Form 6 Form 6 NARMS SIRI Module 2

Form Approved

OMB No: XXXX-XXXX

Expires: XX/XX/XXXX

Module 2: Nontyphoidal Salmonella (except MDR Newport), Escherichia coli, and Vibrio

Foods Eaten: Now I have a few questions about the foods that you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) may have eaten this at home or away from home, such as in a restaurant, takeout, from a street vendor, or at a catered event. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
In the 7 days before the illness began, did you (the patient) eat any:	… in the United States		If traveled outside the United States in 7 days before you (the patient) got sick: (Use a separate sheet if more than 1 country)
	AT Prepared at home	Prepared outside the home	… in Country 1: Name:_______________
Beef?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Pork?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Chicken?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Turkey?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Eggs or egg-containing dishes?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Unpasteurized milk?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Cheese made from unpasteurized or raw milk, including homemade, farm-fresh, and door-to-door cheeses?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Fish or fish products?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Shellfish or seafood without fins (e.g., shrimp, crab, clams, oysters)?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Lettuce or raw spinach?	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know	☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Section Comments.

Fish and Seafood: Now I have some questions about fish and seafood you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. You (the patient) may have eaten this at home or away from home, such as in a restaurant, take-out, or at a catered event, or if you traveled, in another state or country. This does not include canned items, but the fish and seafood could have been fresh, frozen, or could have been eaten alone or as part of a dish, sauce, or dip. As I read each food, please answer as yes, no, may have eaten, or can’t remember eating the food in the 7 days before you (the patient) got sick.
If the patient traveled outside the United States in the 7 days before they got sick, ask for each country they were in during the 7 days before they got sick. Use a separate sheet if they visited more than 1 country. Did you (the patient) eat any:
…in the United States?	…in Country 1: Name: _____________________?
Raw or undercooked fish or fish products, such as sushi, sashimi, ceviche, or poke? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Raw tuna? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know Raw salmon? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know Other raw fish? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know Specify: _________________________________________ Describe the dish: _________________________________ Where was it purchased? ___________________________ Where was it consumed? ___________________________	Raw or undercooked fish or fish products, such as sushi, sashimi, ceviche, or poke? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Raw tuna? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know Raw salmon? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know Other raw fish? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know Specify: _________________________________________ Describe the dish: _________________________________ Where was it purchased? ___________________________ Where was it consumed? ___________________________
Store-bought fish, not including shellfish, prepared at home? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, ☐ Frozen ☐ Fresh ☐ Don’t know How was it prepared? ☐ Raw ☐ Undercooked ☐ Fully cooked ☐ Don’t know Type of fish eaten: ___________________________________ ☐ Don’t know Place purchased from (names, locations): _______________________________________ ☐ Don’t know	Store-bought fish, not including shellfish prepared at home? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, ☐ Frozen ☐ Fresh ☐ Don’t know How was it prepared? ☐ Raw ☐ Undercooked ☐ Fully cooked ☐ Don’t know Type of fish eaten: ___________________________________ ☐ Don’t know Place purchased from (names, locations): _______________________________________ ☐ Don’t know
Fish, not including shellfish, prepared outside the home? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, How was it prepared? ☐ Raw ☐ Undercooked ☐ Fully cooked Type of fish eaten: _______________________ ☐ Don’t know Place purchased from (names, locations): ______________________________________ ☐ Don’t know Dish eaten: _____________________________ ☐ Don’t know	Fish, not including shellfish, prepared outside the home? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, How was it prepared? ☐ Raw ☐ Undercooked ☐ Fully cooked Type of fish eaten: _______________________ ☐ Don’t know Place purchased from (names, locations): ______________________________________ ☐ Don’t know Dish eaten: _____________________________ ☐ Don’t know
Smoked or dried fish, like smoked salmon, lox, bonita, fish jerky? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know	Smoked or dried fish, like smoked salmon, lox, bonita, fish jerky? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know
Shrimp or prawns? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, ☐ Frozen ☐ Fresh ☐ Don’t know Type, variety, brand:______________________ ☐ Don’t know	Shrimp or prawns? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, ☐ Frozen ☐ Fresh ☐ Don’t know Type, variety, brand:______________________ ☐ Don’t know
Crab, lobster, or crayfish? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know	Crab, lobster, or crayfish? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know
Oysters? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Were the oysters raw? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know	Oysters? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Were the oysters raw? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know
Clams, mussels, scallops, or other shellfish? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know	Clams, mussels, scallops, or other shellfish? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know
Any other fish or seafood? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know	Any other fish or seafood? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Type, variety, brand:______________________ ☐ Don’t know
Section Comments.

Water Exposure: Now I have questions about water exposure in the 7 days before your (the patient’s) illness.
In the 7 days before illness began,	… in the United States	If traveled outside the United States in 7 days before you (your child) got sick: (Use a separate sheet if more than 1 country)
		… in Country 1: Name:__________________
Where did the water that you (the patient) drank come from?	☐ Municipal / tap ☐ Well water ☐ Bottled water ☐ Other, specify: ______________________________________ ☐ Don’t know	☐ Municipal / tap ☐ Well water ☐ Bottled water ☐ Other, specify: ______________________________________ ☐ Don’t know
Did you (the patient) swim in, wade in, or enter a pool, ocean, lake, pond, river, stream, or natural spring?	☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, specify: ________________________	☐ Yes ☐ Maybe ☐ No ☐ Don’t know If yes, specify: _______________________
Section Comments.

Animal Contact and Pet Food: Now I have some questions about contact with pets or other animals in the 7 days before your (the patient’s) illness began. Contact is defined as: you (the patient) or someone in the household handling, touching, petting, or otherwise interacting with an animal or the areas where the animal lives/roams. This could have been at your home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location. As I read each exposure, please answer as yes, no, may have had, or can't remember having contact in the 7 days before you (the patient) got sick.
If the patient traveled outside the United States in the 7 days before they got sick, ask for each country they were in during the 7 days before they got sick. Use a separate sheet if they visited more than 1 country. Additionally, for patients who report contact with poultry, please ask if they had any contact within 30 days after returning to the United States (question 1a on the left).  Did you (the patient) or anyone in the household have contact with any of the following types of animals or the areas where the animal lives/roams
…in the United States?	…in Country 1: Name: _____________________?
Chickens/chicks, ducks/ducklings, turkeys, or other backyard poultry?        ​☐​ Yes   ​☐​ No   ​☐​ Maybe   ​☐​ Don’t know  If yes or maybe, please specify the type of poultry  Did contact occur (select all that apply):   ☐ In the 7 days before illness    ☐ Chickens/Chicks  ☐ Ducks/Ducklings    ☐ Turkeys    ☐ Other, specify: ___________________    ☐ Don’t know   ☐ In the 30 days after illness  ☐ Chickens/Chicks  ☐ Ducks/Ducklings    ☐ Turkeys    ☐ Other, specify: ___________________     ☐ Don’t know  Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:____________________________________ ​☐​ Don’t know	Chickens/chicks, ducks/ducklings, turkeys, or other backyard poultry? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, ☐ Chickens/Chicks ☐ Ducks/Ducklings ☐ Turkeys ☐ Other, specify: ___________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:__________________________________ ☐ Don’t know
Turtles or tortoises? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Was the shell <4 inches in diameter (smaller than the palm of an adult hand)? ☐ Yes ☐ No ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:____________________________________ ☐ Don’t know	Turtles or tortoises? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Was the shell <4 inches in diameter (smaller than the palm of an adult hand)? ☐ Yes ☐ No ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:__________________________________ ☐ Don’t know
Other reptiles (such as snakes, lizards, geckos, bearded dragons), amphibians (frogs, toads, salamanders), fish or other aquatic animals? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:____________________________________ ☐ Don’t know Was it fed: ☐ Live mice/rat ☐ Frozen mice/rat ☐ Live chick ☐ Frozen chick ☐ Other feeder animal, specify: ______________ ☐ Not fed feeder animal ☐ Don’t know	Other reptiles (such as snakes, lizards, geckos, bearded dragons), amphibians (frogs, toads, salamanders), fish or other aquatic animals? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:___________________________________ ☐ Don’t know Was it fed: ☐ Live mice/rat ☐ Frozen mice/rat ☐ Live chick ☐ Frozen chick ☐ Other feeder animal, specify: ____________ ☐ Not fed feeder animal ☐ Don’t know
Small mammalian household pet, such as hamster, rat, mouse, guinea pig, gerbil, ferret, sugar glider, or hedgehog (excluding feeder rodents used as pet food for reptiles, see #3c)? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:____________________________________ ☐ Don’t know	Small mammalian household pet, such as hamster, rat, mouse, guinea pig, gerbil, ferret, sugar glider, or hedgehog (excluding feeder rodents used as pet food for reptiles, see #3c)? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:__________________________________ ☐ Don’t know
Any other type of pets (dogs, cats, birds (not poultry, etc.)? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:____________________________________ ☐ Don’t know	Any other type of pets (dogs, cats, birds (not poultry, etc.)? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:__________________________________ ☐ Don’t know
Any other animal (such as farm animals or wildlife)? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:____________________________________ ☐ Don’t know	Any other animal (such as farm animals or wildlife)? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, Please specify the type:______________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:__________________________________ ☐ Don’t know
Did you (the patient) or anyone in the household have contact with animal food, animal treats, animal feeding bowls or equipment, or the area where animal food/treats are stored or where animals are fed? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, What type of animal food: ☐ Dry ☐ Canned ☐ Fresh ☐ Raw ☐ Other, specify: _____________________ ☐ Don’t know Animal food brand: __________________________ ☐ Don’t know Purchase location: __________________________ ☐ Don’t know Animal treat type: ☐ Pig ear ☐ Pizzle/bully stick ☐ Raw hide ☐ Hooves ☐ Jerky-style treat ☐ Biscuit-style treats ☐ Freeze-dried treats ☐ Other, specify: ___________________ ☐ Don’t know Animal treat brand: __________________________ ☐ Don’t know Purchase location: ___________________________ ☐ Don’t know	Did you (the patient) or anyone in the household have contact with animal food, animal treats, animal feeding bowls or equipment, or the area where animal food/treats are stored or where animals are fed? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know If yes or maybe, What type of animal food: ☐ Dry ☐ Canned ☐ Fresh ☐ Raw ☐ Other, specify: _____________________ ☐ Don’t know Animal food brand: _________________________ ☐ Don’t know Purchase location: _________________________ ☐ Don’t know Animal treat type: ☐ Pig ear ☐ Pizzle/bully stick ☐ Raw hide ☐ Hooves ☐ Jerky-style treat ☐ Biscuit-style treats ☐ Freeze-dried treats ☐ Other, specify: ___________________ ☐ Don’t know Animal treat brand: ________________________ ☐ Don’t know Purchase location: _________________________ ☐ Don’t know
Section Comments.

Other Exposures: Now I have a few questions about other exposures you (the patient) might have had in the 7 days before your (the patient’s) illness began.

Yes

Maybe

No

Don’t Know

In the 7 days before illness began, did you (the patient):

☐

☐

☐

☐

1. Attend a gathering outside of your home (e.g., wedding, religious, sporting, entertainment, or cultural event)?

1. What was the gathering? ______________________________________________________

2. Where was the gathering? ______________________ (If outside the US, specify the country)

3. When was the gathering? _______________________

☐

☐

☐

☐

2. Visit, work, or volunteer in a doctor’s office or clinic, urgent care, emergency department, hospital, or other healthcare setting?

Doctor’s office or clinic?	☐ Yes	☐ No	☐ Maybe	☐ Don’t know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
Urgent care?	☐ Yes	☐ No	☐ Maybe	☐ Don’t know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
Emergency department?	☐ Yes	☐ No	☐ Maybe	☐ Don’t know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
Hospital?	☐ Yes	☐ No	☐ Maybe	☐ Don’t know
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know
If visit, were you (the patient) admitted overnight to the hospital?	☐ Yes	☐ No	☐ Maybe	☐ Don’t know
If yes, describe indication, dates, and duration	_______________________________________________________________________________________________________________________________________
Other health care setting?	☐ Yes	☐ No	☐ Maybe	☐ Don’t know
If yes, specify setting:	_____________________________________________
If yes, did you (the patient)	☐ Visit	☐ Work	☐ Volunteer	☐ Don’t know

3. Do you (the patient) have regular contact with any of the following?

☐ Persons experiencing homelessness	☐ Person wearing diapers
☐ Patients in clinics or hospitals	☐ Young children attending daycare or pre-school

If yes, please give further details: __________________________________________________________________________________

4. In the 30 days before illness began, did you (the patient) experience homelessness? That is, were you living in a shelter, car, park, abandoned building, bus or train station, airport, or camping ground?

☐ Yes ☐ No ☐ Prefer not to answer ☐ Don’t know

Yes

Maybe

No

Don’t Know

☐

☐

☐

☐

5. Did you (the patient) eat any foods in the 7 days before illness began that you, friends, or family brought back or someone sent to you from another country?

What was the food?	What country was it from?	How was it stored?

Section Comments.

Public reporting burden of this collection of information is estimated to average 10 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