Complaint received from

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					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 ID: __ __ __ __ - __ __ __

                                                           REPORTER INFORMATION
Complaint received from                                  Address                                        Phone:
                                                                                                        Home
                                                                                                        Work
Person to contact for more information                   Address                                        Phone:
                                                                                                        Home
                                                                                                        Work
Complaint Summary

Type of complaint:          I = Illness                                DW = Poor quality drinking water                      D = Disaster
            CF = Contaminated/adulterated/spoiled food                 RW = Poor quality recreational water                  O = Other
            UE = Unsanitary food establishment                         MP = Complaint related to media publicity
                                                               ILLNESS INFORMATION
Yes    No                                                                                     First symptom:
               Illness-related?   Number ill:                     Number exposed:
                                                                                              Onset Date:                       Time:

Predominant symptoms:             N = Nausea           V = Vomiting          D = Diarrhea
                                  C = Chills           F = Fever             O = Other:
Yes    No      Physician consulted?                     Address                                         Phone

               Name:
Yes    No                         Yes     No
               Hospitalized?                    Emergency room visit?
Hospital and Physician name                              Address                                        Phone

                                                              LABORATORY DATA
Patient name                                             Laboratory name                                Phone


Specimen source             Date collected             Tests                                         Results


                                                                  SUPSECT EXPOSURE
Suspect food/water                                                              Source of food/water

Suspect meal, event, or place                                                                    Date                        Time
Address
Phone
                                                                  SUPSECT EXPOSED
                                           Age/
               NAME                                       STATUS                    CONTACT INFO                             ILLNESS INFO
                                          Gender
                                                            Ill          Address                                    Symptoms:
1.                                                                                                                  Onset date:
                                                            Well         Phone                                      Onset time:
                                                            Ill          Address                                    Symptoms:
2.                                                                                                                  Onset date:
                                                            Well         Phone                                      Onset time:
                                                            Ill          Address                                    Symptoms:
3.                                                                                                                  Onset date:
                                                         Well    Phone                                              Onset time:
                                                 OTHER EXPOSURES (complainant or those ill)
Domestic water source:

Names and locations where foods eaten past 72            Place and locations where water ingested       Place and locations where recreation
hours, other than home                                   past 2 weeks, other than home                  water contacted past 2 weeks




History of exposures              If yes, provide details (places, dates)
      Day Care?

      Food Handler?

      Travel History?

      Other Risk Factor?

Received by                                              Date of complaint/alert                        Time


Investigator’s name                                      Comments