) ☐ Other sauce/side/garnish, specify _____________☐ Unknown What other food items did you eat during your sushi/sashimi meal? ☐ Soy beans (Edamame) ☐ Seaweed salad ☐ Garden/house salad (if yes, salad dressing: ____________) ☐ Dumplings/potstickers ☐ Soup (if yes, what kind:_______) ☐ Deep fried spring/egg roll (if yes, what kind: ____________) ☐ Fresh spring roll (if yes, what kind:_____________) ☐Ice cream (if yes, what kind:_________________) ☐ Other, specify: ________________ ☐ Unknown How did you pay for your sushi/sashimi items? ☐ Cash ☐ Credit card ☐ Check ☐ Unknown Do you have a receipt or credit card proof of purchase for your sushi meal/purchase? ☐ Yes ☐ Maybe ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	California Roll Spicy Tuna roll Spicy Salmon roll Dragon roll Rainbow roll Salmon roll Kappa maki Tako roll Unagi roll Ikura roll Shrimp tempura roll Philadelphia roll Tiger roll Volcano roll Dragon roll Other sushi rolls Other maki Other sashimi
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 6: Fish and Seafood: Now I have some questions about fish or seafood (not including shellfish) you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any fish or seafood? If yes, maybe, ate, or likely ate, please proceed to the fish/seafood-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Fish/Seafood-specific Food Questions If response is yes, maybe, ate, or likely ate to fish/seafood-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: How was it purchased? ☐ Frozen ☐ Fresh ☐ Prepackaged ☐ Pickled ☐ Smoked ☐ In oil ☐ Unknown How was it prepared? ☐ Raw ☐ Undercooked ☐ Fully cooked ☐ Unknown Variety: _________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Place purchased from (names, locations): ________________ ☐ Unknown Purchase date: ____/_____/________ ☐ Unknown Do you have any leftovers available? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: How was it prepared? ☐ Raw ☐ Baked ☐ Steamed ☐ Fried ☐ Sauteed ☐ Smoked Place purchased from (names, locations): ________________ ☐ Unknown Describe dish eaten: _________________________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown What other items were served that you ate? ______________
Yes		Maybe		No		Don’t Know	Salmon Sturgeon Tuna Tuna Tartare Halibut Cod Yellowtail Sablefish Herring Tilapia Sprat Mackerel Sardines Turbot Bullhead Saury Kilka Sea bass Vobla Escolar Butter fish (maslyanaya) Steelhead (semga) Capelin (moyvy) Mahi mahi Catfish Anchovies Snapper Trout Haddock Bass Swordfish Flounder Grouper Perch Gefilte fish Stuffed fish products Smoked salmon Smoked fish Dried fish Lox Bonito flakes Fish jerky Frozen fish sticks Frozen fish nuggets Caviar/Roe Ceviche Other fish or fish products
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 7: Shellfish: Now I have some questions about shellfish you (the patient) might have eaten in the X 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 shellfish could have been fresh, frozen, or could have been eaten alone or as part of a dish, sauce, or dip.

Main Question: Did you (the patient) eat any shellfish? If yes, maybe, ate, or likely ate, please proceed to the shellfish-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Shellfish-specific Food Questions If response is yes, maybe, ate, or likely ate to shellfish-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________ ☐ Unknown Purchase date: ____/_____/________ ☐ Unknown How was it purchased? ☐ Frozen ☐ Fresh ☐ Cooked ☐ Unknown How was it eaten? ☐ Cooked ☐ Raw ☐ Unknown Was it from the deli/fish counter? ☐ Yes ☐ No ☐ Unknown Type: __________________________________ ☐ Unknown Variety: _________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Do you have any leftovers available? ☐ Yes ☐ No | ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: How was it prepared? ☐ Raw ☐ Baked ☐ Steamed ☐ Fried ☐ Sauteed ☐ Smoked Place purchased from (names, locations): ________________ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Meal date: ____/___/_____ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Shrimp Prawns Crab Lobster Crayfish/Crawfish Oysters Clams Mussels Scallops Squid Octopus Abalone Snail Sea urchin Winkles Barnacles Other shellfish or shellfish products
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 8: Eggs: Now I have a few questions about eggs and egg products you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any eggs? If yes, maybe, ate, or likely ate, please proceed to the egg-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Egg-specific Food Questions If response is yes, maybe, ate, or likely ate to egg-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ______ ☐ Unknown Purchase date: ____/_____/_____ ☐ Unknown Type, variety: ____________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Was it Kosher? ☐ Yes ☐ No ☐ Unknown How was it prepared? ☐ Raw ☐ Undercooked/runny yoke ☐ Fully cooked If eggs came from chickens you (the patient) owns, how long have you (the patient) owned these chickens? _______________________________________ ☐ Unknown Do you have any leftovers available? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchase from (names, locations): _______________________________________ ☐ Unknown Purchase date: ____/_____/______ ☐ Unknown Describe dish eaten: _______________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Store-bought eggs Farm-fresh eggs Eggs from backyard flock Quiche Hard boiled eggs Egg sandwiches Egg salad Deviled eggs Egg alternatives liquid eggs Vegan egg substitutes Custard Challah Kugel Other egg types Other egg containing dishes Foods made with raw eggs that were not fully cooked (cookie dough, cake batter, sauces, homemade ice cream, homemade mayo, homemade salad dressing)
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 9: Dairy: Now I have a few questions about dairy products you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any dairy? If yes, maybe, ate, or likely ate, please proceed to the dairy-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Dairy-specific Food Questions If response is yes, maybe, ate, or likely ate to dairy-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ____________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Type: ___________________________________ ☐ Unknown Variety or flavor: __________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Was it: ☐ Raw/unpasteurized ☐ Pasteurized ☐ Unknown Was it Kosher? ☐ Yes ☐ No ☐ Unknown Do you have any leftovers? ☐ Yes ☐ No ☐ Unknown If used as ingredient in dish, describe dish: _______________________________________ ☐ Unknown Do you have any leftovers available? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchase from (names, locations): _____________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Cow milk Whole milk 1% milk 2% milk Skim milk Chocolate milk Lactose-free milk Goat milk Sheep milk Buffalo milk Camel milk Other milk types Yogurt Yogurt drinks Kefir Ayran Than Doogh Almond milk Oat milk Hemp milk Coconut milk Cashew milk Rice milk Soy milk Cream cheese Sour cream Butter Margarine Heavy cream Half and half Coffee creamer Ghee Condensed milk Evaporated milk Buttermilk Cottage cheese Kugel Custard Gelato Ice cream Other dairy products
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 10: Cheese: Now I have a few questions about cheese you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any cheese? If yes, maybe, ate, or likely ate, please proceed to the cheese-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Cheese-specific Food Questions If response is yes, maybe, ate, or likely ate to cheese-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ____________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Type, variety: ____________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Was the cheese raw/unpasteurized? ☐ Yes ☐ No ☐ Unknown What type of milk was used in the cheese? ☐ Cow milk ☐ Goat milk ☐ Sheep milk ☐ Other, specify ____________ ☐ Unknown Was it purchased from a deli? ☐ Yes ☐ No ☐ Unknown How was it packaged? ______________________ ☐ Unknown Was the cheese imported from another country? ☐ Yes ☐ No ☐ Unknown If yes, name of cheese: _____________________ ☐ Unknown If yes, country: ____________________________ ☐ Unknown How often do you usually eat soft cheese, not including cream cheese? ☐ Never ☐ Once a month or less ☐ A few times a month ☐ A few times a week ☐ Most days ☐ Unknown When shopping at a store, did you taste/eat any cheese samples at a cheese or deli counter? ☐ Yes ☐ No ☐ Unknown If yes, please describe: ______________________________ Do you have any leftovers? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchase from (names, locations): _____________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Brie Camembert Bleu cheese Goat cheese Feta Mozzarella Cheddar Gouda Havarti Jack Monterey Jack Swiss Colby Cream cheese Nobulsi/naboulsi St. Nectaire Fontaina Jarlsberg L’Amulette Danish Estron Morbier Rippoz Fromage des Burons Tourree de l’Aubier Anari Edam Bonbel Torte Loaf cheese Limburger Old Heidelberg Gruyere Asiago Parmesan Teleme Saint Marcellin Saint Andre Schloss Robiola Lombardia Pon-l’Eveque Paglietta Maroilles Manouri Mainz Livarot Leiderkranz Kochkase Humboldt fog Harz Hand Explorateur Excelsior Epoisses Crascenza Crema Danica Coulommiers Chaource Carre de l’est Brinza Brillat Savarin Boursault Druzhba (Friendship) Kreiiviias Volna Emmentaler Haloumi Kashkaval Suluguni Madrigal Brynza Farmer’s cheese Queso Para Freir Adobera Añejo Chihuahua/menonita Cuajada Requeson Crema Manchego Panela Oaxaca Asadero Ranchero Cotija Queso Casero Queso blanco Queso fresco Ricotta Burrata Gorgonzola Stilton Clarines Reblochon Edel de Cleron Other prepackaged, shredded, sliced, block, gourmet, or artisanal cheese Cheese from cheese platter/plate Dairy alternative cheese/Vegan cheese
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 11: Leafy Greens: Now I have some questions about leafy greens you (the patient) might have eaten in the X 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 leafy greens grown at home.

Main Question: Did you (the patient) eat any leafy greens? If yes, maybe, ate, or likely ate, please proceed to the leafy green-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Leafy green-specific Food Questions If response is yes, maybe, ate, or likely ate to leafy green-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ___________________________________ ☐ Unknown Was it purchased: ☐ Prepackaged ☐ Whole head/whole hearts ☐ Bundled/loose ☐ Unknown If prepackaged, was it in a: ☐ Bag ☐ Clamshell ☐ Other, specify_________________ ☐ Unknown Type/variety: ­_____________________________ ☐ Unknown If Spinach: ☐ Baby ☐ Long leaf ☐ Mixed ☐ Unknown If Cabbage: ☐ Red ☐ Purple ☐ Green ☐ Other, specify ___________ ☐ Unknown If spring/lettuce mix, what types of lettuce were included? (Describe if name unknown) _________________________ If prepackaged salad, serving size: ☐ Single ☐ Multiple ☐ Unknown If prepackaged salad, what ingredients were included? ___________________________________________________ Brand: ___________________________________ ☐ Unknown Was it organic? ☐ Yes ☐ No ☐ Unknown Purchase date: ____/_____/______ ☐ Unknown Date eaten: ____/_____/______ ☐ Unknown Do you have the receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Any leftover product or packaging? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Romaine Iceberg Green leaf Red leaf Spinach Green cabbage Red cabbage Cole slaw Coleslaw blend (green cabbage, red cabbage, carrots) Garden salad blend (iceberg, carrots, red cabbage) Prepackaged salad kits Kale Arugula Spring Mix/Mesclun Power greens or Super greens Chard Mizuna Radicchio Mustard or collard greens Tatsoi Endive Butter lettuce Lettuce blend Swiss chard Mustard greens Dandelion greens Watercress Napa cabbage Brussel sprouts Bok choy Collard greens Rapini/broccoli raab Turnip greens Salad from a salad bar Salads at a salad bar from a restaurant, grocery store, or institution Salads from a vending machine Leafy greens included on a sandwich, burger, or wrap Other leafy green types
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 12: Herbs: Now I have some questions about herbs you (the patient) might have eaten in the X 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 herbs grown at home.

Main Question: Did you (the patient) eat any herbs? If yes, maybe, ate, or likely ate, please proceed to the herb-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Herb-specific Food Questions If response is yes, maybe, ate, or likely ate to herb-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): _______________________________________ ☐ Unknown Were they purchased ☐ Fresh ☐ Dried ☐ Unknown Packaging? ☐ Loose ☐ Prepackaged ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Brand: __________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Do you still have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Any leftover product or packaging? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Sweet Basil Thai Basil Cilantro Terragon Fennel Curly Parsley Italian Parsley Chives Dill Sage Thyme Sorrel Marjoram Chervil Mint Rosemary Oregano Bay leaf Lemongrass Other fresh herbs Herbs used as garnish
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 13: Sprouts: Now I have some questions about sprouts you (the patient) might have eaten in the X 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 sprouts grown at home.

Main Question: Did you (the patient) eat any sprouts? If yes, maybe, ate, or likely ate, please proceed to the sprout-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Sprout-specific Food Questions If response is yes, maybe, ate, or likely ate to sprout-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): _______________________________________ ☐ Unknown Type, variety: ___________________________ ☐ Unknown Brand: _________________________________ ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Packaging? ☐ Loose ☐ Prepackaged ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Consumption date: ____/____/______ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Any leftover product or packaging? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Alfalfa sprouts Brussel sprouts Broccoli sprouts Mung bean sprouts Soybean sprouts Clover sprouts Lentil sprouts Daikon radish Microgreens Buckwheat sprouts Pea shoots Garden Cress Radish sprouts Buckwheat Red clover Wheatgrass Sunflower sprouts Mustard sprouts Other sprouts Other microgreens
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 14: Tomatoes: Now I have some questions about tomatoes you (the patient) might have eaten in the X 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 tomatoes grown at home.

Main Question: Did you (the patient) eat any tomatoes? If yes, maybe, ate, or likely ate, please proceed to the tomato-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Tomato-specific Food Questions If response is yes, maybe, ate, or likely ate to tomato-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If tomatoes: If prepared at home Place purchased from (names, locations): _________________________________________ ☐ Unknown Brand: ___________________________________ ☐ Unknown Purchase date: ___/____/____ ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Were they on the vine? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Any leftover product or packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Dish eaten: ______________________________ ☐ Unknown Type of tomato: __________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown If Salsa or Pico de Gallo: If prepared at home: List ingredients included: _____________________________________ ☐ Unknown Place purchased from (names, locations): _____________________________________ ☐ Unknown Purchase date: ____/_____/_____ ☐ Unknown Consumption date: ____/____/_____ ☐ Unknown What did you eat with your salsa? _____________________________________ ☐ Unknown Brands of ingredients : ___________________ ☐ Unknown Flavor (traditional, medium, etc.): _____________ ☐ Unknown Best buy date: ____/____/______ ☐ Unknown Lot number: ______________________ ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Red round tomatoes Roma tomatoes Heirloom tomatoes Beefsteak tomatoes Green beefsteak tomatoes Cherry/grape tomatoes Campari tomatoes Cocktail tomatoes San Marzano tomatoes Tomatoes on the vine Brandywine tomatoes Plum tomatoes Other types of tomatoes Salsa Pico de gallo Homemade tomato-based sauces Tomatoes in a salad, sandwich, burger, wrap, or another dish Other tomato types Other salsa types
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 15: Avocados: Now I have some questions about avocados you (the patient) might have eaten in the X 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 avocados grown at home.

Main Question: Did you (the patient) eat any avocados? If yes, maybe, ate, or likely ate, please proceed to the avocado-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Avocado-specific Food Questions If response is yes, maybe, ate, or likely ate to avocado-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If Avocado: If prepared at home: Type: ___________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Consumption date: ____/_____/______ ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Any leftover product or packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown If Guacamole: If prepared at home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ___/____/_____ ☐ Unknown Consumption date: ____/_____/_____ ☐ Unknown What did you eat with your guacamole? ________________________________________ ☐ Unknown Brands of ingredients: ______________________ ☐ Unknown Flavor (traditional, medium, etc.): ____________ ☐ Unknown Best buy date: ___/____/_____ ☐ Unknown Lot numbers of ingredients: __________________ ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Avocado Guacamole
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 16: Potatoes: Now I have some questions about potatoes you (the patient) might have eaten in the X 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 potatoes grown at home.

Main Question: Did you (the patient) eat any potatoes? If yes, maybe, ate, or likely ate, please proceed to the potato-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Potato-specific Food Questions If response is yes, maybe, ate, or likely ate to potato-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type: ☐ Russet ☐ Red ☐ White ☐ Yellow ☐ Yukon Gold ☐ Purple ☐ Fingerling ☐ Sweet potatoes/yams ☐ Other, specify ______________________ ☐ Unknown Brand: ______________________________ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown How were the potatoes prepared at home? _______________________________________ ☐ Unknown Were the potatoes ever consumed raw? ☐ Yes ☐ No ☐ Unknown How were the potatoes stored at home? _______________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Potatoes Mashed potatoes Hash browns Roasted potatoes Scalloped potatoes Potato gnocchi Other premade refrigerated products containing potatoes Dehydrated potatoes or potato flakes Potato starch Potato flour Other potato products
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 17: Onions: Now I have some questions about onions you (the patient) might have eaten in the X 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 onions grown at home.

Main Question: Did you (the patient) eat any onions? If yes, maybe, ate, or likely ate, please proceed to the onion-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Onion-specific Food Questions If response is yes, maybe, ate, or likely ate to onion-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: What color were the onions? ☐ White ☐ Red/Purple ☐ Yellow ☐ Other, specify __________________________ ☐ Unknown Do you usually eat them: ☐ Raw ☐ Cooked ☐ Both Do you usually purchase them: ☐ Fresh ☐ Frozen Place purchased from (names, locations): _______________________________________ ☐ Unknown Brand: _________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Onions in a salad Onions in salsa or pico de gallo Onions on a sandwich or burger White onion Red onion Yellow onion Sweet/Vidalia onions Shallots Green Onions Other Onions
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 18: Mushrooms: Now I have some questions about mushrooms you (the patient) might have eaten in the X 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 mushrooms grown at home.

Main Question: Did you (the patient) eat any mushrooms? If yes, maybe, ate, or likely ate, please proceed to the mushroom-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Mushroom-specific Food Questions If response is yes, maybe, ate, or likely ate to mushroom-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home How were the mushrooms purchased? ☐ Fresh ☐ Frozen How were the mushrooms packaged? ☐ Loose ☐ Packaged Whole ☐ Packaged pre-sliced ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Purchase date: ___/____/_____ ☐ Unknown Brand: __________________________________ ☐ Unknown Do you have product leftover for testing? ☐ Yes ☐ No ☐ Unknown If yes, could we take this food for testing and/or packaging for product information? ☐ Yes ☐ Maybe ☐ No Date eaten: ___/____/_____ ☐ Unknown How were the mushrooms prepared? ☐ Eaten raw (alone or in salad) ☐ Cooked, steamed, sauteed ☐ Cooked into a dish or soup ☐ Other, specify: _____________________ ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Button/white Portobello Shiitake Enoki Wood ear (Kikurage) Cremini/brown Porcini Maitake Oyster King Oyster Bunashimeji-Beech Matsutake/pine Chanterelle Hedgehog Lobster Morel Other mushrooms
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 19: Other Vegetables: Now I have some questions about other vegetables you (the patient) might have eaten in the X 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 other vegetables grown at home.

Main Question: Did you (the patient) eat any other vegetables? If yes, maybe, ate, or likely ate, please proceed to the vegetable-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Other vegetable-specific Food Questions If response is yes, maybe, ate, or likely ate to other vegetable-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Were they organic? ☐ Yes ☐ No ☐ Unknown Packaging? ☐ Loose ☐ Bagged ☐ Clamshell ☐ Crate ☐ Unknown Size of container (1lb, 2lb, snack cup, etc): _______________ ☐ Unknown Brand: ___________________________________ ☐ Unknown Type, variety: _____________________________ ☐ Unknown Place purchased from (names, locations): _________________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Any leftover product or packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Cucumbers Pickles Pickled vegetables Celery Squash/summer squash Zucchini Sweet or bell peppers Hot peppers Snack peppers Carrots Snap peas/pea pods Peas Green beans Broccoli Cauliflower Green onions/scallions Fermented vegetables (kimchi, sauerkraut) Prepackaged vegetable mix Artichoke Radish Beet Turnip Other vegetables
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 20: Stone Fruits: Now I have some questions about stone fruits, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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 stone fruits grown at home.

Main Question: Did you (the patient) eat any stone fruits? If yes, maybe, ate, or likely ate, please proceed to the stone fruit-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Stone Fruit-specific Food Questions If response is yes, maybe, ate, or likely ate to the stone fruit-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Type: ___________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Packaging? ☐ Loose ☐ Bagged ☐ Clamshell ☐ Crate ☐ Unknown Size of container (1lb, 2lb, snack cup, etc): _______________ ☐ Unknown Was it purchased as: ☐ Whole ☐ Cut ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Peaches Nectarines Apricots Persimmons Pluots Plums Plumcots Cherries Mangoes Coconuts Lychees Olives Prepackaged fruit cups Other stone fruits
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 21: Citrus Fruits: Now I have some questions about citrus fruits, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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 citrus fruits grown at home.

Main Question: Did you (the patient) eat any citrus fruits? If yes, maybe, ate, or likely ate, please proceed to the citrus fruit-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Citrus Fruit-specific Food Questions If response is yes, maybe, ate, or likely ate to citrus fruit-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Type, variety: ____________________________ ☐ Unknown If orange: ☐ Navel ☐ Blood ☐ Tangerine ☐ Clementine ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Packaging? ☐ Loose ☐ Bagged ☐ Clamshell ☐ Crate ☐ Unknown Size of container (1lb, 2lb, snack cup, etc.): ______ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Was it purchased as: ☐ Whole ☐ Cut ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Orange Lemon Lime Grapefruit Kumquat Prepackaged fruit cups Other citrus fruits
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 22: Berries: Now I have some questions about berries, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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 berries grown at home.

Main Question: Did you (the patient) eat any berries? If yes, maybe, ate, or likely ate, please proceed to the berry-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Berry-specific Questions If response is yes, maybe, ate, or likely ate to berry-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Brand: ___________________________________ ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Packaging? ☐ Loose ☐ Bagged ☐ Clamshell ☐ Crated ☐ Unknown Size of container (1lb, 2lb, snack cup, etc.): _______________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Was it purchased as: ☐ Whole ☐ Cut ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any left over? ☐ Yes ☐ No ☐ Unknown Do you still have any of the packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Strawberries Blackberries Raspberries Blueberries Cranberries Elderberries Goji berries Boysenberries Grapes Prepackaged fruit cups Other berries
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 23: Melons: Now I have some questions about melons, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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 melons grown at home.

Main Question: Did you (the patient) eat any melons? If yes, maybe, ate, or likely ate, please proceed to the melon-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Melon-specific Food Questions If response is yes, maybe, ate, or likely ate to melon-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Precut? ☐ Yes ☐ No ☐ Unknown Was it organic? ☐ Yes ☐ No ☐ Unknown Variety: ☐ Seeded ☐ Seedless ☐ Unknown Type, brand: ______________________________ ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Is there any leftover in the house, including in the freezer? ☐ Yes ☐ No ☐ Unknown Did you use this melon to make juice (using a type of juicer)? ☐ Yes ☐ No ☐ Unknown If yes, did you place the fruit in the juicer with the rind attached? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any left over? ☐ Yes ☐ No ☐ Unknown Do you still have any of the packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Cantaloupe Watermelon Honeydew Winter melon Sprite melon Rock melon Musk melon Korean melon Bitter melon Athena melon Precut melon Prepackaged fruit cups Other melons
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 24: Tropical Fruits: Now I have some questions about tropical fruits, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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 tropical fruits grown at home.

Main Question: Did you (the patient) eat any tropical fruits? If yes, maybe, ate, or likely ate, please proceed to the tropical fruit-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Tropical Fruit-specific Food Questions If response is yes, maybe, ate, or likely ate to tropical fruit-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Type: ___________________________________ ☐ Unknown Variety: _________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Precut? ☐ Yes ☐ No ☐ Unknown Was it organic? ☐ Yes ☐ No ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Is there any leftover in the house, including in the freezer? ☐ Yes ☐ No ☐ Unknown Did you use this product to make juice (using a type of juicer)? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any left over? ☐ Yes ☐ No ☐ Unknown Do you still have any of the packaging? ☐ Yes ☐ No ☐ Unknown If eaten outside the home Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Pineapple Banana Kiwi Guava Pomegranate Dragon Fruit Papaya Jujube Mangosteen Prepackaged fruit cups Other tropical fruits
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 25: Juices, Ciders, or Smoothies: Now I have some questions about juices, ciders, or smoothies, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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.

Main Question: Did you (the patient) eat any juices, ciders, or smoothies? If yes, maybe, ate, or likely ate, please proceed to the juices, ciders, and smoothies-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Juices, Ciders, and Smoothies-specific Food Questions If response is yes, maybe, ate, or likely ate to juice, cider, or smoothie-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Raw or unpasteurized? ☐ Yes ☐ No ☐ Unknown Type: ___________________________________ ☐ Unknown Variety: _________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Ingredients in juice or smoothie: ______________ ☐ Unknown Was it organic? ☐ Yes ☐ No ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Is there any leftover in the house, including in the freezer? ☐ Yes ☐ No ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any left over? ☐ Yes ☐ No ☐ Unknown Do you still have any of the packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Juice Cider Smoothies
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 26: Pome Fruits: Now I have some questions about pome fruits, not canned, cooked, or frozen, that you (the patient) might have eaten in the X days before your (the patient’s) illness began. I will ask you (the patient) 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 pome fruits grown at home.

Main Question: Did you (the patient) eat any pome fruits? If yes, maybe, ate, or likely ate, please proceed to the pome fruit-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If Apple/Caramel Apple: If prepared at home: How often? ☐ ~1-2x/month ☐ ~1x/week ☐ ~2-4x/week ☐ ~5-7x/week ☐ Unknown Place purchased from (names, locations): _________________________________________ ☐ Unknown Purchase date: ___/____/____ ☐ Unknown Type, variety, brand: _______________________ ☐ Unknown Were the apples eaten: ☐ Alone ☐ Part of a dish If part of a dish, describe dish: _______________________________ Were apples sold: ☐ Loose ☐ In a package/bag ☐ Unknown If packaged, was it: ☐ Plastic bag ☐ Plastic container ☐ Paper bag ☐ Other, specify _____________________ ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown If Caramel Apple: Any toppings? ☐ Nuts ☐ Chocolate ☐ Other, specify ____________ ☐ Unknown Place purchased from (names, locations): _____________________________________ ☐ Unknown What day would you have eaten any caramel apple? ___/___/____ ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown If yes, could we take this food for testing and/or packaging for product information? ☐ Yes ☐ Maybe ☐ No If Pears: If prepared at home: Were they organic? ☐ Yes ☐ No ☐ Unknown Type: ___________________________________ ☐ Unknown If type unknown was the pear: ☐Round or flat fruit with green to yellow skin ☐Round or flat fruit with bronze colored skin and a light brown russet ☐Pear shaped fruit with green or russet skin Packaging? ☐ Loose ☐ Bagged ☐ Clamshell ☐ Crated ☐ Unknown Were the pear(s) consumed: ☐Cooked ☐Fresh ☐Whole ☐Cut or sliced ☐Other specify:____________ ☐ Unknown Size of container (1lb, 2lb, snack cup, etc.): ___________ ☐ Unknown Brand: __________________________________ ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Was it purchased as: ☐ Whole ☐ Cut ☐ Unknown Do you have a receipt or proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any left over? ☐ Yes ☐ No ☐ Unknown Do you still have any of the packaging? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Red delicious apples Golden delicious apples Granny smith apples Honeycrisp apples Gala apples Fuji apples Pink lady apples McIntosh apples Other apples Anjou pears Bartlett pears Bosc pears Fragrant pears Hosui pears Nijusseki pears Shinseiki pears Ya Li pears Other pears Caramel Apples Prepackaged fruit cups
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 27: Frozen Vegetables: Now I have a few questions about frozen vegetables you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any frozen vegetables? If yes, maybe, ate, or likely ate, please proceed to the frozen vegetable-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Frozen Vegetable-specific Food Questions If response is yes, maybe, ate, or likely ate to frozen vegetable-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	Place purchased from (names, locations): _______________________________________ ☐ Unknown Type, variety: : __________________________ ☐ Unknown Brand: _________________________________ ☐ Unknown If medley/blend, specify vegetables included: _______________________________________ ☐ Unknown If medley/blend, name of the medley/blend: _______________________________________ ☐ Unknown Purchase date: ____/_____/______ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Broccoli Cauliflower Green beans Peas Carrots Corn Asparagus Spinach Edamame Potatoes Sweet Potatoes Brussel Sprouts Vegetable Medley/blend Other frozen vegetables
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 28: Frozen Fruits: Now I have a few questions about frozen fruits you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any frozen fruits? If yes, maybe, ate, or likely ate, please proceed to the frozen fruit-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Frozen Fruit-specific Food Questions If response is yes, maybe, ate, or likely ate to frozen fruit-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Type, variety: ____________________________ ☐ Unknown Brand: _________________________________ ☐ Unknown Were they organic? ☐ Yes ☐ No ☐ Unknown Size of container (1lb, 2lb, etc): _____________ ☐ Unknown Was it purchased as: ☐ Whole ☐ Cut/sliced ☐ Cubed ☐ Medley/blend, specify: ___________________ ☐ Other, specify: _____________________ ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown Any receipts or proof of purchase? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Strawberry Blueberry Blackberry Raspberry Mixed berries Peaches Mango Cherries Pineapple Banana Dragon fruit Avocado Acai Fruit medley/blend Smoothie mixes
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 29: Frozen Breakfast Items: Now I have a few questions about frozen breakfast items you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any frozen breakfast items? If yes, maybe, ate, or likely ate, please proceed to the frozen breakfast-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Frozen Breakfast-specific Food Questions If response is yes, maybe, ate, or likely ate to frozen breakfast-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	Place purchased from (names, locations): _______________________________________ ☐ Unknown Type: __________________________________ ☐ Unknown Do you usually like any of the following flavors? ☐ Blueberry ☐ Strawberry ☐ Chocolate Chip ☐ Other, specify __________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Purchase date: ___/____/_____ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown If burrito, bowl, or wrap, list ingredients included in item: _______________________________________ ☐ Unknown
Yes		Maybe		No		Don’t Know	Pancakes Waffles Breakfast sandwiches Breakfast burritos Breakfast bowls French toast French toast sticks Breakfast wraps Sausage Bacon
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 30: Frozen Entrees: Now I have a few questions about frozen entrees items you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any frozen entrees? If yes, maybe, ate, or likely ate, please proceed to the frozen entree-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Frozen Entrée-specific Food Questions If response is yes, maybe, ate, or likely ate to frozen entrée-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	Type, variety, brand: _______________________ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Purchase date: ____/_____/______ ☐ Unknown Any receipts of other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown If boxed/bagged entrée: Type, variety, brand: _______________________ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Specify ingredients: ________________________ ☐ Unknown Any receipts of other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown If frozen pastas: Type, variety, brand: _______________________ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Type: ☐ Gnocchi ☐ Ravioli ☐ Stuffed shells ☐ Other, specify ________________________________ ☐ Unknown Any receipts of other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Stir fry Pasta Lasagna Box/bagged entrees (Hungry Man, Healthy Choice, Stouffer’s, etc) Pot pies Pizza Fish sticks Fish nuggets Chicken nuggets Dumplings or pierogies Vegetarian/Veggie burgers Hot pockets Other frozen entrees or meals
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 31: Frozen Appetizers/Snacks: Now I have a few questions about frozen appetizers/snacks you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any frozen appetizers/snacks? If yes, maybe, ate, or likely ate, please proceed to the frozen appetizer/snack-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Frozen Appetizer/Snack-specific Food Questions If response is yes, maybe, ate, or likely ate to frozen appetizer/snack-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	Brand: ___________________________________ ☐ Unknown Place purchased from (names, locations): ______________________________________ ☐ Unknown How were the frozen foods prepared? ­_______________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Mozzarella sticks Jalapeno poppers Burritos Egg rolls Spring rolls Onion rings Mini burgers Hot pockets Pizza rolls Pizza bagels Burger sliders Taquitos Mini tacos Quesadillas Corn dogs French fries Crinkle fries Curly fries Waffle fries Potato wedges Tater tots/crowns Hashbrown patties Shredded hashbrowns Diced/cubed hashbrowns Croquettes Mashed potatoes Hashbrown O’brien
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 32: Ice Cream and Frozen Yogurt: Now I have a few questions about ice cream and frozen yogurt you (the patient) might have eaten in the X 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 or from a restaurant or specialty ice cream shop.

Main Question: Did you (the patient) eat any ice cream/frozen yogurt? If yes, maybe, ate, or likely ate, please proceed to the ice cream/frozen yogurt-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Ice Cream/Frozen Yogurt-specific Food Questions If response is yes, maybe, ate, or likely ate to ice cream/frozen yogurt-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Brand: ___________________________________ ☐ Unknown Flavor: _________________________________ ☐ Unknown Size/type of container: ☐ Tub ☐ Carton ☐ Box ☐ Pint ☐ Other, specify: _____________________ ☐ Unknown Was it soft serve? ☐ Yes ☐ No ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have any product or packaging leftover for testing? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ________________________________________ ☐ Unknown Describe the type of dish: ___________________ ☐ Unknown Flavor: __________________________________ ☐ Unknown Any add-ins/mix-ins? ______________________ ☐ Unknown Was it soft-serve? ☐ Yes ☐ No ☐ Unknown Name of menu item containing item: __________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Ice cream Ice cream bars Soft serve Ice cream sandwiches Ice cream cones Novelty ice cream Ice cream pints Frozen yogurt Frozen yogurt bars Non-dairy ice cream Custard Gelato
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 33: Peanut Butter and Nut butters: Now I have some questions about peanut butter and other nut butters you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any peanut butter or other nut butters? If yes, maybe, ate, or likely ate, please proceed to the peanut butter/nut butter-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Peanut Butter/Nut Butter-specific Food Questions If response is yes, maybe, ate, or likely ate to peanut butter/nut butter-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Brand: __________________________________ ☐ Unknown Type: ☐ Natural ☐ Creamy ☐ Chunky ☐ Low fat ☐ Low sodium ☐ Other, specify: _________________ ☐ Unknown What size jar? ☐ 16 oz ☐ 28 oz ☐ 40 oz ☐ Other, specify ____________________ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Any receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If left over product is available, would you be able to send us pictures of the product/tell us the lot code? ☐ Yes ☐ No If yes, Lot code: __________________________ ☐ Unknown Would you be willing to have the product tested? ☐ Yes ☐ No If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Peanut butter (PB) PB cookies PB crackers Candy containing PB PB flavored ice cream or frozen yogurt Prepackaged premade PB sandwiches PB pies PB cream puffs PB cheesecakes or other deserts PB nutrition bars PB granola bars PB protein bars Other PB containing foods Almond butter Cashew butter Hazelnut spread Nutella Sunflower butter Cookie butter/speculoos Other nut butters
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 34: Dried Fruits, Nuts, and Seeds: Now I have some questions about dried fruits, nuts, and seeds you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any dried fruits, nuts, seeds? If yes, maybe, ate, or likely ate, please proceed to the dried fruit, nut, seed-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Dried Fruit, Nuts, Seeds-specific Food Questions If response is yes, maybe, ate, or likely ate to dried fruit, nuts, or seed-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	Place purchased from (names, locations): _______________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Type, variety, brand: ______________________ ☐ Unknown Were they eaten: ☐ Alone ☐ Part of a Dish If part of a dish, what dish did you eat that contained this item? ­­­ __________________________________________________ If packaged, were they packaged in a ☐ Plastic container ☐ Jar ☐ Plastic bag ☐ Other, specify ________ ☐ Unknown If nuts: Place purchased from (names, locations): _______________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Type, variety, brand: ______________________ ☐ Unknown Were they eaten: ☐ Alone ☐ Part of a Dish If part of a dish, what dish did you eat that contained this item? ­­­ __________________________________________________ Were they eaten: ☐ Crushed ☐ Whole ☐ Chopped Were they: ☐ Shelled ☐ Unshelled ☐ Pieces If seeds/powder: Place purchased from (names, locations): _______________________________________ ☐ Unknown Type, variety, brand: ______________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Were they eaten: ☐ Alone ☐ Part of a Dish What kind of packaging were they in? ☐ Bulk/self-bagged ☐ Bottled/jarred ☐ Bagged ☐ Unknown Describe packaging: _____________________________________ ☐ Unknown If chia seeds Place purchased from (names, locations): _______________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Type, variety, brand: ______________________ ☐ Unknown Were they eaten: ☐ Alone ☐ Part of a Dish If part of a dish, what dish did you eat that contained this item? ­­­ Type: ☐ Black ☐ White ☐ Brown ☐ Other, specify ________ ☐ Unknown If eaten outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Peanuts Almonds Cashews Walnuts Pecans Pistachios Hazelnuts Filberts Pine nuts (including pesto) Brazil nuts Macadamia nuts Chestnuts Other nuts Trail mix Dried Mango Dried Peaches Dried Bananas Dried Apricots Prunes Raisins Dates Dried cranberries/crasins Sun dried tomatoes Fruit leather Other dried fruits Chia seeds Chia seed powder Flaxseed Flaxseed powder Sesame seeds Other seeds
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 35: Dips and Spreads: Now I have some questions about dips and spreads you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any dips or spreads? If yes, maybe, ate, or likely ate, please proceed to the dip and spread-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Dip and Spread-specific Food Questions If response is yes, maybe, ate, or likely ate to dip and spread-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Place purchased from (names, locations): _______________________________________ ☐ Unknown Purchase date: ____/_____/______ ☐ Unknown Consumption date: ____/____/______ ☐ Unknown What did you eat with your [insert dip/spread]? _______________________________________ ☐ Unknown Brand: _________________________________ ☐ Unknown Flavor, variety: __________________________ ☐ Unknown Best buy date: ____/____/_____ ☐ Unknown Lot number: ____________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Hummus Baba ghanoush Tzatziki Greek yogurt dip Moroccan Matbucha Caponata Spinach and artichoke dip Buffalo chicken dip Bean dips Spanish eggplant salad Muhammara Other dips or spreads
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 36: Flour and Dough: Now I have some questions about flour and dough you (the patient) might have eaten or come into contact with in the X 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.

Main Question: Did you (the patient) eat any flour or dough? If yes, maybe, ate, or likely ate, please proceed to the flour and dough-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Flour and Dough-specific Food Questions If response is yes, maybe, ate, or likely ate to flour and dough-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	☐ From scratch? Type, variety: _____________________ ☐ Unknown Brand: __________________________ ☐ Unknown ☐ Premade dough? Type, variety: _____________________ ☐ Unknown Brand: ___________________________ ☐ Unknown ☐ Prepackaged dry mix (cake mix, pancake mix, etc.) Type, variety: _____________________ ☐ Unknown Brand: ___________________________ ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Purchase date: ____/____/______ ☐ Unknown Best by date: ____/____/_____ ☐ Unknown Lot number: _____________________________ ☐ Unknown Do you still have the flour you used? ☐ Yes ☐ No ☐ Unknown If yes: May we collect the flour for testing? ☐ Yes ☐ No ☐ Unknown Can you take a picture of the front of the bag and another of the best buy date? ☐ Yes ☐ No If baking food with flour: What did you bake/cook? ___________________ ☐ Unknown Brand of flour: ____________________________ ☐ Unknown Type of flour: ☐ Bleached, all-purpose ☐ Unbleached, all purpose ☐ Organic, all purpose ☐ Other, specify _______________ ☐ Unknown Brand of baking soda: ______________________ ☐ Unknown What other ingredients did you use, such as nuts, sugar, butter, extracts, baking chips, etc? ________________________________________________ Place purchased from (names, locations): ________________________________________ ☐ Unknown Purchase date: ____/_____/______ ☐ Unknown Best by date: ____/____/______ ☐ Unknown Lot number: _____________________________ ☐ Unknown Do you still have the flour you used? ☐ Yes ☐ No ☐ Unknown If yes: May we collect the flour for testing? ☐ Yes ☐ No ☐ Unknown Can you take a picture of the front of the bag and another of the best buy date? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Flour Cornstarch Almond flour Potato flour Pizza flour Whole wheat flour Semolina flour Gluten free flour Cookie dough Bread dough Pasta dough Pizza dough Other uncooked dough Cake batter/mix Brownie batter/mix Biscuit batter/mix Muffin batter/mix Pancake batter/mix Waffle batter/mix Other batter/mix Bake or make food containing flour Dough you play with Other dough types or products
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 37: Cereals and Granola: Now I have some questions about cereal and granola you (the patient) might have eaten in the X 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.

Main Question: Did you (the patient) eat any cereals or granola? If yes, maybe, ate, or likely ate, please proceed to the cereal and granola-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Cereal and Granola-specific Food Questions If response is yes, maybe, ate, or likely ate to cereal and granola-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type: ___________________________________ ☐ Unknown Variety: _________________________________ ☐ Unknown Brand: __________________________________ ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Boxed breakfast cereals Oatmeal Cream of wheat Overnight oats Rolled oats Grits Granola Granola bars Other cereals and granola
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 38: Snacks: Now I have some questions about snacks you (the patient) might have eaten in the X 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, vending machine, or at a catered event.

Main Question: Did you (the patient) eat any snacks? If yes, maybe, ate, or likely ate, please proceed to the snack-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Snack-specific Food Questions If response is yes, maybe, ate, or likely ate to snack-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type: ___________________________________ ☐ Unknown Variety: __________________________________ ☐ Unknown Brand: ___________________________________ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Potato chips Corn puffs Crackers Pretzels Stuffed pretzels Seaweed snacks Cookies Snack cakes Chocolate Chocolate chips/chunks Caramel
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 39: Nutritional Powders and Supplements: Now I have some questions about nutritional powders and supplements you (the patient) might have eaten in the X days before your (the patient’s) illness began. This could include things like vitamins, protein powders, and probiotics.

Main Question: Did you (the patient) eat any nutritional powders or supplements? If yes, maybe, ate, or likely ate, please proceed to the nutritional powder and supplement-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Nutritional Powder and Supplement-specific Food Questions If response is yes, maybe, ate, or likely ate to nutritional powder and supplement-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type: ___________________________________ ☐ Unknown Variety: __________________________________ ☐ Unknown Brand: ___________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Place purchased from (names, locations): _______________________________________ ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Protein powder Milk powder Whey Protein shakes Probiotics Prebiotics Vitamin boosters Multivitamins Kratom Nutrition powder Meal replacement powder Greens/superfood smoothie powder Other nutritional powders and supplements
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 40: Deli Salads: Now I have some questions about deli salads you (the patient) might have eaten in the X days before your (the patient’s) illness began. You (the patient) may have eaten these items from a grocery store (purchased at the deli section) or from a restaurant.

Main Question: Did you (the patient) eat any deli salads? If yes, maybe, ate, or likely ate, please proceed to the deli salad-specific food items. If no, likely did not eat, did not eat, or don’t know, skip to next section.
Response Options							Specific Foods	Deli Salad-specific Food Questions If response is yes, maybe, ate, or likely ate to deli salad-specific food items, the following will be asked:
Salm/STEC Responses In the 7 days before the illness began							Did you (the patient) eat:	If prepared at home: Type: ___________________________________ ☐ Unknown Variety: __________________________________ ☐ Unknown Brand: ___________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Ingredients: ______________________________ ☐ Unknown Place purchased from (names, locations): ________________________________________ ☐ Unknown Was this purchased from the deli section of a grocery store? ☐ Yes ☐ No ☐ Unknown Any receipts or other proof of purchase? ☐ Yes ☐ No ☐ Unknown If prepared outside the home: Place purchased from (names, locations): ______________________________________ ☐ Unknown Purchase date: ____/____/_____ ☐ Unknown Dish eaten: _______________________________ ☐ Unknown Ingredients included: _______________________ ☐ Unknown Meal date: ____/_____/_______ ☐ Unknown Do you have a receipt or other proof of purchase? ☐ Yes ☐ No ☐ Unknown Are others who ate the product also sick? ☐ Yes ☐ No ☐ Unknown Do you have leftovers? ☐ Yes ☐ No ☐ Unknown
Yes		Maybe		No		Don’t Know	Pasta salad Potato salad Chicken salad Tuna salad Coleslaw Seafood salad Bean salad Other deli salads
Listeria Responses In the 28 days before the illness began
Ate	Likely Ate		Likely Did Not Eat		Did Not Eat	Don’t Know

Section 41: Food Preparation Habits: Now I have a few questions about how you typically prepare and handle Meat (such as chicken, beef, and turkey).

Meat (such as chicken, beef, turkey)

1. Do you ever cook [insert meat item]? ¨ Yes ¨ Maybe ¨ No ¨ Unknown

2. How often do you eat [insert meat item]? ¨ >Once per week ¨ Once per month ¨ <Once per month ¨ Never ¨ Unknown

3. Do you wash or rinse your raw [insert meat item] before cooking it? ☐ Always ☐ Sometimes ☐ Never ☐ Don’t Know

☐ Water rinse ☐ Other _______

4. How do you store your raw [insert meat item] before cooking? ☐ Freeze in original packaging ☐ Freeze in zip lock bags or storage containers ☐ Refrigerate ☐ Other_________

5. How do you defrost your frozen raw [insert meat item]? ☐ In refrigerator ☐ On countertop ☐ In a sink with water ☐ In the microwave ☐ Don’t defrost it – cook from frozen ☐ Don’t freeze chicken- cook it fresh ☐ Other__________

6. What methods do you use to tell if your [insert meat item] is fully cooked? ☐ Taste ☐ Appearance ☐ Cooking time ☐ Smell ☐ Temperature measured by a Meat Thermometer ☐ Touch ☐ Other__________

7. How long do you wait to store leftover meals containing [insert meat item], after it has been cooked? ☐ Less than 2 hours ☐ 2 hours or more ☐ Don’t know

8. When cooking raw [insert meat item] do you read any cooking or safe handling instructions on the original packaging? ☐ Always ☐ Sometimes ☐ Never ☐ Prefer not to answer

☐ Cooking Instructions only ☐ Safe handling Instructions Only ☐ Both ☐ Other_______________

9. While preparing meals with raw [insert meat item] do you ever taste it before it is completely cooked (For example making sure the spice mix is right?) ☐ Always ☐ Sometimes ☐ Never ☐ Prefer not to answer

10. What do you use to cook raw [insert meat item] (Select all that apply)? ☐ Microwave ☐ Oven ☐ Toaster Oven ☐ Stove Top ☐ Other______

11. After handling [raw/cooked] [insert meat item], what do you usually do? ☐ Continue cooking ☐ Wipe hands ☐ Rinse hands with water ☐ Wash hands with soap and water ☐ Don’t know

12. How often do you use a separate cutting board for raw [insert meat item] and other foods during meal preparation? ☐ Always ☐ Sometimes ☐ Never ☐ Don’t Know

Section 42: Food Preparation Habits: Now I have a few questions about how you typically prepare and handle Vegetables (such as root/allium, leafy greens, cruciferous, stem, etc.)

Vegetables (such as root/allium, leafy greens, cruciferous, stem, etc.)

1. Do you wash or rinse your raw [insert vegetable item] before preparing them?
   ¨ Always ¨ Sometimes ¨ Never ¨ Don’t Know

¨ Water rinse ¨ Other _______

2. How do you typically eat [insert vegetable item]? ¨ Raw ¨ Cooked ¨ Both ¨ Other _________________________________

3. How do you store your [insert vegetable item] before cooking them or using in a dish?

¨ Chop and Freeze ¨ Chop and Refrigerate ¨ Refrigerate whole ¨ Store at room temperature ¨ Other_________________

4. After handling raw [insert vegetable item], what do you usually do?

¨ Continue cooking ¨ Wipe hands ¨ Rinse hands with water ¨ Wash hands with soap and water ¨ Don’t know

5. After preparing [insert vegetable item], what do you usually do?

¨ Wash the cutting board and knife before using them to prepare other vegetables ¨ Rinse the cutting board and knife before using them to prepare other vegetables ¨ Continue to use the cutting board and knife to prepare any other vegetables ¨ Use a different cutting board to prepare any other vegetables ¨ Don’t Know

Section 43: Food Preparation Habits: Now I have a few questions about how you typically prepare and handle Fruit (such as stone fruits, berries, melons, etc.)

Fruit (such as stone fruits, berries, melons, etc.)

1. When bringing home [insert fruit item] and before eating it, where was it stored?

☐ Kitchen counter ☐ Refrigerator ☐ Other, specify ________________ ☐ Unknown

2. How many days do you store your [insert fruit item] before first eating it?

☐ None, eat right away ☐ 1-2 days ☐ 3-4 days ☐ 5-6 days ☐ 7 days or more ☐ Unknown

3. If you purchase a [insert fruit item] as a whole or half, do you normally wash the outside before cutting into the fruit?

☐ Yes ☐ No (skip to question ­­5)

1. When washing [insert fruit item], would you say that you normally:

☐ Scrub the outside of the [insert fruit item] (with wash cloth, sponge, or hand) with water and soap?

How long do you wash the [insert fruit item] under water?

☐ less than 5 seconds

☐ 5-10 seconds

☐ more than 10 seconds

☐ Scrub the outside of the [insert fruit item] (with wash cloth, sponge, or hand) with water only?

How long do you wash the [insert fruit item] under water?

☐ less than 5 seconds

☐ 5-10 seconds

☐ more than 10 seconds

☐ Only rinse it under water (no scrubbing)

How long do you wash the [insert fruit item] under water?

☐ less than 5 seconds

☐ 5-10 seconds

☐ more than 10 seconds

☐ Use a type of fruit/vegetable rinse

☐ Other: ________________________________________________________

4. When cutting whole or half [insert fruit item], do you cut the rind off completely or leave it on?

☐ Cut the rind off completely ☐ Leave the rind on and eat the fruit (with hands or utensils) ☐ Varies

5. When cutting whole or half [insert fruit item], do you cut up the entire [insert fruit item] at one time (even if you save some for later), or cut just part of the [insert fruit item]?

☐ Cut up the entire [insert fruit item] at one time, even if I don’t eat it all at once

☐ Cut up only part of the [insert fruit item] (what you are going to eat at that time)

☐ Varies

6. When cutting the entire whole/half [insert fruit item] and planning to save some, do you cut all the rind off before storing it, or leave the rind on when storing the remainder?

☐ Cut off the entire rind before storing it ☐ Leave the rind on when storing it ☐ Varies

7. If you cut up the entire whole/half [insert fruit item] and save pieces to eat at a different time, how do you store the remaining pieces?

☐ The bag the [insert fruit item] was purchased in ☐ Tupperware container ☐ ZipLock plastic bag ☐ Bowl/plate, covered ☐ Bowl/plate, uncovered

☐ Other, specify _______________________________________________

8. Where do you store the remaining [insert fruit item]?

☐ Refrigerator ☐ Unrefrigerated (kitchen counter, pantry, etc.) ☐ Other, specify ___________________________________

9. How long do you normally store the leftover [insert fruit item] before you finish eating the remainder?

☐ 1-2 days ☐ 3-4 days ☐ 5-6 days ☐ 7 days or more

10. When you eat [insert fruit item], what other foods do you typically eat with it? (e.g. cottage cheese, prosciutto, other fruits)

_________________________________________________________________________________________________________

Section 44: Food Preparation Habits: Now I have a few questions about how you typically prepare and handle Frozen Foods (such as microwave dinners, frozen entrees, frozen pizza, etc.)

Frozen Foods (such as microwave dinners, frozen entrees, frozen pizza, etc.)

1. How do you typically heat up your frozen foods? ☐ Oven ☐ Microwave ☐ Toaster oven ☐ Air fryer ☐ Other, specify ____________ ☐ Unknown

2. Do you use a food thermometer to check the internal temperature when heating frozen foods? ☐ Yes ☐ Maybe ☐ No ☐ Unknown

3. Do you ever eat frozen foods with cold spots? ☐ Yes ☐ Maybe ☐ No ☐ Unknown

4. Do you follow the exact instructions when heating frozen foods? ☐ Yes ☐ Maybe ☐ No ☐ Unknown

Section 45: Laboratory Exposures. Now I will ask you some questions about whether you visited a laboratory or lab in the X days before you (the patient) got sick.

Yes	Maybe	No	Don’t know	Did you (the patient):
☐	☐	☐	☐	Visit a microbiology laboratory (one that uses or runs tests on bacteria) such as at a university, hospital, or other place?
☐	☐	☐	☐	Attend university/college? Name of university/college: __________________________________ Location: _________________________________________________ Did you attend a microbiology or biology laboratory? ☐ Yes ☐ No ☐ Unknown If yes, name of lab course: _________________________________________ Day(s) (circle all that apply): M T W R F Sa Su Time of lab section: ___:___ to ___:___ Are you aware of anyone else who was sick who also attended this laboratory section? ☐ Yes ☐ No ☐ Unknown
☐	☐	☐	☐	Did you work or were you employed in a microbiology laboratory? Name of laboratory/workplace: ________________________________ Location: __________________________________________________
☐	☐	☐	☐	Did you come into close contact with anyone who worked or was a student in a microbiology laboratory? What is their role in the microbiology lab? ______________________________________ What is their relationship to you? _____________________________________________ Name of their laboratory/workplace: ________________________________________ Location: ____________________________________________ Do they work with Escherichia/E. coli? ☐ Yes ☐ No ☐ Unknown If yes, do they know the Escherichia specimen strain number that was used in the lab? ☐ Yes ☐ No If yes, Strain number: __________________________________
Section 46. Lab Practices. Now I will ask you some questions about some of the laboratory practices you were taught or conducted while in lab in the X days before you got sick. If patient did not report laboratory exposure, please skip following section.
Yes	Maybe	No	Don’t Know	Did you (the patient):
☐	☐	☐	☐	Wear gloves while working with bacteria?
☐	☐	☐	☐	Wash your hands with soap and water after taking off gloves?
☐	☐	☐	☐	Wear your lab coat when in the lab? Was there a place to store your lab coat in the laboratory building after the laboratory session? ☐ Yes ☐ No ☐ Unknown Did you wash your lab coat at home? ☐ Yes ☐ No ☐ Unknown
☐	☐	☐	☐	Use the same pen or pencil that you used in lab for other things outside of the laboratory class?
☐	☐	☐	☐	Use the same laboratory notebook for other things outside of the laboratory class?
☐	☐	☐	☐	Carry food or drink with you into the laboratory?
☐	☐	☐	☐	Was there a place away from the lab benches to store backpacks, books, and other materials not related to your laboratory session? Describe: __________________________________________________________________
☐	☐	☐	☐	Receive any education in the lab orientation/from your instructor/in training about the importance of washing your hands, wearing gloves, wearing your lab coat to prevent illness from organisms you are working with in the lab?
☐	☐	☐	☐	Sniff the plates to smell for the type of bacteria during your laboratory session?
☐	☐	☐	☐	Were you ever instructed to sniff the plates to smell for the type of bacteria during your laboratory session?
☐	☐	☐	☐	What kind of tests did you perform with live bacteria? ☐ Streaking plates/slant tubes ☐ Inoculating broth ☐ Biochemical tests ☐ Gram stain ☐ Antimicrobial susceptibility (plate or disc) ☐ Other, describe: _________________ ☐ Unknown

Section 47: 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