Database ID Number
Treating doctor
consent to interview
case obtained
Case (or proxy)
consent to conduct
interview obtained
Name of person
interviewed (if not
case)
Yes
No
Date of
consent:
/
/
Yes
No
Date of
consent:
/
/
Yes
No
Date:
Interviewer name
Database details
finalised
/
/
Typhoid fever (Salmonella Typhi)
ATTEMPTS TO CONTACT TREATING DOCTOR AND CASE
Date
Time
Comments
LOCAL PRIVACY MESSAGE : The information you provide in this questionnaire is for the purpose of
public health follow-up. We do this by trying to find out what is likely to have caused your illness and also by
providing you with information to reduce the spread of illness to others. The data collected is kept confidential
and identifying information will not be disclosed for any other purpose without your consent.
Information read? 
Updated August 2013
Typhoid fever
SECTION 1: DEMOGRAPHIC DATA
Case Questionnaire
Surname:
Other names:
Street Address:
Suburb/Town:
Telephone:
Postcode:
Home: _________________ Work: _________________ Mobile: ______________________
Date of Birth:
or Age:
Sex:
Country of Birth:
Male
Female
Of Aboriginal or Torres Strait Islander origin?
No
Language(s) spoken at
home:
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Unknown
Interpreter required:
Yes
No
Occupation:
Name / Address of
Employer or School or
Child Care Attended:
Telephone:
Date Last Attended:
/
/
Contact Person::
High Risk occupational group?*
Yes
No
* High risk occupations are food handlers, health care workers, child care workers, children in child care, and residents of institutions (i.e. aged care)
SECTIO N 2: TREATING DOCTOR / HOSPITAL FACILITY
Name of treating doctor:
______________________________________________________________________________
Address:
______________________________________________________________________________
Telephone:
______________________________________
ED presentation :
Date of ED presentation:
Admission to hospital:
Date of admission:
Yes
/
No
Hospital name: ___________________________________
No
Hospital name: ___________________________________
/
Yes
/
Fax: ________________________________
/
Date of discharge:
2
/
/
Typhoid fever
Case Questionnaire
SECTION 3: ILLNESS (SUMMARY)
Onset date of illness: ____/____/____
Date(s) of specimen collection: ____/____/_____ ___/____/____
Specimen type:
Faeces
Blood
Other (specify, e.g. urine) _______________________________
Typhoid immunisation history (if known): ________________________________________________________________
Treatment (list antibiotic(s) and treatment duration: ________________________________________________________
Signs & symptoms
Yes / No / Unknown
Signs & symptoms
Yes / No / Unknown
Malaise
Yes
No
Unk
Body aches
Yes
No
Unk
Anorexia
Yes
No
Unk
Diarrhoea
Yes
No
Unk
Fever
Yes
No
Unk
Constipation
Yes
No
Unk
Headache
Yes
No
Unk
Vomiting
Yes
No
Unk
Cough
Yes
No
Unk
Other (specify below):
e.g. splenomegaly
Yes
No
Unk
Rash / skin spots
Yes
No
Unk
SECTION 4: RISK FACTORS
For the Incubation Period
Risk Factor
/
/
to
(Date 4 weeks prior to onset)
Applies
/
/
(Date 3 day prior to onset)
Details
Travel - Domestic
Yes
No
Places Visited: ………………………………………………………
Type of Accommodation: …………………………………………
Departure: ___ / ___ / ___
Return: ___ / ___ / ___
Illness while away
Yes
No
Travel – International
Yes
No
Places Visited: ………………………………………………………
Type of Accommodation: …………………………………………
Departure: ___ / ___ / ___
Return: ___ / ___ / ___
Illness while away
Yes
No
Yes
No
Case
Mother
Father
Country: ………………………………….………………………….
Any symptoms:
Yes .………………….................................
No
If Yes, go to Section 5
If no travel, was case or
their parents born
overseas?
3
Typhoid fever
Risk Factor
Household / Close
contact of person known
to have travelled
overseas?
Household / Close
contact of person known
to have typhoid infection
or similar illness
Case Questionnaire
Applies
Yes
Details
No
Relationship: …………………………………………………………..
Country visited: ……………………………………………………….
Relationship: …………………………………………………………..
Case name: ……………………………………………………………
Database ID No. (if confirmed): ___________________________
Details: …………………………………………………………………..
Yes
No
Yes
No
Had previous typhoid,
infection?
Yes
No
Approx. date: ___ / ___ / ___
Household / Close
contact known to have
had previous typhoid
infection?
Yes
No
Relationship: …………………………………………………………..
Drank untreated water?
Approx. date: ___ / ___ / ___
Yes
No
Specify type: …………………………………. Date :
_____/_____/_____
Location: ………………………………………………………………..
Participated in swimming
/ water sports?
Yes
No
Activity: ……………………………………..… Date :
_____/_____/_____
Type of water (eg. pool, river, etc): ……………………………….
Address: ……………………………………………………………..
Date: _____/_____/_____
Ate oysters / mussels?
Yes
No
Type / Brand:…………………………………………………………..
Where purchased:……………………………………………………
Date: _____/_____/_____
Ate other shellfish?
Yes
No
Type / Brand:…………………………………………………………..
Where purchased:……………………………………………………
Date: _____/_____/_____
Ate imported foodstuffs?
(if in Australia during
incubation period)
Exposure to
raw/untreated sewage?
Yes
No
Type / Brand:…………………………………………………………..
Where purchased:……………………………………………………
Yes
No
Date: _____/_____/_____
Exposure/activity:…………………………………………………………..
4
Typhoid fever
SECTION 5: LOCAL FOOD EXPOSURES
Case Questionnaire
If the case was in Australia for any part of their incubation period, did they visit / attend any of the following? If no,
skip to Section 6.
Incubation period
/
/
to
(date 2 weeks prior to onset )
Name and address of premises
Cafes or restaurants
yes
no
don’t know
Takeaway / fast food outlets
yes
no
don’t know
Parties or functions with
family or friends
yes
no
don’t know
Festivals or commercial public
gatherings (eg fetes, club
social events, markets,
Moomba etc.)
yes
no
don’t know
Continental deli or specialty
grocer
(e.g. Asian supermarket)
yes
no
don’t know
Farms or growers (farm gate
sales or consumption of
unprocessed products)
yes
no
don’t know
SECTION 6: FOLLOW UP AND EXCLUSIONS FOR CASE
5
/
/
(date 1 day prior to onset)
What was eaten?
Typhoid fever
Case Questionnaire
Exclusion required for high risk occupations (health care workers, food handlers, child care workers). To include children in
child care too.
§ Clearance is defined as: 3 consecutive negative stool cultures. These must be taken under the following conditions – (a)
specimens collected ≥ 1 month after onset, (b) specimens collected ≥48 hours after cessation of antibiotic therapy, (c) individual
specimens taken ≥24hours apart.
‡
For the Incubation Period
/
/
to
(date 2 weeks prior to onset )
Tick box that describes case:
/
/
(date 1 day prior to onset)
Institutional resident
Child in CCC
CCC worker
Health care worker
Food handler
If one of the above is selected, please provide the following information:
Name / address of related
premises / institution:
OR
None of these
………………………………………………………………………………………….................
Date last attended: ____/____/____
Movements of case at work / CCC / institution:
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………………..
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………………..
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………………..
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………………..
Date:_____/_____/_____
Day:………………………. Hours:…………….…… Location:..……………………………..
It is required that if the case is in a high risk setting / occupation,
they be excluded from attendance / work until cleared. §
Exclusion required‡?
Yes
No
Exclusion discussed
with case / guardian /
next-of-kin.
Yes
No
Letter sent to contacts at
premises?
Yes
No
Date sent: ____/____/____
Environmental Health
inspection required?
Yes
No
Contact date: ____/____/____
Contact name:
…………………………………………………………………..
Action required:
…………………………………………………………………
Feed back received:
no
yes, …………………………..
Clearance stools taken§
Yes
No
#1: ___ / ___ /___
#2: ___ / ___ /___
#3: ___ / ___ /___
6
Detected
Detected
Detected
Not Detected
Not Detected
Not Detected
Typhoid fever
Case Questionnaire
SECTION 7: FOLLOW UP (AND EXCLUSIONS) FOR CLOSE HOUSEHOLD / TRAVEL COMPANIONS OF CASE
§IIf
yes, contact to report to GP, or CDC to arrange clearance testing via ACT Pathology. § Clearance is defined as: 2 consecutive negative stool cultures. These specimens must be taken
individually and ≥24hours apart.
‡ Exclusion required for high risk contacts (health care workers, food handlers, child care workers).
Name and contact details
Name:
_______________________________
_______________________________
Address:
_______________________________
_______________________________
Phone:
____________________________
Relationship
to case
Household contact
Travel companion
Other
____________________
____________________
____________________
____________________
Symptoms?
Yes§
No
High risk occupation status / exclusion‡
High risk occupation?
Yes
No
Clearance testing required
Yes§
No
If ‘Yes” specify below & record detail in
notes
Food handler
Healthcare worker
Childcare worker
Aged-care
Worker
____________________________________
If ‘Yes” indicate
via GP (provide name
and contact details)
________________________
________________________
________________________
via CDC / ACT Pathology
High risk occupation status / exclusion‡
Clearance testing required
Results
Stool 1.
/
/
________________
Stool 2 .
/
/
________________
Notes:
Name and contact details
Name:
_______________________________
_______________________________
Address:
_______________________________
_______________________________
Phone:
____________________________
Relationship
to case
Household contact
Travel companion
Other
____________________
____________________
____________________
____________________
Symptoms?
Yes§
No
High risk occupation?
Yes
No
If ‘Yes” specify below & record detail in
notes
Food handler
Healthcare worker
Childcare worker
Aged-care
Worker
____________________________________
Notes:
7
Yes§
No
If ‘Yes” indicate
via GP (provide name
and contact details)
________________________
________________________
________________________
via CDC / ACT Pathology
Results
Stool 1.
/
/
________________
Stool 2 .
/
/
________________
Typhoid fever
Name and contact details
Name:
_______________________________
_______________________________
Address:
_______________________________
_______________________________
Phone:
____________________________
Case Questionnaire
Relationship
to case
Household contact
Travel companion
Other
____________________
____________________
____________________
____________________
Symptoms?
Yes§
No
High risk occupation status / exclusion‡
High risk occupation?
Yes
No
Clearance testing required
Yes§
No
If ‘Yes” specify below & record detail in
notes
Food handler
Healthcare worker
Childcare worker
Aged-care
Worker
____________________________________
If ‘Yes” indicate
via GP (provide name
and contact details)
________________________
________________________
________________________
via CDC / ACT Pathology
High risk occupation status / exclusion‡
Clearance testing required
Results
Stool 1.
/
/
________________
Stool 2 .
/
/
________________
Notes:
Name and contact details
Name:
_______________________________
_______________________________
Address:
_______________________________
_______________________________
Phone:
____________________________
Relationship
to case
Household contact
Travel companion
Other
____________________
____________________
____________________
____________________
Symptoms?
Yes§
No
High risk occupation?
Yes
No
If ‘Yes” specify below & record detail in
notes
Food handler
Healthcare worker
Childcare worker
Aged-care
Worker
____________________________________
Notes:
.
8
Yes§
No
If ‘Yes” indicate
via GP (provide name
and contact details)
________________________
________________________
________________________
via CDC / ACT Pathology
Results
Stool 1.
/
/
________________
Stool 2 .
/
/
________________
Typhoid fever
Case Questionnaire
SECTION 8: EDUCATION
Hygiene and preventing transmission discussed with case
Need to show clearance discussed with case
Information requested by case / guardian / next-of-kin
No
No
No
N/A
N/A
N/A
Yes
Yes
Yes, date sent:
_____ /_____ /_____
Name of completing officer: ________________________________________________________________________
Signature: ____________________________________________
Date: _____ /_____ /_____
INVESTIGATION NOTES
Attach extra investigation sheets if necessary
9