Case Report Form - U.s. Department Of Health And Human Services Page 8

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CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
B. Other Dairy
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’ d like to ask you about other dairy items that <case> ate in the 4 weeks before <case’s> illness began.”
Milk
1
2
3
4
99
If 1 or 2, Was any of this milk raw
(unpasteurized)? £ Yes £ No £ DK
- Whole
1
2
3
4
99
- 2%
1
2
3
4
99
- 1%
1
2
3
4
99
- Skim
1
2
3
4
99
- Other milk
1
2
3
4
99
(e.g., chocolate, buttermilk)
Non-dairy milk
(e.g., soy, almond—specify)
1
2
3
4
99
_______________
Frozen yogurt
1
2
3
4
99
Yogurt
1
2
3
4
99
If 1 or 2, Was any of this yogurt raw
(unpasteurized)? £ Yes £ No £ DK
Specify type, if yes _________________
Yogurt drinks
1
2
3
4
99
Butter
(not margarine or other
1
2
3
4
99
butter substitute)
Cream or half-and-half
1
2
3
4
99
Ice cream bars, milkshakes,
1
2
3
4
99
or frozen dairy dessert items
Ice cream
1
2
3
4
99
Was any of the ice cream soft serve?
£ Yes £ No £ DK
Sour cream or crema
1
2
3
4
99
C. Seafood
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 seafood <case> might have eaten in the 4 weeks before <case’s> illness began.”
Precooked shrimp
1
2
3
4
99
Precooked shellfish
1
2
3
4
99
(e.g., crab, mussels, clams—
specify) ______________
Refrigerated smoked or
cured fish that was not from
1
2
3
4
99
a can
(e.g., smoked salmon)
Any raw fish or seafood,
1
2
3
4
99
including sushi
Frozen processed seafood
1
2
3
4
99
(e.g., fish sticks or breaded fish)
D. Dips and Spreads
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 dips and spreads <case> might have eaten in the 4 weeks before <case’s> illness began.”
Hummus
1
2
3
4
99
Refrigerated, fresh salsa or
pico de gallo
1
2
3
4
99
(not from a jar or can)
Guacamole
1
2
3
4
99
Other dips or spreads
(specify)
1
2
3
4
99
________________
8

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