Case Report Form - U.s. Department Of Health And Human Services Page 11
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13CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
I. Vegetables and
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)
other produce
(=2)
eat (=3)
(=4)
(=99)
“Now I have some questions about vegetables, not canned or cooked, <case> might have eaten in the 4 weeks before <case’s> illness began.”
Sprouts
1
2
3
4
99
(including in a sandwich, salad,
If 1 or 2, Which of the following types of
soup, sushi, or other food)
sprouts did you eat?
- Alfalfa
1
2
3
4
99
- Bean (e.g. mung,
1
2
3
4
99
soybean)
- Clover
1
2
3
4
99
- Radish
1
2
3
4
99
- Broccoli
1
2
3
4
99
- Mixed
1
2
3
4
99
- Other sprouts
(specify)
1
2
3
4
99
______________
Cucumbers
1
2
3
4
99
Pea pods/snap peas/snow peas
1
2
3
4
99
Sweet peppers
(green, red,
1
2
3
4
99
orange, or yellow bell peppers)
Hot chili peppers such as
1
2
3
4
99
jalapenos or serranos
Green onions or scallions
1
2
3
4
99
Celery
1
2
3
4
99
Mini-carrots
1
2
3
4
99
Fresh mushrooms
1
2
3
4
99
Pre-cut raw vegetables or
vegetable mixes
1
2
3
4
99
(e.g., celery, onions—specify)
________________
Fresh basil
1
2
3
4
99
Fresh cilantro
1
2
3
4
99
Fresh parsley
1
2
3
4
99
Other fresh herbs
(sage, thyme, dill, etc.—specify)
1
2
3
4
99
________________
Fresh tomatoes
1
2
3
4
99
If 1 or 2, what type(s) of tomatoes?
- Red round
1
2
3
4
99
- Roma
1
2
3
4
99
- Cherry/grape
1
2
3
4
99
- Vine-ripe,’ sold on vine
1
2
3
4
99
- Other
(specify)
1
2
3
4
99
______________
Any lettuce
1
2
3
4
99
If 1 or 2, Was any of this lettuce
prepackaged? £ Yes (specify type & brand)
£ No £ DK ___________________
If 1 or 2, what type(s) of lettuce?
- Iceberg
1
2
3
4
99
- Romaine
1
2
3
4
99
- Mesclun (“spring mix”)
1
2
3
4
99
- Radish
1
2
3
4
99
- Any other leaf lettuce
1
2
3
4
99
__________
(specify)
11
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