Enteric Disease Outbreak Investigation Model: Electronic Appendix A Form for taking a public report of enteric illness The following form is designed to be used to document details of an event reported by a call from the public. Using information gathered from this form, investigators can determine if what they are seeing is an event of interest needing further resources or attention. Investigators may modify this form electronically to fit their needs. (Contact Utah Department of Health for technical assistance.) Refer to Section 1a for more details on recognizing outbreaks from calls from the public.
FOODBORNE, WATERBORNE, ENTERIC ILLNESS REPORT
Complaint received from Person to contact for more information Complaint Summary Type of complaint: I = Illness CF = Contaminated/adulterated/spoiled food UE = Unsanitary food establishment Yes No Illness-related? Number ill: N = Nausea C = Chills REPORTER INFORMATION Address Address Phone: Home Work Phone: Home Work
COMPLAINT ID: __ __ __ __ - __ __ __
DW = Poor quality drinking water RW = Poor quality recreational water MP = Complaint related to media publicity ILLNESS INFORMATION First symptom: Number exposed: Onset Date: D = Diarrhea O = Other: Phone
D = Disaster O = Other
Time:
Predominant symptoms: Yes Yes No No
Physician consulted? Name: Hospitalized? Yes No
V = Vomiting F = Fever Address
Emergency room visit? Address LABORATORY DATA Laboratory name Phone
Hospital and Physician name
Patient name Specimen source Date collected
Phone Results
Tests
Suspect food/water Suspect meal, event, or place Address Phone
SUPSECT EXPOSURE Source of food/water Date Time
SUPSECT EXPOSED NAME 1. 2. 3. Age/ Gender STATUS Ill Well Ill Well Ill Address Phone Address Phone Address CONTACT INFO ILLNESS INFO Symptoms: Onset date: Onset time: Symptoms: Onset date: Onset time: Symptoms: Onset date: Onset time:
Well Phone OTHER EXPOSURES (complainant or those ill)
Domestic water source: Names and locations where foods eaten past 72 hours, other than home Place and locations where water ingested past 2 weeks, other than home Place and locations where recreation water contacted past 2 weeks
History of exposures Day Care? Food Handler? Travel History? Other Risk Factor? Received by Investigator’s name
If yes, provide details (places, dates)
Date of complaint/alert Comments
Time