National Hypothesis Generating Questionnaire

Cyclosporiasis National Hypothesis Generating Questionnaire v 3.0 (January 2018)

General information (Questions to be completed by interviewer before the questionnaire is administered)

1. Classify case based on CDC case definition: Confirmed Probable

Laboratory information:

2. Date(s) stool collected for Cyclospora testing:

3. Test results: Positive Negative Indeterminate Pending

4. Specify type of testing laboratories (Check all that apply including confirmatory lab):
Clinical lab (e.g., at a hospital/clinic) Commercial lab State lab CDC lab

5. Specify testing method(s) (Check all that apply including confirmatory test):
O&P (e.g., light microscopy, UV fluorescence microscopy, stained smears)
GI PCR Panel (e.g., BioFire FilmArray®) PCR (Not part of a panel) Lab-developed test
Other, specify:

6. Specify name(s) of lab-confirmed coinfection: Not applicable

7. Additional information (e.g., patient has appointment to submit stool, lab accession number, etc):

11. Date of interview: (Required)

12. Before this interview, how many times has the case-patient been interviewed about his/her illness? None Once Twice Three or more times Unknown

13. Respondent for the current interview was: Self Parent Spouse Other, specify:

Begin interview

Hello, my name is [state interviewer name]. I am from INTERVIEWER HEALTH DEPARTMENT. We are contacting you because of your (your child's) recent infection with Cyclospora, which is a parasite that causes intestinal illness.

You may have already been contacted by someone at the health department, but I would like to ask you questions in a standard way about your (your child's) illness, and about any travel you may have had or foods you may have eaten before becoming ill.

Are you willing to participate in this investigation?

Public reporting of this collection of information is estimated to average 21 minutes per response...

Section 1: Demographic data

I'd like to begin by asking a few demographic questions.

1. State:   2. County:   3. Zip Code:

4. Date of birth:   5. Age:   6. Sex: Male Female

7. Do you consider yourself of Hispanic or Latino Origin? Yes No Unknown

8. How would you describe your race? White American Indian/Alaska Native Black/African American Asian Native Hawaiian/Other Pacific Islander Unknown
Other, specify:

Section 2: Clinical information

9. What date did you (your child) first feel sick? Approximate date Unknown

Section 3: Travel, events, and ill contacts

10. Have you (your child) had any of the following symptoms?

Diarrhea   Date started:   Date stopped: Ongoing
Weight Loss
Fever
Fatigue
Anorexia
Nausea
Vomiting
Abdominal Cramps

11. Have your (your child's) symptoms stopped? Yes No Date stopped: Unknown

12. Were you (your child) hospitalized overnight? Yes No

a. How many nights were you (your child) hospitalized?

b. Admission Date:

c. Hospital Name:

Section 4: Sources of produce at home

18. Did you (your child) eat foods from home sources? Please list store name, address, city, state, date shopped, food purchased, and shopper card number.

Store name Address City State Date shopped Food purchased Shopper card #

Refused to give shopper card #

Section 5: Sources of produce outside the home

19. Did you (your child) eat foods from restaurants or commercial food establishments?

Restaurant name Address City State Meal date Food eaten

Additional comments:

Section 6: Fresh herbs

20. Fresh basil? Yes Maybe No Don't know

Type(s):

Brand(s):

Place(s) purchased:

21. Fresh cilantro?

Additional comments about fresh herbs:

Section 7: Fresh berries and fruit

30. Fresh red raspberries?

31. Fresh blackberries?

32. Fresh black raspberries?

33. Fresh golden raspberries?

34. Fresh strawberries?

35. Fresh blueberries?

36. Fresh boysenberries?

37. Other fresh berries?

Additional comments about fresh fruit:

Section 8: Leafy greens

58. Pre-made, single serving salads?

59. Iceberg lettuce?

60. Romaine lettuce?

61. Mesclun lettuce?

62. Fresh cabbage?

63. Fresh spinach?

64. Other lettuce or leafy greens?

65. Other prepackaged salad mix?

Additional comments about leafy greens:

Section 9: Other fresh vegetables

66. Cucumbers?

67. Zucchini?

68. Squash?

69. Bell peppers?

70. Hot chili/chili peppers?

71. Celery?

72. “Mini” carrots?

73. Other fresh carrots?

74. Other raw root vegetables?

75. Fresh, raw peas?

76. Broccoli?

77. Cauliflower?

78. Sprouts?

79. Raw onions?

80. Raw green onions/scallions?

81. Fresh tomatoes?

82. Salsa or pico de gallo?

83. Fresh guacamole?

Additional comments, including other types of fresh vegetables:

This completes the interview. Thank you very much for your time. Would you like to provide any additional thoughts about anything we’ve discussed or about this outbreak investigation?