Case Report Form - U.s. Department Of Health And Human Services Page 9
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13CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
E. Fruit
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)
eat (=3)
(=2)
(=4)
(=99)
“Now I have some questions about fresh, frozen, or dried fruits, but not canned or cooked, <case> might have eaten in the 4 weeks before <case’s> illness began. Again, I’m interested in fresh, frozen, or dried.”
Apples, including apple slices
1
2
3
4
99
£ Fresh £ Frozen £ Dried
If 1 or 2, were items purchased pre-sliced?
£ Yes £ No £ DK
Caramel apples
1
2
3
4
99
Grapes
1
2
3
4
99
Raisins
1
2
3
4
99
Pears
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Peaches
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Nectarines
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Apricots
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Plums
1
2
3
4
99
£ Fresh £ Frozen £ Dried
Strawberries
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Raspberries
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Blueberries
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Blackberries
£ Fresh £ Frozen £ Dried
1
2
3
4
99
Cherries
1
2
3
4
99
£ Fresh £ Frozen £ Dried
Honeydew melon
1
2
3
4
99
If 1 or 2, were items purchased pre-sliced?
£ Yes £ No £ DK
Cantaloupe
1
2
3
4
99
If 1 or 2, were items purchased pre-sliced?
£ Yes £ No £ DK
Watermelon
1
2
3
4
99
If 1 or 2, were items purchased pre-sliced?
£ Yes £ No £ DK
Pineapple
1
2
3
4
99
If 1 or 2, were items purchased pre-sliced?
£ Yes £ No £ DK
Mango
1
2
3
4
99
£ Fresh £ Frozen £ Dried
If 1 or 2, were items purchased pre-sliced?
£ Yes £ No £ DK
Papaya
1
2
3
4
99
£ Fresh £ Frozen £ Dried
Avocado
£ Fresh £ Frozen £ Dried
1
2
3
4
99
(including homemade
guacamole)
Fruit salad
1
2
3
4
99
(including pre-cut cubes of a
single fruit)
Other fruit
(specify)
1
2
3
4
99
£ Fresh £ Frozen £ Dried
________________
Fruit sorbet
1
2
3
4
99
F. Animal Contact
Contact
Likely
Likely NO
NO contact
Don’t
Type of animal or pet food
Place of contact or purchase
contact
contect
know
(=1)
(=4)
(=2)
(=3)
(=99)
“Now I have three questions about animal contact <case> might have had in the 4 weeks before <case’s> illness began.”
Spent time at a petting zoo,
farm, or other venue with
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2
3
4
99
livestock, such as cattle,
sheep, goats, etc.
Fed a cat or dog raw pet food
1
2
3
4
99
(i.e., pet food marketed as raw)
Fed a cat or dog refrigerated,
frozen, or freeze-dried pet
1
2
3
4
99
treats
9
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