Case Report Form - U.s. Department Of Health And Human Services Page 12
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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)
(Continued)
Other prepackaged leafy
green
1
2
3
4
99
(e.g., kale, spinach—
specify) _______________
Premade green salad that
includes other ingredients
1
2
3
4
99
besides greens
(e.g., cobb, Caesar salads)
Other produce
(specify)
1
2
3
4
99
________________
J. Deli Salads
Ate
Likely
Likely
Did NOT
Don’t
Details (e.g., type, variety, brand, packaging, shape/size,
Place of purchase or consumption
(=1)
ate
did NOT
eat
know
how prepared)
(=2)
eat (=3)
(=4)
(=99)
“Now I have some questions about deli salads that <case> might have eaten in the 4 weeks before <case’s> illness began. Please do not include homemade items, but only those made in a factory,
restaurant, or outside the home.”
Potato salad
1
2
3
4
99
If 1 or 2, Was this item purchased from a
deli counter?
£ Yes £ No £ DK
Pasta salad
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Egg salad
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Tuna salad
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Chicken salad
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Bean salad
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Seafood salad
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Cole slaw
1
2
3
4
99
If 1 or 2, Purchased from a deli counter?
£ Yes £ No £ DK
Other ready-to-eat meat or
1
2
3
4
99
vegetable salad not made
If 1 or 2, Purchased from a deli counter?
at home
£ Yes £ No £ DK
Anything from a salad bar
1
2
3
4
99
12
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