Outbreak Interview Practice Page 4
ADVERTISEMENT
1
2
3
4
5Appendix 3
Outbreak Interview Practice, page 4 of 2
Case ID or Name ____________________________
Respondent was...
self
parent
spouse
___________________Interviewed by ________ on
____/
____
m
d
Age _____
Sex
M
F
State of Residence ______
County _________
First positive specimen collected
____/
____/
____
Source
stool
urine
blood
____________
m
d
yy
Get precise answers for onset times if at all possible. Without a date and time, it’s hard to make a decent epi curve or to calculate
incubation times. Estimates are OK. Prompt as needed: "What is your best guess of the time?" Don’t let them get away with vague stuff like
“morning” or “some time after midnight.” Be careful with times such as "midnight" or early morning hours—which day do they mean? By
“2 am Friday night,” for example, do they really mean Saturday morning? Keep probing until it is unambiguous, and then write down
what they mean—not just what they say. Midnight will be considered as the end of the day (e.g., 11:59 pm).
Onset of first symptoms
____/
____/
____
Time of first onset
____ am
noon
____ pm
midnight
m
d
yy
Onset of first vomiting or diarrhea
____/
____/
____
Time of first V or D
____ am
noon
____ pm
midnight
m
d
yy
Is there any reason to suggest that this person might be a secondary case (e.g., known exposure to sick person <onset)?
yes
no
i
Y
?
N
LEAD-IN QUESTIONS
[
]
Was anyone else in your household sick with diarrhea or vomiting in the week before you got sick?
single person in HH
A
If yes, when did they first get sick?
____/
____/
____
m
d
yy
Did you spend any time out of your home state in the
7
days before you got sick?
B
If yes, which other states or countries did you visit?
Did you visit an emergency room because of your illness?
C
Were you formally admitted to the hospital overnight? (Distinguish admission from short stay observation)
_____ days
D
Do you make a point to select mostly “organic” produce when you shop?
E
Are you a vegetarian or vegan?
F
Before you got sick, were you on any kind of special or restricted diet for medical, weight loss, religious, or any other reasons?
G
If yes, describe…
Do you keep any kind of food diary—any regular record of what you eat? (If yes, use to help answer questions.)
H
Now I’d like to ask you about a long list of food items, and for each one my question will be “Did you eat it in that same 7- day period
before you got sick?” For each item, give me a “yes” or “no” if you remember eating or even tasting it in those
7
days before you got sick.
Some of the questions might seem a little repetitive, but try and answer each question individually, even if you think it was already covered.
Unless I say otherwise, I’m interested in whether you ate these items at home or away from home—either one, OK?
ii
Y
?
N
MISCELLANY 1
[
]
raisins
A
any other commercial dried fruit (specify)
B
any pre-made pudding or custard (not a mix)
C
applesauce
D
chips (potato, corn, Fritos, etc); pretzels
E
other packaged snack food and treats (e.g., Pirate’s Booty)
F
salsa
if yes,
red
green
cooked
fresh
G
commercial tomato sauce
H
any other kind of store-bought, packaged sauce or dip
I
flavored oils
J
taco shells
K
tortillas
L
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical