LORAIN COUNTY PUBLIC HEALTH/LAW ENFORCEMENT INVESTIGATION
DEMOGRAPHIC INFORMATION
Last Name:
First Name:
Middle Name:
Social Security Number: (e.g. 123-45-6789)
Driver’s License Number:
Gender:
 Male
Age:
DOB: (mm/dd/yyyy)
Address
House No. (e.g. 12345)
City
Ethnicity: (check)
 White  Black/Afr. Amer.
 Amer. Ind./An
Street Name (e.g. E 105th)
State
 Pac. Islander
 Hispanic
 Female
 Other desc. _____________________
Street Ext. (e.g. Dr.)
Zip Code
County
Apt No.
Country of Origin
If not USA, Yrs. in USA
Home Phone: e.g. (440) 345-1111
Work Phone: e.g. (440) 345-1111
Cell Phone: e.g. (440) 345-1111
Pager: e.g. (440) 345-1111
Fax: e.g. (440) 345-1111
Other (please specify):
Occupation (brief description)
Sensitive Occupation (check)
Restricted (check)
 Not Applicable
 Not Applicable
 Food Handler
 Direct Patient Care
 Childcare Attendee/Staff
If yes, where:
Employer’s Name:
Employer’s Address (street no., street name, city, state, zip code):
 Yes
 No
Employer’s Phone (if different
from Work Phone):
Religious Affiliation
Level of Education
Record of Personal Property (bag & tag): __________________________________________________________________
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Last Name:
First Name:
Middle Name:
ACTIVITIES/TRAVEL INFORMATION
Activities within the last 30 days: _____________________________________________________________________
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Normal mode(s) of transportation, including route to and from work everyday:
Did the victim attend a public event within the last 30 days (i.e. sporting event, social function, restaurant, etc.)?
 Yes
 No
If yes, where and dates/times? _______________________________________________________________________
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Did the victim or family travel more than 50 miles in the last 30 days?
 Yes
 No
If yes, where and dates/times? _______________________________________________________________________
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Last Name:
First Name:
Middle Name:
Did travel include airline, cruise ship, train, bus?
 Yes
 No
If yes, provide travel details (flight number, bus number, destination): __________________________________________________
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Did the victim or family travel outside the USA in the last 30 days?
 Yes
 No
If yes, where and dates/times? _______________________________________________________________________
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Did travel include airline, cruise ship, train, bus?
 Yes
 No
If yes, provide travel details (flight number, bus number, destination): __________________________________________________
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Was there contact with any other person who has traveled outside the USA within the last 30 days?
 Yes
 No
If yes, provide names and contact information. ____________________________________________________________
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Last Name:
First Name:
Middle Name:
EXPOSURE/INCIDENT INFORMTION
Recent exposure to: (check all that apply)
If exposed, describe:
 Chemical Agent
 Biological Agent
 Radiological Agent
 Suspected
Identification of agent:
Is agent:
Time/Date of exposure:
Is time/date:  Suspected
 Presumed
 Presumed
 Confirmed
 Confirmed
Potential methods of exposure:
 Inhalation
 Ingestion
Exact location of incident:
 Injection
 Absorption
 Other _________________________________________
Is location:  Suspected  Presumed  Confirmed
Did the victim hear any unusual statements (i.e. threatening statements, information on biological agents)?
 Yes
 No
If yes, what statements? ___________________________________________________________________________
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Did the victim see any unusual devices or anyone spraying anything?
 Yes
 No
If yes, explain. _________________________________________________________________________________
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Has the victim detected any unusual odors or tastes?
 Yes
 No
If yes, what odors/tastes? __________________________________________________________________________
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Last Name:
First Name:
Middle Name:
Were there any potential dispersal devices, laboratory equipment, suspicious activities?
 Yes
 No
If yes, explain. _________________________________________________________________________________
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 Yes
Has the victim been exposed to animals/pets?
If yes, indicate type:
 Dog
 Cat
 Bird
 No
 Reptile
 Amphibian
 Other __________________________
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If yes, where and dates? (zoo, petting zoo, farm, fair, pet store, homes, etc.)
Has the victim noticed any sick or dead animals?
 Yes
 No
If yes, what animals and where? ______________________________________________________________________
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What is the victim’s residential water source?
 City Water
 Well Water
Was there recreational water exposure?
If yes, type:
 Pool
 Spa
 Other ___________________________________________
 Yes
 Bathing Beach
 No
 Lake/River
 Other ____________________________________
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If yes, where and dates?
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Last Name:
First Name:
Middle Name:
MEDICAL INFORMATION
Onset Date: (mm/dd/yyyy)
Onset Time: (e.g. 10:30 am)
Illness Duration: (in hours)
Victim’s account of what happened or how he/she might have gotten sick:
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Did you see a physician for this?
 Yes
 No
Were you hospitalized?
 Yes
If yes, hospital name, admit time/date, location, etc.:
 No
Were samples taken?
 Yes
If yes, appointment time/date, physician’s name, contact information, etc.:
If yes, date(s):
If yes, type(s):
 No
Who collected, tested, analyzed, and had access to samples?
Does the victim have any allergies to medications?
If so, which medications?
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 Yes
 No
 Unknown
9/8/04
Last Name:
First Name:
Middle Name:
SYMPTOMS
(Y=yes, N=no, U=unknown)
SYMPTOMS
Duration
(Y=yes, N=no, U=unknown)
(In hours)
Duration
(In hours)
Y

N

U

Headache
_______
Y

N

U
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Bloody Stools
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
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Chills
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
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Shortness of Breath
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
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
Fever
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


Wheezing
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
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
Fatigue
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

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Sneezing
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
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Muscle Weakness
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
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Wet Cough
_______

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Paralysis
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

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Dry Cough
_______


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Jaundice
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Itchy Skin
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Nausea
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Rash
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Vomiting
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Hives
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Abdominal Cramps
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Watery eyes
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Diarrhea
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Swelling eyes
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Other (desc.)
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Other (desc.)
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Other (desc.)
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Other (desc.)
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Did the victim have contact with an ill person prior to onset of symptoms?
 Yes
 No
If yes, describe. ________________________________________________________________________________
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Does the victim know of others who have the same symptoms?
If yes, provide names, relationship to victim, and contact information.
 Yes
 No
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Does the victim know of anyone else who had become ill or died?
 Yes
 No
If yes, describe. _________________________________________________________________________________
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Last Name:
First Name:
Middle Name:
SAFETY INFORMATION
Is there presence of any information that would indicate a suspicious event?
 Yes
 No
If yes, what information? __________________________________________________________________________
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Are there any safety or security issues for investigating personnel?
 Yes
 No
If yes, what issues? ______________________________________________________________________________
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Is the victim’s disease contagious?
 Yes
 No
 Unknown
Is the agent communicable person-to-person?
 Yes
 No
 Unknown
If yes, what PPE is needed?
Goggles
 Face Shield
 Gloves (latex, Vitron, nitrile, butyl, neoprene)
 Mask (surgical, N-95)
 Powered air purifying respirator (PAPR)
 Aprons
 Half-face respirator w/ canisters
 Chemical resistant suit
 Boots
 Full-face respirator w/ canisters
 Self-contained breathing apparatus (SCBA)
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If yes, what precautions should investigators take?
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Where should sick people be referred?
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Last Name:
First Name:
Middle Name:
INVESTIGATION INFORMATION
What makes the case a suspect? ______________________________________________________________________
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Number of victims:
Is number:  Suspected  Presumed  Confirmed
Cluster of casualties:
Is cluster:
 Suspected  Presumed  Confirmed
If a biological event, is it a single incident or does it involve multiple
releases?
 Single Event
 Multiple Releases
Is this:
 Suspected  Presumed  Confirmed
CASE DISTRIBUTION
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Common denominators among cases: (check all that apply)
 Race
 Socio-economic status
 Religion
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Employment
 Sociopolitical groups/organizations
 Locations
 Events
 Travel
 Other ___________________________________________________________________________
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Last Name:
First Name:
Middle Name:
WITNESSES TO SUSPICIOUS EVENT
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
Name: ___________________________________________________________________________
DOB: ____________________
Complete Address: ______________________________________________________________________________________________
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Types of physical evidence that should be sought:
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