Case ID Number
& Initials
Outbreak Name:
.
Pathogen: Salmonella Typhimurium
Phage Type: 135
MLVA Pattern:
.
Yes / No
Date: date.
Data entered in
Background Food
Consumption Excel
Yes / No
Date: date.
Line list updated?
Yes / No
Date: date.
Person Interviewed if
not case &
Relationship to case
OZFOODNET
National Hypothesis
Generating Case
Questionnaire
Interpreter used?
language:
PROBABLE
SOURCE?
ATTEMPTS TO CONTACT CASE
NA – No Answer
THM – Telstra Home Messages
AM – Answering Machine
INT – Interviewed
DT – Disconnected Tone
ET – Engaged Tone
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Date/Time
Online Database
Updated?
.
Yes / No
Date: date.
.
Has the case died?
Yes / No
Date: date.
GP consent to
interview obtained?
Yes / No
Date: date.
If applicable
PHU consent
obtained?
Yes / No
Date: date.
Comments
.
.
.
.
.
.
.
Staff
Initials
.
.
.
.
.
.
.
PRIVACY MESSAGE: information.
In investigations such as these, we are governed by state laws of confidentiality and
privacy.
This limits the amount of information that we are able to feedback about the
investigation.
Please note that we liaise with the State Food Authority, within these laws, to help
prevent any further instances from occurring.
Information Read Y / N
v980615
National Outbreak
SECTION 1: DEMOGRAPHIC DATA
Case Questionnaire
SURNAME/FAMILY NAME:
OTHER NAMES:
PARENT/GUARDIAN NAME: (IF APPLICABLE)
STREET ADDRESS:
SUBURB/TOWN: .
TELEPHONE: H
POSTCODE: .
W
M
(If case if <18 months of age, use different questionnaire at Environmental Factors page)
SEX .sex
AGE .
DOB DOB
EMAIL: .
WERE YOU BORN IN AUSTRALIA? Y / N
Specify Country of Birth
DO YOU IDENTIFY AS BEING OF ABORIGINAL OR TORRES STRAIT ISLANDER ORIGIN?
No / Unknown / Aboriginal / Torres Strait Islander / Both Aboriginal Torres Strait Islander.
LANGUAGE SPOKEN AT HOME?
OCCUPATION (OF CASE OR PARENT/S OF CASE)
high risk occupations include food handlers, health care workers, child care workers and residents of
Institutions (ie: aged care)
>See last page for guidelines
NAME/ADDRESS OF SCHOOL/DAY CARE/INSTITUTION:
DAYS ATTENDED?
Y / N MON
Y / N TUES
Y / N WED
Specify Name of School/Institution.
Y / N THURS
Y / N FRI
(STAYS OVERNIGHT?
.
SECTION 2: TREATING DOCTOR / HOSPITAL
Name of Treating Dr:
.
Address:
.
Telephone:
.
Date of visit to GP:
Facsimile:
Did case present to hospital
(e.g. Emergency Dept)?
Y/N
Was case admitted to hospital?
Y/N
Hospital UR No:
Did the patient die from this
disease?
Language
Y/N
Name of
Hospital:
Date of
Admission:
Date of
Discharge
Date of
Death
DOB
.
.
DOB
DOB
DOB
.
Updated HNEOFN February 2014
2
National Outbreak
SECTION 3: ILLNESS (SUMMARY)
Case Questionnaire
Date of Specimen Collection: .Date
Type of Specimen Faeces / Blood / Urine / Other
Other Specify: Other
What was your first symptom? (see below) .
Onset date of first symptom: Date.
Time of onset: .time
Symptoms
Fever
Nausea
Vomiting
Abdominal pain
Lethargy
Headache
Diarrhoea
Bloody stools
Watery stools
Other (Specify)
.
DURATION OF DIARRHOEA:
Yes/No
(optional)
Date of onset
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
.Date
.Date
.Date
.Date
.Date
.Date
.Date
.Date
.Date
Y/N
.Date
num. Days/Hours.
TOTAL DURATION OF GASTRO SYMPTOMS: num.
Days/Hours.
DATE AND TIME OF RECOVERY: .Date
 Treatment:
Were you given antibiotics to treat this illness? Y / N
If yes: What antibiotics?
.
Are you still taking antibiotics? Y / N
For how days did you take antibiotics? .
Other comments:
.
SECTION 4: CONTACT DATA
In the week (7 days) prior to onset of illness, has the case:




had contact with a family member with a similar illness? Y / N
 give details below:
had contact with a friend or work/school colleague with a similar illness? Y / N
give details:
Name
Relationship
Address and phone (if different to case)
Phone
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
SECTION 5: TRAVEL
Updated HNEOFN February 2014
3
National Outbreak
Case Questionnaire
In the week (7 days) prior to onset of illness, did [you/the case] travel?
Travel Details
Travel
Destination/s (include stopovers):
Specify accommodation:
Date of departure: date.
International / overseas
Y/N
Date of arrival: date.
Mode of transport: Bus / Plane / Train / Cruise.
Provide any details of transport e.g. airline/flight number
Destination/s (include stopovers):
Specify accommodation:
Date of departure: date.
Interstate:
Y/N
Date of arrival: date.
Mode of transport: Bus / Plane / Train / Cruise.
Provide any details of transport e.g. airline/flight number
Destination/s (include stopovers):
Specify accommodation:
Date of departure: date.
Date of arrival: date.
Intrastate:
Y/N
Mode of transport: Bus / Plane / Train / Cruise.
Provide any details of transport e.g. airline/flight number
Destination/s:
Camping/Bushwalking
Y/N
Dates: from: date.
to: date.
Water supply:
If the case has travelled overseas during their incubation period section 6 may not need to be completed
SECTION 6: FOOD HISTORY
Has the case tried any new or different foods recently? Y / N If yes specify:
.
Has the case been on any specific diets lately? Y / N If yes specify: .
Three day (or 7 day) food history:
Complete the 3-day (or 7-day) food history on the following pages. If a detailed 3-day food
history cannot be recalled, request information on what is usually eaten at each meal.
Collect as much detail as possible for each meal (e.g. for a salad sandwich list all
ingredients; for a meal cooked at home list everything eaten) and the number of people that
shared each meal. For each food indicate if the meal was prepared and consumed at
home, and give details of where items/ingredients were purchased. If not eaten at home
give name and address of place where eaten.
If the food history is incomplete or vague, complete the 7-day trawling questionnaire.
Updated HNEOFN September 2008
4
National Outbreak
Case Questionnaire
Day of onset of illness
Meal (list all foods eaten)
Breakfast
.
Between breakfast and lunch
.
Date: .date
Prepared and eaten at home. If yes, give details
of ingredients and where they were purchased:
Prepared elsewhere and eaten at home
(takeaway) If yes, give details of where
purchased (including address):
Prepared and eaten elsewhere.
give details including address:
Yes / No
Yes / No
Yes / No
.
.
.
Yes / No
Yes / No
Yes / No
.
Lunch
.
.
Yes / No
Yes / No
.
Between lunch and dinner
.
Yes / No
.
Yes / No
.
Dinner
.
.
Yes / No
.
After dinner
.
Yes / No
.
Updated HNEOFN September 2008
Yes / No
.
Yes / No
.
If yes,
.
Yes / No
.
Yes / No
.
Yes / No
.
Yes / No
.
5
National Outbreak
Case Questionnaire
Day 1 (day before onset )
Meal (list all foods eaten)
Breakfast
.
Between breakfast and lunch
.
Date: .date
Prepared and eaten at home. If yes, give details
of ingredients and where they were purchased:
Prepared elsewhere and eaten at home
(takeaway) If yes, give details of where
purchased (including address):
Prepared and eaten elsewhere.
give details including address:
Yes / No
Yes / No
Yes / No
.
.
.
Yes / No
Yes / No
Yes / No
.
Lunch
.
.
Yes / No
Yes / No
.
Between lunch and dinner
.
Yes / No
.
Yes / No
.
Dinner
.
.
Yes / No
.
After dinner
.
Yes / No
.
Updated HNEOFN September 2008
Yes / No
.
Yes / No
.
If yes,
.
Yes / No
.
Yes / No
.
Yes / No
.
Yes / No
.
6
National Outbreak
Case Questionnaire
Day 2 (2 days before onset)
Meal (list all foods eaten)
Breakfast
.
Between breakfast and lunch
.
Date: .date
Prepared and eaten at home. If yes, give details
of ingredients and where they were purchased:
Prepared elsewhere and eaten at home (takeaway)
If yes, give details of where purchased (including
address):
Prepared and eaten elsewhere. If
yes, give details including address:
Yes / No
Yes / No
Yes / No
.
.
.
Yes / No
Yes / No
Yes / No
.
Lunch
.
.
Yes / No
Yes / No
.
Between lunch and dinner
.
Yes / No
.
Yes / No
.
Dinner
.
.
Yes / No
.
After dinner
.
Yes / No
.
Updated HNEOFN September 2008
Yes / No
.
Yes / No
.
.
Yes / No
.
Yes / No
.
Yes / No
.
Yes / No
.
7
National Outbreak
Case Questionnaire
Day 3 (3 days before onset)
Meal (list all foods eaten)
Breakfast
.
Between breakfast and lunch
.
Date: .date
Prepared and eaten at home. If yes, give details
of ingredients and where they were purchased:
Prepared elsewhere and eaten at home
(takeaway) If yes, give details of where
purchased (including address):
Prepared and eaten elsewhere. If
yes, give details including address:
Yes / No
Yes / No
Yes / No
.
.
.
Yes / No
Yes / No
Yes / No
.
Lunch
.
.
Yes / No
Yes / No
.
Between lunch and dinner
.
Yes / No
.
Yes / No
.
Dinner
.
.
Yes / No
.
After dinner
.
Yes / No
.
Updated HNEOFN September 2008
Yes / No
.
Yes / No
.
.
Yes / No
.
Yes / No
.
Yes / No
.
Yes / No
.
8
National Outbreak
Case Questionnaire
Where does the case (or the case household) normally obtain the following items of food? This should always
be completed if the 7-day trawling food questionnaire is not completed.
Chicken and other poultry
Chicken and other
poultry
☐Free Range
☐Normal/General
☐Organic
☐Corn Feed
Name of premises
☐ WW
☐ Coles
☐ Aldi
☐ IGA
☐ Butchery
☐ Other
Cuts Purchased :
Would chicken be eaten
☐ Breast
on a weekly basis?
☐ Thigh
☐ yes ☐ no
☐ Tenderloins
How many days per week ☐ Drumsticks
on average would chicken ☐ Kebab
☐ BBQ Chicken
be eaten? 0
☐ Other
specify below
Click here to enter
Name of premises
Any other meats
☐
☐
☐
☐
☐
☐
Eggs
☐Free Range
☐Caged
☐Barn Laid
☐Organic
☐Backyard
State brand if known:
Click here to enter text.
Store eggs in:
☐ In Fridge
☐ Not in fridge
Date Saved: 8 February 2016
document1
WW
Coles
Aldi
IGA
Butchery
Other
Name of premises
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
WW
Coles
Aldi
IGA
Greengrocer
Markets
Backyard chooks
Direct from Farm
Other
Don't know
Address of premises
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
☐Deli ☐Pre-Packed
☐Deli ☐Pre-Packed
☐Deli ☐Pre-Packed
☐Deli ☐Pre-Packed
☐Deli ☐Pre-Packed
Click here to enter text.
☐Deli ☐Pre-Packed
Address of premises
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Address of premises
Click here to enter t.
Click here to enter t.
Click here to enter t.
Click here to enter t.
Click here to enter t.
Click here to enter t.
Click here to enter t.
Click here to enter t.
Page 9
National Outbreak
Case Questionnaire
Did you eat any eggs or something that contains eggs?
☐ Yes
☐ No
☐ Don't know
Please specify what was eaten and how it was cooked and a date if known
Click here to enter text.
Any eggs eaten raw or runny:
☐ Yes
☐ No
☐ Don't know
Enter a batch number if have one
Click here to enter text.
Name of premises
Address of premises
Groceries
Click here to enter text.
☐ WW
Click here to enter text.
☐ Coles
Click here to enter text.
☐ Aldi
Click here to enter text.
☐ IGA
Click here to enter text.
☐ Other
Click here to enter text.
☐ Don't know
Fruit and vegetables
(include roadside stalls and
home grown)
Date Saved: 8 February 2016
document1
Name of premises
☐
☐
☐
☐
☐
☐
☐
☐
WW
Coles
Aldi
IGA
Greengrocer
Markets
Other
Don't know
Address of premises
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Page 10
National Outbreak
Case Questionnaire
In the week (7 days) prior to illness did the case eat or buy food from:
Name and address of premises
Cafes or restaurants
.
.
.
Yes / No / Unknown
Bakery
.
Date & time eaten food: .date
Yes / No / Unknown
Parties or functions with family
or friends
.
Date & time eaten food: .date
Yes / No / Unknown
Takeaway / fast food outlets
What was eaten and when?
.
Date & time eaten food: date.
.
.
Yes / No / Unknown
Date & time eaten food: date.
Festivals or commercial public
gatherings (eg fetes, club
social events, markets, etc.)
.
.
Date & time eaten food: date.
Yes / No / Unknown
Continental deli or specialty
grocer
(e.g. Asian supermarket)
.
.
.
.
Yes / No / Unknown
Farms or growers (farm gate
sales or consumption of
unprocessed products)
Yes / No / Unknown
Were any other attendees at these meals/functions ill with gastro symptoms? Yes / No / Unknown
Date and Time
date.
If yes give details
.
Date Saved: 8 February 2016
document1
Page 11
National Outbreak
Case Questionnaire
SECTION 8: COMMENTS OR CONCLUSIONS
Food samples obtained for the investigation: ☐ yes ☐
Type of Food
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
no give details in the table below:
Date Collected
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Result of Analysis
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
SIGNATURE
How long did it take to complete this questionnaire?
How well did the case recall the information requested?
☐ very well
Choose an item.
☐ well
minutes
☐ not well
☐ not at all
Name of interviewer (please print clearly):
INVESTIGATION NOTES
Date Saved: 8 February 2016
document1
Page 12
National Outbreak
Case Questionnaire
OPTIONAL
SECTION 9: EDUCATION AND EXCLUSIONS
Hygiene and preventing transmission
discussed
☐
Yes
☐
No
☐
N/A
Information requested (brochure)
☐
Yes
☐
No
☐
N/A
Date Sent: Click here to enter a date.
Privacy Information requested
☐
Yes
☐ No
☐
N/A
Date Sent:Click here to enter a date.
Is case a child in care, resident of an institution or in a high-risk occupation?
☐ YES  Continue below
☐
NO  End of questionnaire
Each state to insert any
specific exclusion criteria
☐
CHILD IN CHILD CARE
School / Child care exclusion required
☐
Yes
☐ No
☐
N/A
Exclusion(s) discussed with parent / guardian?
☐
Yes
☐ No
☐
N/A
☐
CHILD CARE WORKER
Work exclusion required?
☐
Yes
☐
No
☐
N/A
Exclusion discussed with case?
☐
Yes
☐
No
☐
N/A
☐
FOOD HANDLER
Work exclusion required?
☐
Yes
☐ No
☐
N/A
Exclusion discussed with case?
☐
Yes
☐
☐
N/A
☐
No
HEALTH CARE WORKER
Work exclusion required?
☐
Yes
☐
No
☐
N/A
Exclusion discussed with case?
☐
Yes
☐
No
☐
N/A
☐
RESIDENT OF AN INSTITUTION (e.g. aged care facility, residential care unit etc)
Isolation required?
Isolation discussed with primary carer?
Date Saved: 8 February 2016
document1
☐
☐
Yes
Yes
☐
☐
No
☐
N/A
Exclusion from school or
child care is required until
diarrhoea has ceased.
It is recommended that the
case be excluded from
work until diarrhoea has
ceased
All food handlers with
diarrhoea are to be
excluded from work until
diarrhoea has ceased.
It is recommended that the
case be excluded from
work until diarrhoea has
ceased
It is recommended that the
case be isolated from well
residents (as far as
practicable) until diarrhoea
has ceased.
Page 13