Case Report Form - U.s. Department Of Health And Human Services Page 13
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13CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
K. Other Foods
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)
(=2)
eat (=3)
(=4)
(=99)
“Now I have some questions about other foods <case> might have eaten in the 4 weeks before <case’s> illness began.”
Freshly-made smoothie
with fresh or frozen fruit or
1
2
3
4
99
produce
Tahini
1
2
3
4
99
Tofu, tempeh, or seitan
1
2
3
4
99
Rice noodles
1
2
3
4
99
Sandwiches from a
refrigerated case or vending
1
2
3
4
99
machine
Peanut butter or other nut
1
2
3
4
99
butters or nut cheeses
Nuts, including peanuts,
1
2
3
4
99
almonds, cashews
Seeds, including chia, hemp,
1
2
3
4
99
flax, or sunflower
Food brought here from
1
2
3
4
99
another country
Any seasonal foods or special foods <case> ate during the last 4 weeks? ____________________________________________________________________
______________________________________________________________________________________________________________________
Are there any other food items <case> ate that we didn’t talk about already? ________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Optional questions: (Interviewer note: These questions can be helpful in outbreak investigations and for targeting prevention efforts.)
1.
In what country was <case> born?
£ In the United States or its territories (e.g., Puerto Rico, Guam)
£ Outside the United States (specify) ______________________
If outside the United States: What year did this person come to live in the United States? __________________
£
£
£
2.
What is <case’s> primary language?
English
Spanish
Other (specify) _____________________ £ Unknown
13
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