Form 7 Form 7 NARMS SIRI Module 3

Form Approved

OMB No: XXXX-XXXX

Expires: XX/XX/XXXX

Module 3: Salmonella Newport (REPJJP01)

Other Sources of Food: Now I have some questions about any other food you (the patient) ate in the 7 days before your illness began that was prepared outside your (the patient’s) home, but not at a restaurant or fast-food restaurant. This includes food from family or friends (like, a neighbor brings over a meal, or a potluck) or food bought from individuals online (like on Facebook).
Yes	Maybe	No	Don’t Know	In the 7 days before the illness began, did you (the patient) eat any:
☐	☐	☐	☐	Food prepared by neighbors, relatives, friends, or acquaintances, like a pre-made meal that you reheat and serve at home or at an event or party?
				What was the food? ­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________ Where/who did you get it from? _____________________________________________________
☐	☐	☐	☐	Foods sold by private persons (not a store or a business), like a person selling food from their home, car, street cart or table, or at a swap meet?
				What was the food? ­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________ Where/who did you get it from? _____________________________________________________
☐	☐	☐	☐	Foods that you, friends, or family brought back, or someone sent to you from Mexico or another country?
				What was the food? ­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________ Where/who did you get it from? _____________________________________________________
☐	☐	☐	☐	Foods bought online (not from a grocery store), like from Facebook or Instagram?
				What was the food? ­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________ Where/who did you get it from? _____________________________________________________
Section Comments.

Meat: Now I have a few questions about meat that you (the patient) might have eaten in the 7 days before your (the patient’s) illness began. The meat could have been eaten as part of dish. You (the patient) could have eaten these either in your home or outside the home, or if you traveled, in another country. As I read each food, please answer as yes, no, may have eaten, or can't remember eating the food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	Did you (the patient):
☐	☐	☐	☐	Eat any ground beef prepared at home? This could include foods such as hamburger patties, casseroles, tacos, soups, or pasta sauces
				Was it purchased: ☐ In a tray ☐ As a chub ☐ Pre-formed patties ☐ Other, specify ___________ Type, variety, brand: _______________________________________ Place purchased from (names, locations): ____________________________ Shopper card number: ___________________________________ Date purchased: ___/___/______ How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Don’t know Did you purchase the ground beef fresh or frozen? ☐ Fresh ☐ Frozen ☐ Don’t know How did you store your raw ground beef before cooking? ☐ Frozen in original packaging ☐ Frozen in zip lock bags or storage containers ☐ Refrigerated ☐ Other _____________ If purchased or stored frozen, how did you defrost your frozen raw ground beef? ☐ In refrigerator ☐ On countertop ☐ In a sink with water ☐ In the microwave ☐ Didn’t defrost it – cooked from frozen ☐ Other _________ What was the size of the beef package you purchased? ____ lbs Don’t know What was the percent lean/fat? ____% lean Don’t Know 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 ☐ Don’t know If yes, would you be willing to share a picture of the receipt with health officials? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Can we collect any leftover ground beef for testing? ☐ Yes ☐ No ☐ None leftover If yes, did you handle the ground beef after illness? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know
☐	☐	☐	☐	Eat any ground beef prepared outside the home?
				Place purchased from (names, locations): _______________________________________ Dish eaten: ____________________________________________________ Date: ___/___/______ b. How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Don’t know
☐	☐	☐	☐	Even if you didn’t eat it yourself, did you touch, handle, or prepare any raw ground beef?
				Is this the same ground beef described in question 1 of this section? ☐ Yes (skip to question 4) ☐ No (Continue with b.– m.) Was it purchased: ☐ In a tray ☐ As a chub ☐ Pre-formed patties ☐ Other, specify ___________ Type, variety, brand:_______________________________________ Place purchased from (names, locations): ____________________________ Shopper card number: _______________________________ Date purchased: ___/___/______ Did you purchase the ground beef fresh or frozen? ☐ Fresh ☐ Frozen ☐ Don’t know How did you store your raw ground beef before cooking? ☐ Frozen in original packaging ☐ Frozen in zip lock bags or storage containers ☐ Refrigerated ☐ Other _____________ If purchased or stored frozen, how did you defrost your frozen raw ground beef? ☐ In refrigerator ☐ On countertop ☐ In a sink with water ☐ In the microwave ☐ Didn’t defrost it – cooked from frozen ☐ Other _________ What was the size of the beef package you purchased? ____ lbs ☐ Don’t know What was the percent lean/fat? ____% lean ☐ Don’t know 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 ☐ Don’t know If yes, would you be willing to share a picture of the receipt with health officials? ☐ Yes ☐ Maybe ☐ No ☐ Don’t know Can we collect any leftover ground beef for testing? ☐ Yes ☐ No ☐ None leftover If yes, did you handle the ground beef after illness? ☐ Yes ☐ No
☐	☐	☐	☐	Eat any steaks, stews, roasts, carne asada, carne mechada, menudo, cabeza, lengua, or other beef items prepared at home?
				What type of beef product? ☐ Steak ☐ Stew ☐ Roast ☐ Carne asada ☐ Carne mechada (shredded beef) ☐ Menudo (beef tripe stew) ☐ Cabeza (beef cheeks) ☐ Lengua (beef tongue) ☐ Other, specify __________________ ☐ Don’t Know How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Don’t know Type, variety, brand, or if no brand, how packaged: __________________________________________________________________________ Place purchased from (names, locations): __________________________________________________________________________ e. Date purchased: ___/___/______
☐	☐	☐	☐	Eat any steaks, stews, roasts, carne asada, carne mechada, menudo, cabeza, lengua, or other beef items prepared outside the home?
				What type of beef product? ☐ Steak ☐ Stew ☐ Roast ☐ Carne asada ☐ Carne mechada (shredded beef) ☐ Menudo (beef tripe stew) ☐ Cabeza (beef cheeks) ☐ Lengua (beef tongue) ☐ Other, specify __________________ ☐ Don’t Know How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Don’t know Place purchased from (names, locations): _______________________________________ c. Date purchased: ___/___/______
☐	☐	☐	☐	Eat any dried meats or beef jerky?
				Type of meat ________________________ ☐ Don’t know Brand name (if purchased from a store): ________________________ ☐ Don’t know Where did you get it from (store name, friend, family, online purchase, etc): _____________________________________________________________________ ☐ Don’t know Date purchased: ___/___/______
☐	☐	☐	☐	Eat any veal? Type, variety, brand: ___________________________________________________ ☐ Don’t know Place purchased from (names, locations): __________________________________ ☐ Don’t know How was it consumed? ☐ Raw ☐ Pink/red inside ☐ Well-done, no pink inside ☐ Don’t know
☐	☐	☐	☐	Eat any pork prepared at home (like whole pig, chops, tenderloin, roast, shoulder, ground, etc.)? Type/cut: ☐ Ground ☐ Whole pig ☐ Pork chops ☐ Pork ribs ☐ Other, specify: ____________________________________ ☐ Don’t know Brand(s): ____________________________________________________________ ☐ Don’t know Place purchased from (names, locations): __________________________________ ☐ Don’t know
☐	☐	☐	☐	Eat any pork prepared outside the home? This would include pig roasts, sit-down restaurants, fast food restaurants, take-out, food trucks, cafeterias, delivery from restaurants, etc. Place purchased from (names, locations): __________________________________ ☐ Don’t know Dish eaten: __________________________________________________________ ☐ Don’t know
☐	☐	☐	☐	Eat any other meat like lamb, goat, bison, or game meat? Type, variety, brand: ___________________________________________________ ☐ Don’t know Place purchased from (names, locations): __________________________________ ☐ Don’t know
Section Comments.

Milk and Cheese: Now I have a few questions about milk and cheese you (the patient) might have had in the 7 days before your (the patient’s) illness began, either in your home or away from home, or if you traveled, in another country. As I read each food, please answer yes, no, maybe, or can't remember eating that food in the 7 days before you (the patient) got sick.
Yes	Maybe	No	Don’t Know	Did you (the patient):
☐	☐	☐	☐	Drink or use any raw (unpasteurized) milk?
				How did you use the raw milk? ☐ Drink ☐ Cook ☐ Other: _______________________ What type of milk (cow, goat, other)? __________________________________________ Where did you get the raw milk from? (Store name, dairy, farm, relative, friend, online purchase, etc.): _______________________________ Location (name, city): _______________________________________ Date(s) purchased: _____________________________________ Brand name (if purchased from a store): ________________________ Any leftover milk for testing? ☐ Yes ☐ No ☐ Don’t Know Are you a part of any cow-share program? ☐ Yes ☐ No ☐ Don’t Know If yes, please provide details_____________________________________________________
☐	☐	☐	☐	Eat any soft cheese, such as queso fresco, blanco, panela, cotija, Oaxaca, etc.?
				Type of soft cheese: ☐ Queso fresco ☐ Queso blanco ☐ Quesito Casero ☐ Asadero ☐ Cotija ☐ Panela ☐ Queso Ranchero ☐ Requeson ☐ Crema ☐ Oaxaca / Quesillo ☐ Other: ___________________________________ ☐ Don’t know Pasteurized or unpasteurized: ☐ Pasteurized ☐ Unpasteurized ☐ Don’t remember ☐ Don’t know How was the cheese packaged (include weight, shape, color)? _____________________ Was there a label on the package? ☐ Yes ☐ Maybe ☐ No ☐ Don’t Know - If Yes, brand name: ☐ El Mexicano ☐ Cacique ☐ Jalisco ☐ Los Altos ☐ Fud ☐ Ranchero ☐ Don Francisco ☐ Other: _________________ ☐ Unbranded from deli ☐ Don’t know Where did you get the soft cheese from? ☐ Grocery store ☐ Restaurant ☐ Family Member ☐ Friend ☐ Street Vendor ☐ Sidewalk Cart ☐ Farmers Market ☐ Door-to-Door Salesperson ☐ Swap meet ☐ Flea market ☐ Catering Truck ☐ Website (Craig’s List, Facebook, etc.) ☐ Other: _________________ ☐ Don’t know Location (name, city): _______________________________________ Shopper card number: ______________________________________ Date(s) purchased: _____________________________________ Any leftover cheese for testing? ☐ Yes ☐ No ☐ 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.
Yes	Maybe	No	Don’t Know	Did you (the patient) eat any:
☐	☐	☐	☐	Raw or undercooked fish or fish products, such as sushi, sashimi, ceviche, or poke?
				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?
				☐ 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?
				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?
				Type, variety, brand:_________________________________________ ☐ Don’t know
☐	☐	☐	☐	Shrimp or prawns?
				☐ Frozen ☐ Fresh ☐ Don’t know Type, variety, brand:_______________________________________ ☐ Don’t know
☐	☐	☐	☐	Crab, lobster, or crayfish?
				Type, variety, brand:_______________________________________ ☐ Don’t know
☐	☐	☐	☐	Oysters?
				Were the oysters raw? ☐ Yes ☐ No ☐ Maybe ☐ Don’t know
☐	☐	☐	☐	Clams, mussels, scallops, or other shellfish?
				Type, variety, brand:____________________________ ☐ Don’t know
☐	☐	☐	☐	Any other fish or seafood?
				Type, variety, brand:____________________________ ☐ Don’t know
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.
Yes	Maybe	No	Don’t Know	Did you (the patient) have contact with:
☐	☐	☐	☐	Any animals or the areas where the animal lives/roams?
				What type(s)? ____________________________________________________ ☐ Don’t know Where did contact occur (such as home or other residence, workplace, petting zoo, retail stores, etc.)? Specify:_________________________________________ ☐ Don’t know
☐	☐	☐	☐	Animal food, animal treats, animal feeding bowls or equipment, or the area where animal food/treats are stored or where animals are fed?
				What type of animal food: ☐ Dry ☐ Canned ☐ Fresh ☐ Raw ☐ Other, specify: _______________________________ ☐ 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.

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 MS H21-8, Atlanta, Georgia 30333; ATTN: PRA