Case Report Form - U.s. Department Of Health And Human Services Page 10
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13CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
G. Deli Meats
Details (e.g., type, variety, brand, packaging, shape/size,
Place of purchase or consumption
Ate
Likely
Likely
Did NOT
Don’t
ate
did NOT
eat
know
(=1)
how prepared)
(=2)
eat (=3)
(=4)
(=99)
“For this section, I’m going to ask you questions about deli meats <case> might have eaten in the 4 weeks before <case’s> illness began.”
Ham
1
2
3
4
99
If 1 or 2, Was this item sliced at a deli
counter? £ Yes £ No £ DK
Bologna
1
2
3
4
99
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Turkey breast
1
2
3
4
99
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Chicken deli meat
1
2
3
4
99
(NOT fresh or rotisserie chicken)
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Roast beef
1
2
3
4
99
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Pastrami or corned beef
1
2
3
4
99
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Liverwurst or
1
2
3
4
99
braunschweiger
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Paté or meat spread that was
1
2
3
4
99
not canned
Head cheese
1
2
3
4
99
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Pepperoni
1
2
3
4
99
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Any other Italian-style meats,
1
2
3
4
99
such as salami or prosciutto
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
Other deli/luncheon meat
1
2
3
4
99
(specify)
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
__________________
Anything from a deli area
1
2
3
4
99
where meat is sliced
If 1 or 2, Sliced at a deli counter?
£ Yes £ No £ DK
H. Other Meat/
Ate
Likely
Likely
Did NOT
Don’t
Details (e.g., type, variety, brand, packaging, shape/size,
Place of purchase or consumption
ate
did NOT
eat
know
(=1)
how prepared)
Poultry
(=2)
eat (=3)
(=4)
(=99)
“Now I have some questions about other meat and poultry, including ready-to-eat items, <case> might have eaten in the 4 weeks before <case’s> illness began.”
Precooked sausage
1
2
3
4
99
Precooked chicken
(whole or
1
2
3
4
99
parts, including rotisserie)
Other precooked meat
1
2
3
4
99
(specify) ___________
Cured or dried meat
(e.g., jerky)
1
2
3
4
99
Hot dogs
1
2
3
4
99
If 1 or 2, Were the hot dogs: £ Heated
before being eaten £ Not heated before being
eaten
£ DK
(eaten directly out of package)
Frozen processed poultry
(e.g., chicken nuggets or
1
2
3
4
99
turkey pot pie—specify)
________________
Ground chicken or turkey
1
2
3
4
99
(specify) _____________
10
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