Form 5 Form 5 NARMS SIRI Module 1

Form Approved

OMB No: 0XXX-XXXX

Expires: XX/XX/20XX

Module 1: Questions common to all nontyphoidal Salmonella, Escherichia coli, Vibrio, and Campylobacter.

Interviewer & Patient Information (Questions 1-13 to be completed by interviewer prior to questionnaire administration)
PulseNet ID #: ________________________ and/or WGS ID: ______________________			State/Local/Other ID #: _____________________
NORS ID: __________________ ☐ No NORS ID ☐ Don’t know		List any other laboratory IDs linked to this episode or person: _____________________________________________________________
Date of Interview:	__ __ / __ __ / __ __ __ __ M M D D Y Y Y Y
Interviewer Agency or Organization: ________________________________________
Language interview conducted in ☐ English ☐ Spanish ☐ Other (specify):_______________
Respondent was: ☐ Self ☐ Parent ☐ Spouse or domestic partner ☐ Other (specify):_______________
State and county of residence? State _______ County ____________________
Age at time of illness _______ ☐ Days ☐ Months ☐ Years ☐ Don’t know
Sex: ☐ Male ☐ Female
Is the patient known to have died by the date this form was completed? ☐ Yes ☐ No If yes, date of death __ __ / __ __ / __ __ __ __ M M D D Y Y Y Y If yes, did the death certificate include the illness associated with this pathogen as the primary or contributory cause? ☐ Yes ☐ No ☐ Don’t know
Before this interview, was the patient (or their surrogate) interviewed about their illness by a local or state public health official? ☐ Yes ☐ No ☐ Don’t know

Hello, my name is <interviewer name>. I am calling on behalf of the <state health department name>. Is this [name]? We are contacting you about a recent illness. You may have already been contacted by the health department. I would like to ask you a few additional questions about your (the patient’s) illness and about any exposures you (the patient) may have had before becoming ill. Your help in the investigation is very important and may help prevent others from getting sick. Your participation is voluntary, and you may refuse to answer any question at any time. All information will be kept confidential to the extent permitted by law. No names or other identifying information will be used in any reports. This interview will likely take about 15 minutes. Are you willing to help by participating in this interview? <Make sure the patient is over 18. If they are a minor, you need parental consent to interview.>

☐ Yes

Thank you. Before we begin, can you confirm your date of birth for me? This is done to protect their security and make sure you are talking to the correct person.

Now that I have confirmed your identity, I can tell you that we are talking about your recent <pathogen> diagnosis. <Pathogen> is a diarrheal illness and it was detected after you provided your health care provider with a specimen, such as stool, blood, or urine.

☐ No

Thank you for your time. Can I answer any questions for you? If you wish at any time to complete the questionnaire, please call <phone number>.

Clinical Information: First, I have a few questions about your (the patient’s) illness.

1. What date did you (the patient) first feel sick? __ __ / __ __ / __ __ __ __ ☐ Don’t know
   M M D D Y Y Y Y

1. If unknown, please enter specimen collection date: __ __ / __ __ / __ __ __ __ ☐ Don’t know

M M D D Y Y Y Y

2. How many days total were you (the patient) sick? _______ days ☐ Don’t know ☐ Still sick

Yes

Maybe

No

Don’t Know

Did you (the patient):

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3. Have any diarrhea (defined as ≥3 loose stools in 24 hours)?

a. What day did it start? __ __ / __ __ / __ __ __ __ ☐ Don’t know

M M D D Y Y Y Y

b. What day did it end? __ __ / __ __ / __ __ __ __ ☐ Don’t know ☐ Still sick

M M D D Y Y Y Y

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4. Have any blood in the stool?

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5. Have a fever (defined as temperature ≥100.4°F)?

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6. Have any close contact with anyone with diarrhea or vomiting in the week before illness?

What is their relationship to you?	When did they first become ill?	Were they a member of your household?	For interviewer only: If confirmed diagnosis, what is their PulseNet or WGS ID?
	☐ Less than 24 hours before you (the patient) ☐ At least 24 hours before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t know	☐ Yes ☐ Maybe ☐ No ☐ Don’t know
	☐ Less than 24 hours before you (the patient) ☐ At least 24 hours before you (the patient) ☐ After your (the patient’s) illness onset ☐ Don’t know	☐ Yes ☐ Maybe ☐ No ☐ Don’t know

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7. Get admitted overnight to a hospital for this illness?

a. How many nights did you (the patient) spend in the hospital? __________ ☐ Don’t know

b. Did you (the patient) stay overnight in an Intensive Care Unit (ICU) or Critical Care Unit (CCU)?

☐ Yes ☐ No ☐ Don’t know

1. If yes, how many nights in ICU or CCU? _______________

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8. Develop serious problems or complications as a result of this illness, such as bacteria in the blood, sepsis (or an extreme response to the infection), infection of the joints or bones, hemolytic uremic syndrome (or kidney failure), meningitis, or other problems?

Bacteria in the blood?		☐ Yes	☐ Maybe	☐ No	☐ Don’t know
Sepsis (or extreme response to the infection)?		☐ Yes	☐ Maybe	☐ No	☐ Don’t know
Infection of the joints or bones?		☐ Yes	☐ Maybe	☐ No	☐ Don’t know
HUS (or kidney failure)?		☐ Yes	☐ Maybe	☐ No	☐ Don’t know
Meningitis?		☐ Yes	☐ Maybe	☐ No	☐ Don’t know
Other?		☐ Yes	☐ Maybe	☐ No	☐ Don’t know
If yes, please specify:	____________________________________________________

If yes,

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9. Take any antibiotics for this illness? If yes, I will be asking more questions about the antibiotic, so it may be helpful to get the pill bottles or packages if available.

Examples of antibiotics are azithromycin (called Zithromax or Z pack), amoxicillin (Amoxil), amoxicillin/clavulanic acid (Augmentin), ciprofloxacin (Cipro), cephalexin (Keflex), trimethoprim-sulfamethoxazole (Bactrim or Septra.)

1. Please list the name, start date, and duration for every antibiotic.

Antibiotic name

Start date (MM/DD/YYYY; for any part of the date not known, enter ‘99’ or ‘9999’)

Duration taken (days)

1

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

2

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

3

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

4

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

5

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

2. In the 24 hours after taking the antibiotic(s) did your (the patient’s) symptoms

☐ Get better / improve ☐ Stay the same ☐ Get worse

☐ Other (specify): ______________________________________________

Section Comments.

Clinical Risk Factors: Now I have a few questions about medications you (the patient) may have taken in the 30 days before illness began, any medical conditions you (the patient) have or have had, and any procedures you (the patient) have had.

Yes

Maybe

No

Don’t Know

In the 30 days before illness, did you (the patient):

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1. Take an antibiotic by mouth or injection?

If yes, please list the name, start date (at least the month) and duration for every antibiotic.

Antibiotic name

Start date (MM/DD/YYYY; for any part of the date not known, enter ‘99’ or ‘9999’)

Duration taken (days)

1

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

2

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

3

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

4

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

5

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__ __ / __ __ / __ __ __ __

____________ ☐ Still taking

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2. Take any medication to block stomach acid (e.g., proton pump inhibitors, histamine antagonists, antacids)?

Examples of medications to block stomach acid include Prevacid (Lansoprazole), Nexium (Esomeprazole), Pepcid (Famotidine), Zantac (Ranitidine), Maalox, Pepto, or Tums.

1. If yes, what type?

☐ Proton pump inhibitors (e.g., Dexlansoprazole/Dexilant, Esomeprazole/Nexium, Lansoprazole/Prevacid, Omeprazole/Prilosec, Omeprazole-sodium bicarbonate/Zegerid, Pantoprazole/Isopan, Rabeprazole/AcipHex)

☐ Histamine antagonist (e.g., Cimetidine/Tagamet, Famotidine/Pepcid, Nizatidine/Axis, Ranitidine/Zantac)

☐ Antacids (e.g., Amphojel, Dialume, Genaton, Maalox, Di-Gel, Gelusil, Mylanta, Rulox, Tempo, Gaviscon, Ami-Lac, Pepto, Caltrate, Tums, Rolaids, Gas-X with Maalox, Riopan, Milk of Magnesia, Ri-Mag, Ron-Acid)

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3. Take any antidiarrheal or antimotility medication (e.g., Pepto-Bismol, Kaopectate, Immodium, Lomotil)?

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4. Take any laxative or stool softener (e.g., senna, docusate, bisacodyl, lactulose)?

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5. Take any probiotics or prebiotics (e.g., yogurts and other fermented products, capsules, pills, powders, any foods or drinks labeled as containing ‘live and active capsules’ or ‘probiotics’)?

If yes, what type:

Capsule or Pill?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Powder?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Drink?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Yogurt (non-drinkable)?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
Other?	☐ Yes		☐ Maybe	☐ No	☐ Don’t know
If yes, please specify:		____________________________________________________

Yes

Maybe

No

Don’t Know

If the patient is not a female of childbearing age, skip question 6

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6. At the time your illness began, were you pregnant?

Have you (the patient) ever been told by a physician that you (the patient) have or had any of the following conditions:

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7. Immune deficiency, low immune system, or a condition that could lead to immune deficiency (e.g., complement deficiency, antibody or immunoglobulin deficiency, asplenia)?

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8. Sickle cell disease?

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9. Cancer (including leukemia/lymphoma)?

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10. Diabetes?

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11. Irritable bowel syndrome?

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12. Peptic ulcer disease?

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13. Gastroesophageal reflux disease (or GERD)?

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14. Liver cirrhosis or liver failure?

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15. Other chronic health condition?

1. Specify: ___________________________________________________________

Have you (the patient) ever had any of the following procedures or treatments:

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16. Immunosuppressive medicine or medicine that lowers your immune system, such as medicines you would take for autoimmune disease, cancer, or organ transplant?

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17. Radiation therapy?

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18. Bariatric surgery (e.g., gastric bypass, gastric banding)?

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19. Other abdominal surgery (e.g., removal of appendix, removal of gall bladder, any surgery of the stomach, small intestine, or large intestine)?

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20. Organ transplant (e.g., kidney)?

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21. Bone marrow transplant?

Section Comments.

Travel: Next I have some questions about any travel you (the patient) might have done, either for work or for pleasure. As I read each question, please answer as yes, no, maybe, or don’t know.

Yes

Maybe

No

Don’t Know

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

City and State	Date of Arrival	Date of Departure	Accommodation Type (e.g., hotel, motel, private home rental, family member’s private home) & Name

List all cities and states inside the United States where you (the patient) might have purchased or eaten foods. This includes foods eaten at airports, bus, or train stations.

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2. In the 6 months before illness, did you (the patient) travel to a country outside of the U.S.?

List all countries outside the United States where you (the patient) might have purchased or eaten foods, drank untreated water, or had contact with animals. This includes at airports, bus, or train stations.

• City and Country	Date of Arrival	Date of Departure	Accommodation Type (e.g., hotel, private home rental, cruise ship, family member’s private home) & Name	Reason(s) for Travel
  				Tourism Business or work Visiting friends or relatives Other: ________________
  				Tourism Business or work Visiting friends or relatives Other: ________________
  				Tourism Business or work Visiting friends or relatives Other: ________________
  				Tourism Business or work Visiting friends or relatives Other: ________________
  				Tourism Business or work Visiting friends or relatives Other: ________________
  				Tourism Business or work Visiting friends or relatives Other: ________________

  Module 2: If the patient spent all 7 days before illness began outside of the U.S., skip to Section: Foods Eaten.

• Modules 3 & 4: If the patient spent all 7 days before illness began outside of the U.S., skip to last section, Section: Race, Ethnicity, Languages, and Occupation

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3. Did any household member or close contact return from visiting another country during the 30 days before you (the patient) got sick?

1. Which country/countries? __________________________________________________________

2. Were they ill with symptoms similar to your (the patient’s) symptoms? ☐ Yes ☐ No ☐ Don’t know

Section Comments.

Sources of food prepared at home: Now I have a few questions about where the food you (the patient) ate came from that was prepared at home in the 7 days before your illness began. This isn’t necessarily where you shopped during that week, but where the food you (the patient) ate came from, which could include older shopping purchases. This could include grocery stores, warehouse stores, farmers’ markets, home delivery, delis, swap meets, ethnic or specialty markets, butchers, live animal markets, food or meal subscription services, or groceries that were bought several weeks ago but consumed in the 7 days before you (the patient) got sick. I’m going to ask a few questions about stores you (the patient) may have shopped at, as well as any shopper card numbers you (the patient) may have. Store shopper or membership information can help provide detailed information, such as brands, varieties, purchase date, that you may not know or remember. You may also be able to access your own purchase history through an online account. We can then compare it with other people’s purchase histories to see if the same food is reported or identified. Your purchase history will only be shared on a need-to-know basis with local, state, or federal staff during the investigation. This information could help prevent additional illnesses. Additionally, I’ll also ask a few questions about dietary practices and restrictions.

1. Do you (the patient) keep Halal? ☐ Yes ☐ No ☐ Don’t know

2. Do you (the patient) keep Kosher? ☐ Yes ☐ No ☐ Don’t know

3. Do you (the patient) follow any other type of diet or have other dietary restrictions? ☐ Yes ☐ No (if yes, specify) _________________________________________________________________________________________________________________

4. Please specify all locations you (the patient) may have shopped at (please list store names, address/location, and shopper card # (if applicable) mentioned by the interviewee below: Remember to collect all shopper cards used for the household. Sometimes shopper card numbers can be phone numbers.)

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

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

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

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

Section Comments: Additional Store/Retail Names and Locations.

Sources of food prepared outside the home: Now I have a few questions about the food that you (the patient) ate outside your (the patient’s) home or that was prepared outside your home such as restaurants, fast food chains, or take out. It could be helpful to check credit card statements or receipts or phone photos to refresh your memory. I’m going ask about each place you (the patient) would have eaten food from during the 7 days before you were sick.

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

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

To make sure we’ve covered all the possible restaurants/stores you (the patient) may have eaten at, did you (the patient):

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

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

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

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

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

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

SUSPECTED FOOD OR ANIMAL CONTACT
Yes	Maybe	No	Don’t Know
☐	☐	☐	☐	Was there a particular food that you (the patient) ate or a particular animal you had contact with in the 7 days before your (the patient’s) illness began that you think could have led to the illness?
				If yes or maybe, please specify:____________________________________________________________

Race, Ethnicity, Languages, and Occupation: In this section, we will ask questions about your (the patient’s) race, ethnicity, languages spoken at home, and occupation. We are collecting this information from all ill people. By knowing more about your (the patient’s) race, ethnicity, languages, and occupation 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.

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. ________________________________

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

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

3. Does your occupation include any of the following?

☐ Preparing or handling food ☐ Animal slaughter or processing ☐ Commercial animal production (e.g., farming)

☐ Crop production ☐ Animal food manufacturing ☐ Animal care (e.g., veterinary hospital or clinic, pet store)

☐ Daycare or school ☐ Health care or patient care

☐ No ☐ Unknown ☐ Refused

Public reporting burden of this collection of information is estimated to average 15 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