National Outbreak
Case Questionnaire
7-day trawling questionnaire - to be completed in conjunction with the National Outbreak Questionnaire
In the seven (7) days prior to illness, did the case eat any of the following foods? (Include all foods consumed during the incubation period and note any commercial brands).
Yes / No / Unsure
Yes / No / Unsure
MEAT PRODUCTS - PURCHASED RAW
Specify
Pink when eaten?
Deli / Pre-packaged.
prepared at home from pre-cut chicken parts
Organic / Free Range / Corn Feed / Normal
Yes / No / Unsure
Specify type of cut
Marinated / Seasoned
/ Plan
prepared at home from whole chickens
Yes / No / Unsure
Deli / Pre-packaged.
Organic / Free Range / Corn Feed / Normal
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Fresh value added chicken products cooked/consumed at
home – schnitzel, gourmet ready to cook products (not
purchased frozen)
Deli / Pre-packaged.
minced chicken
minced turkey
Yes / No / Unsure
Specify product
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
other turkey (whole or parts)
Yes / No / Unsure
duck or other poultry (quail, spatchcock)
Yes / No / Unsure
pre-frozen hamburger patties eaten at home
Yes / No / Unsure
fresh (not store-frozen) hamburger at home (rissole)
anything made with minced beef at home
Yes / No / Unsure
Yes / No / Unsure
Other beef (steak, roasts, etc.)
Yes / No / Unsure
Page 1
Purchased / obtained
from?
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
MEAT PRODUCTS - PURCHASED RAW
Specify
veal
Yes / No / Unsure
Yes / No / Unsure
Case Questionnaire
Pink when eaten?
Purchased / obtained
from?
Yes / No / Unsure
MEAT PRODUCTS PURCHASED RAW
sausages – prompt type
Y / N Beef
Y / N Lamb
Specify
Pink when eaten?
Purchased / obtained
from?
.
Yes / No / Unsure
Y / N Chicken
Y / N Pork
Yes / No / Unsure
pork
Yes / No / Unsure
Yes / No / Unsure
lamb
Yes / No / Unsure
.
.
Yes / No / Unsure
kebab –
Y / N Beef
Yes / No / Unsure
.
Specify Flavour
.
Y / N Chicken
Y / N Lamb
Yes / No / Unsure
Y / N Pork
Game meat (venison, pheasant, etc.)— fresh, frozen, or
dried
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
SEAFOOD
Deli / Pre-packaged.
Yes / No / Unsure
Specify Meat.
Specify
Raw /Cooked
.
Purchased / obtained
from?
fish – bought in a shop and cooked at home (prepacked,
from seafood counter)
.
R/C
.
fish – self caught and cooked at home
.
R/C
.
crab
.
R/C
.
oysters
.
R/C
.
clams, mussels, scallops, other shellfish
.
R/C
.
Page 2
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Case Questionnaire
SEAFOOD
Specify
Raw /Cooked
Purchased / obtained
from?
Prawns, lobster, other seafood – fresh, frozen,
prepackaged, type, imported
.
R/C
.
Products containing fish (e.g. fish sticks)
.
R/C
.
R/C
R/C
.
.
Products containing seafood: (e.g. crab sticks, marinara)
smoked or dried fish (e.g., smoked salmon)
.
COOKED, FERMENTED OR SMOKED MEAT
PRODUCTS
any pre-packaged sliced deli meats )
Type / brand
Y / N ham
Y / NRoast beef
Y / N chicken
Y / N Mortadella
Y / N turkey
Y / N Devon
Y / N corned beef
Y / N Strasburg
Y / N pastrami
Y / N Kabana
Purchased / obtained
from?
.
Y / N Specify Other
Yes / No / Unsure
any other sliced DELI meats
(not pre-packaged)
Y / N ham
Y / NRoast beef
Y / N chicken
Y / N Mortadella
Y / N turkey
Y / N Devon
Y / N corned beef
Y / N Strasburg
Y / N pastrami
Y / N Kabana
.
Y / N Specify Other
Yes / No / Unsure
frankfurts –
Deli / Pre-packaged. .
bacon –
Deli / Pre-packaged.
Yes / No / Unsure
Yes / No / Unsure
.
.
Brand.
Deli / Pre-packaged.
Y / N Salami
Page 3
.
National Outbreak
Yes / No / Unsure
Case Questionnaire
COOKED, FERMENTED OR SMOKED MEAT
PRODUCTS
Type / brand
Y / N Pepperoni
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
fresh cream from a carton
Yes / No / Unsure
whipped cream in spray cans
Yes / No / Unsure
natural or flavoured store-bought yogurt
Yes / No / Unsure
frozen yogurt
Yes / No / Unsure
ice cream - tub
Yes / No / Unsure
Deli / Pre-packaged.
other frozen dairy products: (ice cream bars,
frozen dairy dessert, Vitari, Sorbet,
prepackaged cheese cakes)
any unpasteurized (raw) milk
any pasteurized (“regular”) milk
Yes / No / Unsure
Yes / No / Unsure
flavoured milk (e.g., chocolate)
Yes / No / Unsure
powdered milk
.
.
Deli / Pre-packaged.
.
.
MILK & DAIRY PRODUCTS
buttermilk (liquid, not powdered)
Yes / No / Unsure
.
store-bought
Y / N Beef Sticks
Y / N Jerky
other –
Y / N Proscuitto Y / N Speck
Y / N Capocollo
Yes / No / Unsure
Purchased / obtained
from?
Type / brand
Purchased / obtained
from?
.
.
.
.
.
.
.
Y / N Soy.
Y / N Soy .
.
Y / N Soy .
.
Soy Y
/N.
Cows Y
.
/ N goats Y / N soy Y / N
.
.
/ N goats Y / N soy Y / N .
Y / N Full cream Y / N Lite White
Cows Y
Soy
Skim
.
.
Y/N .
.
Page 4
Y/N
.
National Outbreak
Yes / No / Unsure
Case Questionnaire
MILK & DAIRY PRODUCTS
Type / brand
Purchased / obtained
from?
.
.
Yes / No / Unsure
custard (pre-prepared, custard power)
Yes / No / Unsure
dairy desserts (Yogo, Crème Caramel)
Yes / No / Unsure
cheese (packaged)
Yes / No / Unsure
any cheese sold as or cut from solid blocks
.
.
Yes / No / Unsure
cream cheese
.
.
Yes / No / Unsure
sour cream
.
.
Yes / No / Unsure
cottage cheese
Yes / No / Unsure
ricotta
.
.
Yes / No / Unsure
feta
.
.
Yes / No / Unsure
any cheese spread
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Soy
.
Y/N .
.
.
.
.
.
processed cheese (Cheese sticks, Kraft, Le
Snack)
any cheese made from goat or sheep milk
any other imported cheese
any cheese made from unpasteurized milk
(homemade or sold off-the-farm or door-todoor)
Page 5
.
.
.
.
.
.
.
.
.
National Outbreak
Case Questionnaire
Yes / No / Unsure
EGGS
eggs at home
Yes / No / Unsure
Brand if known
.
Type / brand
Y/N
Free range
Y/N
caged
Y/N
organic
Y/N
barn laid
Purchased/ obtained
from
.
Y / N. home laid
Yes / No / Unsure
eggs away from home
Yes / No / Unsure
eggs anywhere that were raw or runny
anything made with raw eggs
Yes / No / Unsure
Yes / No / Unsure
anything made with lightly cooked eggs
How do you cook your eggs?
Yes / No / Unsure
Yes / No / Unsure
.
.
e.g
Y/N
Y/N
Y/N
Y/N
Tiramisu
Cake Batter
Aioli,Caesar
Tartare sauce
Y / N Hollandaise sauce
Y / N Choclate mousse
Y / N Homemade
mayonnaise
Y / N Raw egg milkshake
Y / N Asian pork roll
Y / N homemade custard, Y / N homemade ice cream,
Hard / Medium / Soft
Y / N Fried Y / N Boiled Y / N Scrambled
egg substitute (powdered egg)
.
.
.
Page 6
Y / N Poached
.
.
National Outbreak
Yes / No / Unsure
Case Questionnaire
FRESH VEGETABLES PRODUCE
corn
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
celery
carrots
cucumbers
broccoli
cauliflower
capsicum
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Y/N
Y/N
Y/N
Y/N
chilli
red
orange,
green,
bell)
asparagus
snow peas
other fresh peas
green beans
onions
Yes / No / Unsure
Y / N white,
Y / N red,
Y / N brown
Descriptor
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Page 7
Raw /
Cooked
Type / brand
Purchased / obtained
from?
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
FRESH VEGETABLES PRODUCE
spring onions
leeks
avocado
tomatoes
Y / N truss,
Y / N hydro
Y / N roma
Y / N cherry
Y / N grape
Y / N general
cabbage
alfalfa sprout
bean sprouts
any other sprouts (radish, brocolli)
Salad mix – bagged or sealed
(baby spinach, rocket)
loose salad mix
lettuce iceberg / other
other leafy greens
fresh garlic
fresh ginger
Case Questionnaire
Descriptor
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Page 8
Raw /
Cooked
Type / brand
Purchased / obtained
from?
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
mushrooms
radishes
FRESH FRUIT PRODUCE
apples
pears
peaches
nectarines
apricots
oranges
mandarines
grapefruit
lemons
lime
other citrus fruit specify
cherries
plums
Case Questionnaire
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Descriptor
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Page 9
R/C
.
.
R/C
.
.
Raw /
Cooked
Type / brand
Purchased / obtained
from?
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
FRESH FRUIT PRODUCE
grapes
Y / N white
Y / N black
bananas
canteloupe melon, rockmelon
honeydew melon
watermelon
any other melon specify
kiwi fruit
pineapple
mango
paw paw
blueberries
raspberries
strawberries
other berries specify
packaged fruit salad
any other exotic fruits (Dragonfruit,
Case Questionnaire
Descriptor
Raw /
Cooked
Loose / Sealed / Pre-cut /
Organic / Imported .
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
R/C
.
.
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Page 10
Type / brand
Purchased / obtained
from?
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
FRESH FRUIT PRODUCE
star apple)
herbs
any homegrown
fruits/vegetables/herbs (manure
used?)
Case Questionnaire
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
Loose / Sealed / Pre-cut /
Organic / Imported .
CONVENIENCE AND SNACK FOODS
pre-prepared pasta salad
pre-prepared potato salad
pre-prepared coleslaw
other packaged salads Specify
(Sundried tomatoes,
olives)
Pre-packed antipasto products
nuts
Y / N In shell
Raw /
Cooked
Descriptor
Type / brand
R/C
.
.
R/C
.
.
Purchased / obtained from?
.
.
.
.
.
.
.
Y / N cashew
Y / N peanut
Y / N pistachio
Y / N packaged
Y / N almond
Y / N loose
Y / N other .
Y / N walnut
Page 11
Purchased / obtained
from?
.
.
.
Y / N Mixed/
peanut butter
hazelnut spread (Nutella)
sunflower seeds
sesame seeds
tahini / hommus / halva / other
sesame products
dried fruit – raisins, sultanas,
prune, apricot
packaged dip specify
pâté – prepackaged, deli
Type / brand
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Case Questionnaire
CONVENIENCE AND SNACK FOODS
meat paste
frozen meals (Lean Cuisine,
Weight Watchers)
frozen berries specify
frozen vegetarian products (e.g.
vegieburgers)
frozen chicken strips or nuggets (at
home)
any other frozen chicken products
– schnitzel, kiev
frozen meat products (pies,
sausage rolls, lasagna)
frozen pizza
frozen fish & seafood (fish fingers,
crumbed fish)
dry instant noodles - flavour
soft noodles (refrigerated or shelf
stock)
any foods bought in bulk (where
you fill a bag or
container from a larger bin)
tofu
chocolate
coconut (desiccated, shreaded)
any imported ethnic specialty foods
(sauerkraut, cured sausage)
Pre mix cake ingredients
Pre prepared pancake ingredients
Pasta – Fresh/Frozen pre prepared
cooked at home – Meat filled,
plain, vegetable filled, cheese
filled
Type / brand
DRINKS
Purchased / obtained from?
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Type / brand
Page 12
Purchased / obtained
from?
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Case Questionnaire
freshly squeezed fruit juice – homemade, juice bar,
grocer
Homemade from oranges
.
.
kept in fridge, one day only – in a sealed water jug
freshly made vegetable juice – homemade, juice bar,
grocer
juice from frozen concentrate
commercially bottled water or water cooler
SALAD DRESSINGS AND SAUCES
.
.
.
.
.
.
Type / brand
Purchased / obtained
from?
Yes / No / Unsure
salad dressings specify
.
.
Yes / No / Unsure
mayonnaise (Homemade or Pre-prepared)
.
.
Yes / No / Unsure
sauces / chutneys
.
.
Yes / No / Unsure
cooking sauces, marinades
.
.
Yes / No / Unsure
coconut (milk, cream)
.
.
Yes / No / Unsure
others specify
.
.
Yes / No / Unsure
Yes / No / Unsure
HERBS AND SPICES
Type / brand
any spices bought in bulk (from a bin or other
container)
Purchased / obtained
from?
.
.
Yes / No / Unsure
At home - any spices opened in the 2 weeks before
illness onset specify
.
.
Yes / No / Unsure
dried herbs / spices specify
.
.
Yes / No / Unsure
FOODS FROM COMMERCIAL
PREMISES
BBQ Chicken
Yes / No / Unsure
Purchased / obtained from?
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Page 13
.
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
BURGER at a fast-food outlet –
McDonalds, Takeaway food
premises
BEEF or produce containg beef
prepared or eaten outside the
home
CHICKEN or produce containing
chicken prepared or eaten
outside the home
FISH or produce containg fish
prepared or eaten outside the
home
Commercially prepared deli-type
SANDWICH or filled ROLL
(Deli, McDonalds, sandwich
shop)
SALAD BAR ingredients – self
serve or served for you
PIZZA from a pizzeria
Yes / No / Unsure
BURRITO or “wrap”
Yes / No / Unsure
indicate type of meat:
Case Questionnaire
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Beef
Y / N Pork
Y / N Fish
Y / N Other.
Specify .
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Chicken
Specify .
Specify.
Specify.
Specify.
Specify.
Specify.
Y / N Beef Y / N Chicken
Y / N Other.
Y / N Pork
Y / N Fish
.
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
rice paper rolls
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
.
FOODS FROM COMMERCIAL
PREMISES (Cont.)
kebab / souvlaki (stick, vertical
spit)
Purchased / obtained from?
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Beef
Y / N Chicken Y / N Pork
Y / N Other.
.
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Y / N Fish
National Outbreak
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
Yes / No / Unsure
spring rolls/ dim sim
satay sticks
chicken pieces
pies/ pasties/ sausage rolls
ready to eat pasta products i.e.:
lasagne, filled pasta –
quiche
soft serve ice cream
commercially prepared bakery
products – cake, cheesecake,
finger bun
Case Questionnaire
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
prompt ingredients .
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
FOODS FROM COMMERCIAL
PREMISES (Cont.)
ethnic specific fast foods specify
(Indian, Chinese)
Y / N sushi Y / N sashimi
prompt ingredients
.
.
.
.
.
.
.
.
Purchased / obtained from?
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Page 15
.
.
National Outbreak
.
Yes / No / Unsure
Yes / No / Unsure
pre-prepared meals made
commercially to eat at home
other specify
Yes / No / Unsure
Yes / No / Unsure
Case Questionnaire
BABY FOOD PRODUCTS
Formula (S26) powdered, liquid
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
Y / N Eat in
Y / N Take away
Y / N Purchased to reheat at home
.
.
Type / brand
Purchased / obtained from?
.
.
Yes / No / Unsure
Baby Food – can, glass jar
.
.
Yes / No / Unsure
other
.
.
NOTES:.
Page 16