Form Cdc 54.48 - Cyclosporiasis Surveillance Case Report Form Page 2
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Exposures during 2 weeks before onset of illness:
(For dates, be as specific as possible. However, approximations [e.g., mm/yyyy] are okay.)
History of travel (during 2 weeks before onset of illness):
Yes
No
Unknown
International travel (country):
(
Unknown dates of travel and unable to approximate)
(1) ______________________
Departure date: __________
Return date: __________
(2) ______________________
Departure date: __________
Return date: __________
(3) ______________________
Departure date: __________
Return date: __________
U.S. travel (state):
(
Unknown dates of travel and unable to approximate)
(1) ______________________
Departure date: __________
Return date: __________
(2) ______________________
Departure date: __________
Return date: __________
(3) ______________________
Departure date: __________
Return date: __________
Fresh produce exposures (produce eaten or tasted during 2 weeks before onset of illness):
Fresh berries:
Yes (If yes, specify types; check all that apply)
No
Unknown
Strawberries
Blackberries
Blueberries
Raspberries
Black raspberries
Golden raspberries
Unknown type of berry
Other types of berries (specify): __________________________________________________________
Fresh herbs:
Yes (If yes, specify types; check all that apply)
No
Unknown
Cilantro
Oregano
Thyme
Mint
Dill
Parsley
Rosemary
Basil (specify types):
Sweet basil
Thai basil (i.e., green leaves and purple stems)
Purple basil (i.e., purple leaves and stems)
Other types of herbs (specify): ___________________________________________________________
Unknown type of herb
Lettuce:
Yes (If yes, specify types; check all that apply)
No
Unknown
Mesclun (a.k.a., spring mix, field greens, baby greens, & gourmet salad mix)
Arugula
Other types of lettuce (specify): _________________________________________________________
Unknown type of lettuce
Other types of fresh produce:
Yes (If yes, specify types; check all that apply)
No
Unknown
Fruit, other than berries (specify types): ____________________________________________________
Snow peas (flat, shiny pea pods containing tiny peas)
Other types of fresh produce (specify): ____________________________________________________
Unknown type of fresh produce
Did the case-patient attend any events (e.g., wedding reception) (during 2 weeks before onset of illness)?
Yes
No
Unknown
If yes, specify type of social or other event: _____________________________ Event date: __________
Does the case-patient know of other ill persons?
Yes
No
Unknown
If yes, did health department obtain contact information and investigate further (provide comments below)?
Yes
No
Under consideration (or pending)
Unknown
Change Text Size
Comments and additional data:
Name (person filling out form): _____________________________________ Title: _____________________________
Phone: _____________ FAX: _____________ Email: ___________________________________________________
Name of investigating health department: __________________________ Date form submitted: __________
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CDC 54.48 (E), Revised August 2010, CDC Adobe Acrobat 9.3, S508 Electronic Version, September 2010
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