iPHIS Case ID #: __________
Version: January 19, 2016
Ontario Shigellosis Investigation Tool
Legend
♦ System-Mandatory  Required
for interview with case
Cover Sheet
Date Printed:
Note that this page can be autogenerated in iPHIS
♦ Client Name:
YYYY-MM-DD
Bring Forward Date:
YYYY-MM-DD
iPHIS Client ID #:
Enter number
♦ Investigator:
Enter name
♦ Branch Office:
_
_
Enter office
♦ Reported Date:
Enter health unit
♦ Is this an outbreak associated case?
☐ Yes, OB # ####-####-###
_
Alias:
Enter alias
_
_
♦ Gender: ______________ ♦ Age: ________________________
♦ Gender: Enter gender
♦ Age: Enter age
♦ DOB: __________________________________________
♦ DOB:
YYYY-MM-DD
Address:
______________________________________________
Address:
Enter address
_
1: ###-###-####
Tel. 1: Tel.
________________________________________________
☐ No, link to OB # 0000-2005-043 in iPHIS
Is the client in a high-risk occupation/ environment?
Email 1:
Enter email address
_
_
Email 2:
Enter email address
_
_
_
_
☐ No
Is the client homeless? ☐ Yes
New Address:
♦ Language:
♦ Physician’s Name:
☐ No
Enter address
Specify
_
Translation required? ☐ Yes
☐ No
_
_
Enter name
♦ Role:
☐ Attending Physician ☐ Family Physician
☐ Specialist
☐ Walk-In Physician
☐ Other
☐ Unknown
OPTIONAL
Additional Physician’s Name:
Proxy respondent
Enter name
_
Specify
_
_
Address:
Tel:
☐ Parent/Guardian ☐ Spouse/Partner
☐ Other
_
Type: Home
☐ Home
☐ Mobile
☐ Work ☐ Other, specify:
Type:
 Mobile
 Work
Tel. 2: ###-###-####
 Other, please specify: _____________________________
Type: ☐ Home ☐ Mobile ☐ Work ☐ Other, specify:
♦ Disease: SHIGELLOSIS
Name:
Enter name
YYYY-MM-DD
Diagnosing Health Unit:
☐ Yes
Personal Health Information
_
Role:
Enter name _
Enter address
###-###-####
Fax:
Enter role
_
###-###-####
_
_
Verification of Client’s Identity & Notice of Collection
Client’s identity verified? ☐ Yes, specify: ☐ DOB ☐ Postal Code ☐ Physician
☐ No
Notice of Collection
Please consult with local privacy and legal counsel about PHU-specific Notice of Collection requirements under
PHIPA s. 16. Insert Notice of Collection, as necessary.
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 1 of 14
Ontario Shigellosis Investigation Tool
iPHIS Case ID #: __________
Version: January 19, 2015
Record of File
♦ Responsible
♦ Investigator’s
Date
Name
Signature of
Investigator
Investigator’s
Initials
YYYY-MM-DD
Specify
Specify
Specify
☐ PHI ☐ PHN
☐ Other _______
Assignment Date
YYYY-MM-DD
Specify
Specify
Specify
☐ PHI ☐ PHN
☐ Other _______
Health Unit
Investigation Start Date
Specify
Specify
Designation
Call Log Details
Date
Call 1
Call 2
Call 3
Call 4
Call 5
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
Start
Time
☐AM
☐PM
☐AM
☐PM
☐AM
☐PM
☐AM
☐PM
☐AM
☐PM
Type of Call
Outcome
☐ Outgoing
☐ Incoming
☐ Outgoing
☐ Incoming
☐ Outgoing
☐ Incoming
☐ Outgoing
☐ Incoming
☐ Outgoing
☐ Incoming
☐ contact made
☐ voice mail
☐ contact made
☐ voice mail
☐ contact made
☐ voice mail
☐ contact made
☐ voice mail
☐ contact made
☐ voice mail
Investigator’s
initials
☐ message left with person
☐ no message left
☐ message left with person
☐ no message left
☐ message left with person
☐ no message left
☐ message left with person
☐ no message left
☐ message left with person
☐ no message left
_____
_____
_____
_____
_____
Date letter sent: YYYY-MM-DD
Case Details
♦ Aetiologic Agent
☐ S. boydii (Group C)
☐ S. Non Groupable/Typable
Subtype
Specify
♦ Classification
☐ Confirmed ☐ Probable ☐ Does Not Meet Definition
♦ Classification Date
YYYY-MM-DD.
☐ Confirmed ☐ Probable
☐ Suspect
☐ Does Not Meet Definition
♦ Outbreak
YYYY-MM-DD.
♦ Outbreak Case
Classification
♦ Disposition
♦ Status
♦ Priority
☐ S. flexnerie (Group B)
☐ S. Unspecified
Further Differentiation
☐ S. sonnei (Group D)
☐ S. Other (specify) _____________
Specify
Classification Date
☐ Complete
☐ Closed- Duplicate-Do Not Use
☐ Entered In Error
☐ Lost to Follow Up
☐ Does Not Meet Definition ☐ Untraceable
♦ Disposition Date
YYYY-MM-DD.
☐ Closed
Initial here
♦ Status Date
YYYY-MM-DD.
☐ Open (re-opened)
Initial here
♦ Status Date
YYYY-MM-DD.
☐ Closed
Initial here
♦ Status Date
YYYY-MM-DD.
☐ High
Investigator’s Initials: ____________
☐ Medium
Designation: ☐ PHI
☐ Low
☐ PHN
(At health unit’s discretion)
Other: __________
Page 2 of 14
Ontario Shigellosis Investigation Tool
iPHIS Case ID #: __________
Version: January 19, 2015
Symptoms
Incubation period can range from 12-96 hours, usually 1-3 days, but can be up to one week for S. dysenteriae.
Communicability: during the acute infection and until the infectious agent is no longer present in feces, usually within
weeks after illness. Secondary attack rates in households can be as high as 40%. Asymptomatic carriers may transmit
infection.
Specimen collection date: YYYY-MM-DD.
Abdominal Pain
Refused
Not Asked
Don’t Know
Ensure that
symptoms in bold
font are asked
No
♦ Response
Yes
♦ Symptom
 Use as
 Onset
Onset
(choose
one)
Date
YYYY-MMDD
Onset Time
24-HR Clock
HH:MM
(discretionary)
 Recovery
Date
YYYY-MM-DD
(one date is
sufficient)
☐
☐
☐
☐
YYYY-MMDD.
HH:MM
YYYY-MM-DD.
☐
☐
☐
☐
☐
YYYY-MM-DD.
HH:MM
YYYY-MM-DD.
☐
☐
☐
☐
☐
☐
YYYY-MM-DD.
HH:MM
YYYY-MM-DD.
Nausea
☐
☐
☐
☐
☐
☐
YYYY-MM-DD.
HH:MM
YYYY-MM-DD.
Vomiting
☐
☐
☐
☐
☐
☐
YYYY-MM-DD.
HH:MM
YYYY-MM-DD.
☐
☐
☐
☐
☐
☐
YYYY-MM-DD.
HH:MM
YYYY-MM-DD.
☐
☐
☐
☐
Bloody Diarrhea
☐
Fever
Asymptomatic
Diarrhea
Other, specify
(e.g. Tenesmus,
Toxaemia)
♦ Complications
☐ Hemolytic Uremic Syndrome
☐ None
☐ Other
☐ Unknown
Incubation Period
- 7 days
- 4 days
- 12 hours
onset
YYYY-MM-DD.
YYYY-MM-DD.
YYYY-MM-DD.
YYYY-MM-DD.
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 3 of 14
Ontario Shigellosis Investigation Tool
Immunocompromised
(specify)
(e.g. by medication or by
disease such as cancer,
diabetes, etc.)
Other (specify)
(e.g. use of antacid, surgery,
etc.)
Unknown
Details
If yes, specify
☐ ☐ ☐ ☐
If yes, specify
☐ ☐ ☐ ☐
☐ ☐
Hospitalization & Treatment
Mandatory in iPHIS only if admitted to hospital
Did you go to an emergency
room?
☐ Yes
☐ No
If yes, Name of hospital: Enter name
Date(s): YYYY-MM-DD
♦ Were you admitted to
☐ Yes
☐ No
☐ Don’t recall
If yes, Name of hospital: Enter name
hospital as a result of your
illness (not including stay in
the emergency room)?
iPHIS Case ID #: __________
Not asked
Unknown
No
 Response
Yes
 Medical Risk Factors
Version: January 19, 2015
♦ Date of admission: YYYY-MM-DD
 Date of discharge: YYYY-MM-DD
☐ Unknown discharge date
→ For iPHIS data entry – if the case is hospitalized enter information under Interventions.
Were you prescribed
antibiotics or medication
for your illness?
☐ Yes
☐ No
☐ Don’t recall
If yes, Medication: Enter name
Start date: YYYY-MM-DD
Route of administration: Enter route
Did you take over-thecounter medication?
☐ Yes
☐ No
☐ Don’t recall
If yes, specify
End date: YYYY-MM-DD
Dosage: Enter dosage
Treatment information can be entered in iPHIS under Cases > Case > Rx/Treatments>Treatment as per current iPHIS User
Guide
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 4 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
iPHIS Case ID #: __________
NOTE TO INVESTIGATORS
S. dysenteriae cases should be interviewed based on a 7 day period.
Date of Onset, Age and Sex
Age:
Did you attend any special
functions such as weddings,
parties, showers, family
gatherings or group meals in the
4 days prior to the onset of your
illness?
Behavioural Social Risk
Factors in the 4 days before
onset of illness
Travel
No
☐
☐ Male ☐ Female ☐ Transgender ☐ Unknown
Details
☐
If yes, specify
If yes, specify
☐
☐
☐
If yes, specify (e.g. location, number attended, any ill)
☐
☐
☐
 Response
Details
Not asked
Were you on any specific diet(s)
in the 4 days prior to the onset of
your illness (e.g. vegetarian,
vegan, gluten-free, kosher, halal,
etc.)?
☐
Yes
Do you have any idea how you
became sick?
Sex:
Unsure
Response
Yes
Preliminary Questions
______
Unknown
YYYY-MM-DD
No
Date of Onset:
Complete this section if faxing pages 5-8, 13- 14 to Public Health Ontario is required

Travel outside province in the
last 4 days prior to illness
(specify)
Within Canada
Outside of Canada
☐ ☐ ☐ ☐
☐ ☐ ☐ ☐
From: YYYY-MM-DD
To: YYYY-MM-DD
Where: Specify
From: YYYY-MM-DD
To: YYYY-MM-DD
Where: Specify
☐ ☐ ☐ ☐ Hotel/Resort: Specify
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 5 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
 Food History
iPHIS Case ID #: __________
Required for sporadic cases
Please try to remember what you ate in the last 4 days before you started feeling sick. We’ll start with the day you got
sick and work backwards. If a meal was eaten out, specify where you ate and what was eaten, including garnishes and
beverages.
Day
Day 0
(day of
onset)
Day 1
(1 day
before
onset)
Day 2
(2 days
before
onset)
Day 3
(3 days
before
onset)
Meal AM/ PM
Breakfast
☐ AM
☐ PM
Lunch
☐ AM
☐ PM
Dinner
☐ AM
☐ PM
Snacks
☐ AM
☐ PM
Breakfast
☐ AM
☐ PM
Lunch
☐ AM
☐ PM
Dinner
☐ AM
☐ PM
Snacks
☐ AM
☐ PM
Breakfast
☐ AM
☐ PM
Lunch
☐ AM
☐ PM
Dinner
☐ AM
☐ PM
Snacks
☐ AM
☐ PM
Breakfast
☐ AM
☐ PM
Lunch
☐ AM
☐ PM
Dinner
☐ AM
☐ PM
Snacks
☐ AM
☐ PM
Investigator’s Initials: ____________
Place
Food Consumed
(for establishments, please include
name, address, city/town)
(include name and location of
grocers and restaurants)
Designation: ☐ PHI
☐ PHN
Other: __________
Page 6 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
 Food History
Day
Day 4
(4 days
before
onset)
Required for sporadic cases
Meal AM/ PM
Breakfast
☐ AM
☐ PM
Lunch
☐ AM
☐ PM
Dinner
☐ AM
☐ PM
Snacks
☐ AM
☐ PM
Not asked
Other (specify)
 Consumption of dips
Salsa
Other (specify)
 Consumption of ready-to-eat
products
 Consumption of raw fruits
Details
Unknown
Green salad
(include name and location of
grocers and restaurants)
No
Pasta salad
(for establishments, please include
name, address, city/town)
Yes
Potato salad
Food Consumed
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Foodborne
 Consumption of salad
Place
 Response
Behavioural Social Risk
Factors in the 4 days before
onset of illness
(specify)
iPHIS Case ID #: __________
Investigator’s Initials: ____________
(e.g. Brand name, purchase/consumption location, product
details, date of exposure)
iPHIS character limit: 50.
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Designation: ☐ PHI
☐ PHN
Other: __________
Page 7 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
 Response
No
Unknown
Not asked
☐
☐
☐
☐
☐
☐
☐
☐
Foodborne
 Consumption of raw
vegetables (specify)
 Consumption of
raw/undercooked shellfish
Details
Yes
Behavioural Social Risk
Factors in the 4 days before
onset of illness
 Consumption of
raw/unpasteurized milk/milk
products
Other (specify)
iPHIS Case ID #: __________
(e.g. Brand name, purchase/consumption location, product
details, date of exposure)
iPHIS character limit: 50. Please use ‘Notes’ if needed
Specify
Specify
Specify
☐
☐
☐
☐
☐
☐
☐
☐
Specify
Waterborne
Residential drinking water source?
 Private water system
(specify if treated, e.g. Brita,
boiled, UV light, on tap filter,
reverse osmosis, etc.)
Specify
☐
☐
☐
☐
 Municipal water system
(specify if treated, e.g. Brita,
boiled, UV light, on tap filter,
reverse osmosis, etc.)
Specify
☐
☐
☐
☐
☐
☐
☐
☐
Within Ontario (specify)
☐
☐
☐
☐
Specify
Outside Ontario (specify)
☐
☐
☐
☐
Specify
 Anal-oral contact
☐
☐
☐
☐
Specify
 Close contact with case
☐
☐
☐
☐
Specify
 Poor hand hygiene
☐
☐
☐
☐
Specify
 Other (specify)
☐
☐
☐
☐
Specify
☐
☐
→ For iPHIS data entry – check Yes for Unknown if all other Behavioural
Risk Factors are No or Unknown.
 Recreational water contact
(specify)
Specify
Other Modes of Transmission
 Unknown
♦ Create Exposures
Identify Exposures to be entered in iPHIS. → For iPHIS data entry – record details of exposure(s) in iPHIS Case Exposure
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 8 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
iPHIS Case ID #: __________
Form as required.
Premise Referral
Has a food premise(s) been identified as a
possible source?
☐ Yes
If yes, refer premises to the Food Safety Program and create an
exposure as appropriate.
☐ No
High Risk Occupation/High Risk Environment
Is the client in a high risk
occupation or high risk
environment (including paid and
unpaid/volunteer position)?
☐ Yes
☐ Daycare/kindergarten staff or attendees
☐ No
☐ Food handler
☐ Health care provider
☐ Other (specify)
Occupation: Specify
Name of
Daycare/Kindergarten/Employer
Enter name
Daycare/Kindergarten/Employer
Contact Information (name, phone
number, etc.)
Enter contact information
Address
Enter address
Is the case still infectious?
☐ Yes
☐ No
Exclusion required from
daycare/kindergarten/work?
☐ Yes
Permission to release case’s
diagnosis to
daycare/kindergarten/work?
☐ Yes
☐ No
Last day case attended
daycare/kindergarten/work:
Case/Parent/Guardian advised that
public health unit will contact
daycare/ kindergarten/work?
YYYY-MM-DD
☐ Yes
☐ No
Enter name of individual permission granted by
☐ No
Refer to the current Infectious Diseases Protocol, Shigellosis chapter, Appendix A, Management of Cases section for
exclusion pertaining to day care staff and attendees, food handlers, and health care providers.
→ For iPHIS data entry – if the case is excluded from work or daycare/kindergarten, enter information under
Interventions.
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 9 of 14
Ontario Shigellosis Investigation Tool
iPHIS Case ID #: __________
Version: January 19, 2015
Laboratory Specimen Clearance Results
Specimen Type
Collection Date
YYYY-MM-DD
Result Date
YYYY-MM-DD
Result
Comments/Client Notification
1
2
3
4
5
6
Symptomatic/Asymptomatic Contact Information
Are you aware of anyone who experienced any symptoms before, during, or after you
(or case) became ill? This includes those in your (case’s) family, household, daycare or
kindergarten class, sexual partner(s), friends or coworkers.
☐ Yes
☐ No
☐ N/A
Contact 1
Name
Enter name
Relation to case
Contact information
(phone, address, email)
Enter contact information
Notes
Enter notes
Recommend contact seek medical attention/testing?
☐ Yes
☐ No
Specify
☐ N/A
Contact 2
Name
Enter name
Relation to case
Contact information
(phone, address, email)
Enter contact information
Notes
Enter notes
Recommend contact seek medical attention/testing?
Investigator’s Initials: ____________
☐ Yes
Designation: ☐ PHI
☐ No
☐ PHN
Specify
☐ N/A
Other: __________
Page 10 of 14
Ontario Shigellosis Investigation Tool
iPHIS Case ID #: __________
Version: January 19, 2015
Education/Counselling
Discuss the relevant sections with case
Hand Hygiene
☐
Wash hands with soap and water after using the bathroom, changing diapers and before
preparing meals or eating meals.
Recovery
☐
If you continue to feel unwell, or new symptoms appear/symptoms change – seek medical
attention.
Food Safety
☐
Avoid preparing or serving food while ill with diarrhea or vomiting. Consider reassignment of
duties.
☐
Proper cooking temperatures for all food. Cook and reheat food to a safe internal temperature.
☐
Ensure foods are stored at either below 4ᵒC or above 60ᵒC.
☐
Prevent cross contamination when preparing/handling food:


Water
Fomites
Clean raw vegetables and fruit, including those used as garnishes,
Store raw and cooked foods separately.
☐
Avoid swimming or using a pool/spa, hot tub or splash pad if ill with diarrhea or vomiting, and
until 48 hours after symptoms resolve.
☐
If using well water, test water regularly as water quality can change frequently. If results are
adverse, boil or treat water for consumption.
☐
If using surface water, boil or treat if testing is not readily available (e.g. while camping) or if test
results indicate it is unsafe for consumption.
☐
For more information on small drinking water systems and well disinfection, please visit
www.health.gov.on.ca/english/public/program/pubhealth/safewater/safewater_resources.html
and Public Health Ontario’s Well Disinfection Tool at
http://www.publichealthontario.ca/en/ServicesAndTools/Tools/Pages/Well-DisinfectionTool.aspx.
☐
 Clean and disinfect surfaces (e.g. cutting boards, counters, utensils, diaper changing area,
etc.).


Sexual
Transmission
☐
Certain sexual activities increase the risk of transmission.

☐
A 200 ppm chlorine solution should be sufficient to reach a medium level disinfection to
kill or reduce most bacteria, viruses and fungi to acceptable levels. Mix 1 teaspoon (4mL)
of bleach with 4 cups (1 litre) of water.
A 400 ppm is more appropriate for disinfecting more heavily soiled utensils and surfaces.
Mix 2 teaspoons (8mL) of bleach with 4 cups (1 litre) of water.
Avoid anal-oral sexual contact while symptomatic or with symptomatic individuals.
Review importance of personal hygiene.
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 11 of 14
Ontario Shigellosis Investigation Tool
Education/Counselling
Travel-related
Illness
Discuss the relevant sections with case
☐
Refer to the Government of Canada’s Travel Health and Safety Page: www.phacaspc.gc.ca/tmp-pmv/info/index-eng.php.
☐
In areas where hygiene and sanitation are inadequate:

Bottled water from a trusted source is recommended instead of tap water.
Use bottled water for drinking, preparing food and beverages, making ice,
cooking, and brushing teeth. Alternatively, water can be boiled, chemically
disinfected or filtered. Instructions for each method should be consulted.
 Avoid salads, already peeled or pre-cut fresh fruit, uncooked vegetables, and
unpasteurized milk and milk products, such as cheese.
 Eat only food that has been fully cooked and is still hot, and fruit that has been
washed in clean water and then peeled by the traveler. Avoid buying ready to eat
foods from a street vendor.
☐
Accidental ingestion or contact with recreational water from lakes, rivers, oceans, and
inadequately treated swimming pools can cause many enteric illnesses.
Outcome
Outcome
iPHIS Case ID #: __________
Version: January 19, 2015
Mandatory in iPHIS only if Outcome is Fatal
♦ Fatal
☐ Unknown
☐
☐ Ill
☐ Pending
☐ Residual effects
☐ Recovered
♦ Cause(s) of Death?
Specify
♦ Type of
☐ Reportable Disease Contributed to but was Not the underlying cause of death
Death
☐ Reportable Disease was the Underlying cause of Death
☐ Reportable Disease was Unrelated to the cause of Death
☐ Unknown
Outcome
Date
YYYY-MM-DD
Investigator’s Initials: ____________
Date
Accurate
☐ Yes Specify source (e.g. death certificate)
☐ No
Designation: ☐ PHI
☐ PHN
Other: __________
Page 12 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
iPHIS Case ID #: __________
Interventions
 Intervention Type
♦ Start Date
 End Date
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
YYYY-MM-DD
_____
YYYY-MM-DD
YYYY-MM-DD
☐
_____
YYYY-MM-DD
YYYY-MM-DD
Food Recall
☐
_____
YYYY-MM-DD
YYYY-MM-DD
Hospitalization
☐
_____
YYYY-MM-DD
Letter - Client
☐
_____
YYYY-MM-DD
YYYY-MM-DD
Letter - Physician
☐
_____
YYYY-MM-DD
YYYY-MM-DD
Other (i.e. contacts assessed,
PHI/PHN contact information)
☐
YYYY-MM-DD
YYYY-MM-DD
Intervention
implemented
(check all that
apply)
Investigator’s
initials
Counselling
☐
_____
Education
(e.g. disease fact sheet, general food
safety chart/cooking temperature
chart, handwashing information)
☐
ER visit
☐
Exclusion
_____
_____
→ For iPHIS data entry – enter information under Cases > Case > Interventions.
Thank you
Thank you for your time. This information will be used to help prevent future illnesses caused by Shigella. Please note that
another investigator may contact you again to ask additional questions if it is identified that there is a possibility that you
are included in an outbreak.
Progress Notes
Enter notes
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
Page 13 of 14
Ontario Shigellosis Investigation Tool
Version: January 19, 2015
Shopping Venues
iPHIS Case ID #: __________
Optional for sporadic cases
Where did (you/case) usually purchase food for home consumption (include grocery stores, farmers markets,
specialty stores, ethnic markets, food banks, etc.)?
Don’t know
Name(s), Address(es) and Date(s) of purchase
No
Response
Yes
Types of food premises
☐
☐
☐
Specify
Mini mart (e.g. 7-11)
☐
☐
☐
Specify
Ethnic specialty markets
☐
☐
☐
Specify
Delicatessens/bakeries
☐
☐
☐
Specify
Fish shop, meat shop, butcher’s shop
☐
☐
☐
Specify
Farmer’s market
☐
☐
☐
Specify
Home delivery services (e.g. grocery
gateway, Schwan’s, Meals on Wheels,
etc.)
☐
☐
☐
Specify
Other
☐
☐
☐
Specify
Grocery store/supermarkets/food
warehouse (e.g. Costco)
If yes, do you use any loyalty cards at
the grocery stores identified (e.g.
membership, PC points, Air Miles,
etc.)?
☐ Yes
☐ No
☐ Don’t know
Investigator’s Initials: ____________
Designation: ☐ PHI
☐ PHN
Other: __________
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