**RECREATIONAL WATER OUTBREAK IN *\[LOCATION\]***

> CASE report number \|\_\_\| - \|\_\_\|\_\_\|\_\_\|
>
> Matched CONTROL #1 \|\_\_\| - \|\_\_\|\_\_\|\_\_\| - \|\_\_\|
>
> Matched CONTROL #2 \|\_\_\| - \|\_\_\|\_\_\|\_\_\| - \|\_\_\|
>
> **NAME OF
> INTERVIEWER\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **CASE: LAST NAME\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FIRST
> NAME\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

# TELEPHONE NUMBER\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

# DATE OF INTERVIEW\|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|\_\_\|\_\_\|

> **[Telephone Contact History]{.underline}**
>
> Date (mm/dd) Time (am/pm) Outcome/Comment Initials
>
> 1.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 2.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 3.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 4.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 5.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 6.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 7.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 8.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 9.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> 10.\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_
>
> **OUTCOME CODES:**
>
> 01 = completed interview 08 = no eligible respondent
>
> 02 = refused interview 09 = language barrier
>
> 03 = no answer 10 = interview terminated within questionnaire
>
> 04 = busy tone 11 = physical/mental impairment
>
> 05 = non-working number 12 = answering machine
>
> 06 = fax machine 13 = setting up a better time
>
> 07 = business phone 99 = unknown

+-----------------------------------------------------------------------+
| > \* TEXT IN REGULAR TYPE IS TO BE READ TO THE RESPONDENT.            |
| >                                                                     |
| > **\* TEXT IN BOLD IS AN INSTRUCTION FOR THE INTERVIEWER AND SHOULD  |
| > NOT BE READ TO THE RESPONDENT.**                                    |
+-----------------------------------------------------------------------+

**ADULT CASE QUESTIONNAIRE**

**RECREATIONAL WATER OUTBREAK IN *\[LOCATION\]***

> **If the case-patient\'s age is unknown,**
>
> **GO TO Q. 1.**
>
> **If the case-patient is 18 years or older,**
>
> **GO TO Q. 7**
>
> **If the case-patient is younger than 18 years but older than or equal
> to 12 years of age, GO TO Q. 15**

##### If the case-patient is younger than 12 years of age, 

##### GO TO PEDIATRIC CASE QUESTIONNAIRE 

### AGE UNKNOWN

> **\[TO THE PERSON ANSWERING THE PHONE IF AN ADULT, OTHERWISE ASK FOR
> AN ADULT\]**
>
> **1.** Hello, my name is \_\_\_\_\_\_\_\_\_. I\'m calling from the
> \_\_\_\_\_\_\_\_ Health Department. We are investigating cases of
> diarrhea occurring among people who live in \_\_\_\_\_\_\_\_\_\_\_
> *\[location\].* To determine what factors may have played a role in
> causing illness among people living in *(your/our)* community, we are
> conducting a survey. Is this the residence of
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> (*case-patient\'s name*)?
>
> \_\_\_ YES **(GO TO Q. 2)**
>
> \_\_\_ NO **(GO TO Q. 1a)**
>
> **1a. If NO,** Do you know at what telephone number I could reach
> (*him/her*)?
>
> \_\_\_ YES,
>
> **(LIST ALTERNATE NUMBER \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)**
>
> Thank you very much for your time.
>
> **END INTERVIEW**
>
> \_\_\_ NO or DON'T KNOW
>
> Is this **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** *\[phone number\]*?
>
> Sorry, I must have the wrong telephone number.
>
> **END INTERVIEW**
>
> **2.** Depending on \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_'s (*case-patient\'s
> name*), we would like to speak with (*him/her*) or (*his/her*) parent
> or guardian. Is \_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*case-patient\'s name*)
> 18 years of age or older?
>
> \_\_\_ YES **(GO TO Q. 3)**
>
> \_\_\_ NO **(GO TO Q. 2a)**
>
> **2a. If NO,** Is (*he/she*) 12 years of age or older?
>
> \_\_\_ YES **(GO TO Q. 16)**
>
> \_\_\_ NO **(GO TO PEDIATRIC CASE QUESTIONNAIRE)**
>
> **3.** May I speak with (*him/her*)?
>
> \_\_\_ YES, already on phone
>
> **(IF THE CASE-PATIENT IS THE PERSON TO WHOM YOU HAVE JUST BEEN
> SPEAKING, GO TO Q. 13)**
>
> \_\_\_ YES, not on phone
>
> **(IF THE CASE-PATIENT IS SOMEONE OTHER THAN WITH WHOM YOU HAVE BEEN
> SPEAKING, GO TO Q. 12)**
>
> \_\_\_ YES, but not home now **(GO TO Q. 4)**
>
> \_\_\_ NO, not able to speak to (*him/her*) **(GO TO Q. 5)**
>
> **4.** Is there another telephone number at which I could reach
> (*him/her*)?
>
> \_\_\_ YES
>
> **(LIST ALTERNATE NUMBER \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)**
>
> Thank you very much for your assistance.
>
> **END INTERVIEW**
>
> \_\_\_ NO **(GO TO Q. 4a).**
>
> **4a.** When would be a good time to call back to reach (*him/her*)?
>
> **(LIST DAY AND TIME \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)**
>
> Thank you very much for your time.
>
> **END INTERVIEW**
>
> **5.** Why am I not able to speak with
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*case-patient\'s
> name*)?
>
> \_\_\_ Died **(GO TO Q. 6)**
>
> \_\_\_ Hospitalized **(GO TO Q. 6)**
>
> \_\_\_ Mentally incapacitated**(GO TO Q. 6)**
>
> \_\_\_ Doesn\'t speak English **(GO TO Q. 6)**
>
> \_\_\_ Other,
> specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> **(GO TO Q. 6)**
>
> **6.** Sorry to have disturbed you. Thank you for your time.
>
> **STOP INTERVIEW**
>
> **[AGE 18 YEARS OR OLDER]{.underline}**
>
> **\[TO THE PERSON ANSWERING THE PHONE IF AN ADULT, OTHERWISE ASK FOR
> AN ADULT\]**
>
> **7.** Hello, my name is \_\_\_\_\_\_\_\_\_. I\'m calling from the
> \_\_\_\_\_\_\_\_ Health Department. We are investigating cases of
> diarrhea occurring among people who live in \_\_\_\_\_\_\_\_\_\_\_
> *\[location\].* To determine what factors may have played a role in
> causing illness among people living in *(your/our)* community, we are
> conducting a survey. Is this the residence of
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> (*case-patient\'s name*)?
>
> \_\_\_ YES **(GO TO Q.8)**
>
> \_\_\_ NO **(GO TO Q. 7a)**
>
> **7a. If NO,** Do you know at what telephone number I could reach
> (*him/her*)?
>
> \_\_\_ YES,
>
> **(LIST ALTERNATE NUMBER \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).**
>
> Thank you very much for your time.
>
> **END INTERVIEW**
>
> \_\_\_ NO or DON'T KNOW
>
> Is this \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ *\[phone number\]*?
>
> Sorry, I must have the wrong telephone number.
>
> **END INTERVIEW**
>
> **8.** May I speak with (*him/her*)?
>
> \_\_\_ YES, already on phone
>
> **(IF THE CASE-PATIENT IS THE PERSON TO WHOM YOU HAVE JUST BEEN
> SPEAKING, GO TO Q. 13)**
>
> \_\_\_ YES, not on phone
>
> **(IF THE CASE-PATIENT IS SOMEONE OTHER THAN WITH WHOM YOU HAVE BEEN
> SPEAKING, GO TO Q. 12)**
>
> \_\_\_ YES, but not home now **(GO TO Q. 9)**
>
> \_\_\_ NO, not able to speak to him/her **(GO TO Q. 10)**
>
> **9.** Is there another telephone number at which I could reach
> (*him/her*)?
>
> \_\_\_ YES
>
> **(LIST ALTERANATE NUMBER \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).**
>
> Thank you very much for your assistance.
>
> **END INTERVIEW**
>
> \_\_\_ NO **(GO TO Q. 9a)**
>
> **9a.** When would be a good time to call back to reach (*him/her*)?
>
> **(LIST DAY AND TIME \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).**
>
> Thank you very much for your time.
>
> **END INTERVIEW**
>
> **10.** Why am I not able to speak with
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*case-patient\'s
> name*)?
>
> \_\_\_ Died **(GO TO Q. 11)**
>
> \_\_\_ Hospitalized **(GO TO Q. 11)**
>
> \_\_\_ Mentally incapacitated **(GO TO Q. 11)**
>
> \_\_\_ Doesn\'t speak English **(GO TO Q. 11)**
>
> \_\_\_ Other,
> specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> **(GO TO Q. 11)**

11. Sorry to have disturbed you. Thank you for your time. **END
    INTERVIEW**

#### TO THE CASE-PATIENT

> **\[TO THE CASE-PATIENT\]**
>
> **12.** Hello, my name is \_\_\_\_\_\_\_\_\_\_\_\_\_\_. I'm calling
> from the \_\_\_\_\_\_\_\_\_\_\_ Health Department.
>
> **13.** We are investigating cases of diarrhea occurring among people
> who live in \_\_\_\_\_\_\_\_\_\_ (*location*). We are conducting a
> survey to help us determine what factors may have played a role in
> causing illness among people living in *(your/our)* community.
>
> We realize that you may have already spoken to the Health Department;
> however, we are interested in finding out more about this illness so
> that we can develop guidelines for preventing and controlling
> Cryptosporidiosis, the diarrheal disease that we have seen in
> *(your/our)* community.
>
> You have been selected to participate in this survey because of your
> illness. The answers that you give will remain confidential. Your
> participation in these efforts will greatly enhance our understanding
> of this illness in *(your/our)* community.
>
> This should take approximately \_\_\_\_\_\_\_\_\_ minutes (*adjust
> time for number of questions to be asked*). Your participation is
> voluntary and all information you give will be kept confidential to
> the extent legally possible. Some of the questions may be sensitive.
> You may refuse to answer any question at any time. Neither your name
> nor any identifying information will appear on any report. We will be
> happy to answer all your questions at the end of the interview. A
> final report will be available at the health department.
>
> Do you agree to participate in this survey?
>
> \_\_\_ NO, **END INTERVIEW**...Sorry to have disturbed you. Thank you
> for your time.
>
> \_\_\_ I DON'T HAVE TIME NOW, **END INTERVIEW** **(GO TO Q. 14)**
>
> \_\_\_ YES, **CONTINUE INTERVIEW**\... It would be helpful if you had
> a calendar in front of you, as we will be discussing specific dates.
> Would you like a minute to get one? **(GO TO Q. 13a)**
>
> **13a.** May we begin now?

## 

> \_\_\_ YES **(GO TO Q. 29)**
>
> \_\_\_ NO **(GO TO Q. 14)**
>
> **14.** Your participation in this study is very important. We are
> trying to determine why people in the community are getting sick. May
> I schedule a time to talk that would be more convenient for you?
>
> \_\_\_ YES **(LIST DATE AND TIME** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> **)**.
>
> Thank you very much for your time. We will call you again at the
> arranged time.
>
> **END INTERVIEW**
>
> \_\_\_ NO...Sorry to have disturbed you. **END INTERVIEW**

######### YOUNGER THAN 18 YEARS BUT OLDER THAN OR EQUAL TO 12 YEARS OF AGE 

> **\[TO THE PERSON WHO ANSWERS THE PHONE IF AN ADULT, OTHERWISE ASK FOR
> AN ADULT\]**
>
> **15.** Hello, my name is \_\_\_\_\_\_\_\_\_. I\'m calling from the
> \_\_\_\_\_\_\_\_ Health Department. We are investigating cases of
> diarrhea occurring among people who live in \_\_\_\_\_\_\_\_\_\_\_
> *\[location\].* To determine what factors may have played a role in
> causing illness among people living in *(your/our)* community, we are
> conducting a survey. Is this the residence of
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> (*case-patient\'s name*)?
>
> \_\_\_ YES **(GO TO Q. 16)**
>
> \_\_\_ NO **(GO TO Q. 15a)**
>
> **15a. If NO,** Do you know at what telephone number I could reach
> (*him/her*)?
>
> \_\_\_ YES
>
> **(LIST ALTERANATE NUMBER\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_)**
>
> Thank you very much for your time.
>
> **END INTERVIEW**
>
> \_\_\_ NO or DON'T KNOW
>
> Is this \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ *\[phone number\]*?
>
> Sorry, I must have the wrong telephone number.
>
> **END INTERVIEW**
>
> **16.** Are you (*his/her*) parent or guardian?
>
> \_\_\_ YES **(GO TO Q. 19)**
>
> \_\_\_ NO **(GO TO Q. 17)**
>
> **17.** Could I speak with (*his/her*) parent or guardian?
>
> \_\_\_ YES **(GO TO Q. 18)**
>
> **\_\_\_** YES, but not at home now (**GO TO Q.23)**
>
> \_\_\_ NO, not able to speak to him/her **(GO TO Q. 17a)**
>
> **17a.** Your family's participation in this study is very important.
> We are trying to determine why people in the community are getting
> sick. May I schedule a time to talk with (*him/her*) that would be
> more convenient?
>
> \_\_\_ YES **(LIST DATE AND TIME** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> **)**.
>
> Thank you very much for your time. We will call you again at the
> arranged time.
>
> **END INTERVIEW**
>
> \_\_\_ NO or DON'T KNOW...Sorry to have disturbed you.
>
> **END INTERVIEW**

**\[TO THE PARENT OR GUARDIAN\-\--ADULT PERMISSION\]**

> **18.** Hello, my name is \_\_\_\_\_\_\_\_\_\_\_\_\_\_. I'm calling
> from the \_\_\_\_\_\_\_\_\_\_\_ Health Department.
>
> **19.** We are investigating cases of diarrhea occurring among people
> who live in \_\_\_\_\_\_\_\_\_\_ (*location)*. We are conducting a
> survey to help us determine what factors may have played a role in
> causing illness among people living in *(your/our)* community.
>
> We realize that you may have already spoken to the Health Department;
> however, we are interested in finding out more about this illness so
> that we can develop guidelines for preventing and controlling
> Cryptosporidiosis, the diarrheal disease that we have seen in
> *(your/our)* community.
>
> *(Child's name\_\_\_\_\_\_\_\_)* has been selected to participate in
> this survey because of *(his/her)* illness. The answers that
> *(he/she)* gives will remain confidential. Your child's participation
> in these efforts will greatly enhance our understanding of this
> illness in *(your/our)* community.
>
> This should take approximately \_\_\_\_\_\_\_\_\_ minutes (*adjust
> time for number of questions to be asked*). Your child's participation
> is voluntary and all information *(he/she)* gives will be kept
> confidential to the extent legally possible. Some of the questions may
> be sensitive. Your child may refuse to answer any question at any
> time. Neither your child's name nor any identifying information will
> appear on any report. We will be happy to answer all your questions at
> the end of the interview. A final report will be available at the
> health department.
>
> Do you agree to allow your child to participate in this survey?
>
> \_\_\_ NO, **END INTERVIEW**...Sorry to have disturbed you. Thank you
> for your time.
>
> \_\_\_ WE DON'T HAVE TIME NOW, **END INTERVIEW** **(GO TO Q. 21)**
>
> \_\_\_ YES **(GO TO Q. 20)**
>
> **20.** May I have your permission to speak with
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*child's name*)?
>
> \_\_\_ YES **(GO TO Q. 22)**
>
> \_\_\_ NO **(GO TO Q. 21)**
>
> **21.** Your child\'s participation in this study is very important.
> We are trying to determine why people in the community are getting
> sick. May I schedule a time to talk with (*him/her*) that would be
> more convenient?
>
> \_\_\_ YES
>
> **(LIST DATE AND TIME** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **)**.
>
> Thank you very much for your time. We will call you again at the
> arranged time.
>
> **END INTERVIEW**
>
> \_\_\_ NO or DON'T KNOW...Sorry to have disturbed you.
>
> **END INTERVIEW**

22. May I speak with \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*child's name*)?

> \_\_\_ YES **(GO TO Q. 27)**
>
> \_\_\_ YES but not home **(GO TO Q. 23)**
>
> \_\_\_ YES but not able **(GO TO Q. 25)**
>
> **23.** Is there another telephone number at which I could reach
> (*him/her*)?
>
> \_\_\_ YES
>
> **(LIST ALTERNATE NUMBER \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).**
>
> Thank you very much for your assistance.
>
> **END INTERVIEW**
>
> \_\_\_ NO **(GO TO Q. 24)**
>
> **24.** When would be a good time to call back at this number to reach
> (*him/her*)?
>
> **(LIST DAY AND TIME \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).** Thank
> you very much for your time.
>
> **END INTERVIEW**
>
> **25.** Why am I not able to speak with
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*child's name*)?
>
> \_\_\_ Died **(GO TO Q. 26)**
>
> \_\_\_ Hospitalized **(GO TO Q. 26)**
>
> \_\_\_ Mentally incapacitated**(GO TO Q. 26)**
>
> \_\_\_ Doesn\'t speak English **(GO TO Q. 26)**
>
> \_\_\_ Other,
> specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> **(GO TO Q. 26)**

26. Sorry to have disturbed you. Thank you for your time. **END
    INTERVIEW**

> **\[TO THE CASE-PATIENT\-\--12-17 YEAR OLD ASSENT\]**
>
> **27.** Hello, my name is \_\_\_\_\_\_\_\_\_\_\_\_\_\_. I'm calling
> from the \_\_\_\_\_\_\_\_\_\_\_ Health Department. We are
> investigating cases of diarrhea occurring among people who live in
> \_\_\_\_\_\_\_\_\_\_ (*location)*. We are conducting a survey to help
> us determine what factors may have played a role in causing illness
> among people living in *(your/our)* community.
>
> We realize that you may have already spoken to the Health Department;
> however, we are interested in finding out more about this illness so
> that we can develop guidelines for preventing and controlling
> Cryptosporidiosis, the diarrheal disease that we have seen in
> *(your/our)* community.
>
> You have been selected to participate in this survey because of your
> illness. The answers that you give will remain confidential. Your
> participation in these efforts will greatly enhance our understanding
> of this illness in *(your/our)* community.
>
> This should take approximately \_\_\_\_\_\_\_\_\_ minutes *\[adjust
> time for number of questions to be asked\]*. Your participation is
> voluntary and all information you give will be kept confidential to
> the extent legally possible. Some of the questions may be sensitive.
> You may refuse to answer any question at any time. Neither your name
> nor any identifying information will appear on any report. We will be
> happy to answer all your questions at the end of the interview. A
> final report will be available at the health department.
>
> Do you agree to participate in this survey?
>
> \_\_\_ NO, **END INTERVIEW**...Sorry to have disturbed you. Thank you
> for your time.
>
> \_\_\_ I DON'T HAVE TIME NOW, **END INTERVIEW** **(GO TO Q. 28)**
>
> \_\_\_ YES, **CONTINUE INTERVIEW**\... It would be helpful if you had
> a calendar in front of you, as we will be discussing specific dates.
> Would you like a minute to get one in front of you? **(GO TO Q. 27a)**
>
> **27a.** May we begin now?

## 

> \_\_\_ YES **(GO TO Q. 29).** Please have your parent or guardian
> present to help you with the questions.
>
> \_\_\_ NO **(GO TO Q. 28)**
>
> **28.** Your participation in this study is very important. We are
> trying to determine why people in the community are getting sick. May
> I schedule a time to talk that would be more convenient for you?
>
> \_\_\_ YES **(LIST DATE AND TIME** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> **)**. Thank you very much for your time. We will call you again at
> the arranged time. **END INTERVIEW**
>
> \_\_\_ NO...Sorry to have disturbed you. **END INTERVIEW**

#### CASE DEFINITION

> **29.** Before we continue, between \_\_\_\_\_\_\_\_\_\_
> (*MM/DD/YYYY*) and \_\_\_\_\_\_\_\_\_\_ (*MM/DD/YYYY*), were you ill
> with diarrhea, meaning three or more loose or watery stools or bowel
> movements in a 24-hour period, if that is unusual for you?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
> **(GO TO Q. 30)**
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(GO TO Q. 29a)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77 **(GO TO Q.
> 29a)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99 **(THANK
> RESPONDENT, END INTERVIEW)**
>
> **29a.** Between \_\_\_\_\_\_\_\_\_\_ (*MM/DD/YYYY*) and
> \_\_\_\_\_\_\_\_\_\_ (*MM/DD/YYYY*), did you have any amount of
> diarrhea?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
> **(GO TO Q. 29b)**
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(THANK RESPONDENT,**
>
> **END INTERVIEW)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77 **(THANK
> RESPONDENT,**
>
> **END INTERVIEW)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99 **(THANK
> RESPONDENT,**
>
> **END INTERVIEW)**
>
> **29b.** Have you had a positive *Cryptosporidium* lab test on a stool
> sample you submitted to a healthcare provider?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
> **(GO TO SECTION A, Q.A-1)**
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(THANK RESPONDENT,**
>
> **END INTERVIEW)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(THANK
> RESPONDENT,**
>
> **END INTERVIEW)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\..... 99 **(THANK
> RESPONDENT,**
>
> **END INTERVIEW)**
>
> **30.** Have you had a positive *Cryptosporidium* lab test on a stool
> sample you submitted to a healthcare provider?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\..... 99
>
> \|\_\_\| **CASE**
>
> Beginning \_\_\_\_\_\_\_\_\_\_(*MM/DD/YYYY*) through
> \_\_\_\_\_\_\_\_\_\_(*MM/DD/YYYY*): at least 1 day of diarrhea (3
> loose stools within a 24 hour period)
>
> *OR*
>
> any diarrhea beginning \_\_\_\_\_\_\_\_\_\_(*MM/DD/YYYY*) through
> \_\_\_\_\_\_\_\_\_\_(*MM/DD/YYYY*) and a positive cryptosporidium lab
> test
>
> \|\_\_\| **NOT A CASE**
>
> NO diarrhea beginning \_\_\_\_\_\_\_\_\_\_(*MM/DD/YYYY*) through
> \_\_\_\_\_\_\_\_\_(*MM/DD/YYYY*)
>
> **[SECTION A.]{.underline} CLINICAL INFORMATION**
>
> **Number range CHAPTERBEFORE YOU INTERVIEW THE CASE, HAVE A CALENDAR
> IN FRONT OF YOU.**
>
> **read:** I WOULD NOW LIKE TO ASK YOU SOME ADDITIONAL QUESTIONS ABOUT
> YOUR ILLNESS.
>
> **A1.** On what date did your diarrhea (loose or watery stools) begin?
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> MM DD YY
>
> **IF RESPONDENT CANNOT REMEMBER THE EXACT DATE THE DIARRHEA BEGAN,
> PROMPT FOR THE *[WEEK]{.underline}* THE DIARRHEA BEGAN. ENTER THE DATE
> OF WEDNESDAY OF THAT WEEK**
>
> **A2.** **If not exact date diarrhea began, enter**
>
> ***approximate date***
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> MM DD YY
>
> **THE EXPOSURE PERIOD OF INTEREST WILL BE FROM 2 WEEKS BEFORE THE
> ONSET DATE (dATE FROM a1 OR a2) UP TO AND INCLUDING THE ONSET DATE
> (dATE FROM a1 OR a2). rECORD THIS 2-WEEK PERIOD IN THE SPACE BELOW for
> use in asking the exposure questionS:**
>
> **EXPOSURE PERIOD FROM**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> **TO**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> MM DD YY MM DD YY
>
> (onset date minus 2 wks) (onset date from A1 or A2)
>
> **A3.** When your diarrhea was at its worst, what was the
> ***[maximum]{.underline}*** number of loose or watery stools you had
> in a 24-hour period during this illness?
>
> **NUMBER** **\|\_\_\|\_\_\|**
>
> UNKNOWN\...\...\...\...\...\...\...77
>
> REFUSED\...\...\...\...\...\...\...\....99
>
> **A4.** Did you have blood in your stool?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.... 2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\.....99
>
> **A5.** Was there a period when your diarrhea went away for at least a
> day and then came back?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(GO TO A7)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77 **(GO TO A7)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A7)**
>
> **A6.** **IF YES TO A5,** How many times did this happen?
>
> **\|\_\_\|\_\_\|** Times
>
> **A7.** Do you currently have diarrhea?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.... 1
> **(GO TO A9)**
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77 **(GO TO A9)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A9)**
>
> **A8.** **IF** **NO TO A7**, What date did the diarrhea
> ***[completely]{.underline}*** end (include ***[all]{.underline}*** of
> the diarrhea free days if there were any)?
>
> Date: **\|\_\_\|\_\_\| - \|\_\_\|\_\_\| -** \|\_\_\|\_\_\|
>
> MM DD YY
>
> **A9. *[In addition to diarrhea]{.underline}*,** which of the
> following symptoms did you have, and how long did you experience each
> from beginning to end, regardless of whether you felt better on some
> days in between? **\[READ THE LIST OF SYMPTOMS. IF YES, ENTER THE
> CORRESPONDING DURATION FOR EACH.\] (U=UNKNOWN; R=REFUSED)**

+-----------------+-----+-----+------+-------+-------+-----+--------+
| **SYMPTOM**     | **0 | **1 | *    | *     | *     | **  | **R**  |
|                 | day | da  | *2-5 | *6-14 | *\>14 | U** |        |
|                 | s** | y** | da   | d     | d     |     |        |
|                 |     |     | ys** | ays** | ays** |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **a.** Nausea   | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **b.** Vomiting | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **c**. Headache | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **d**. Loss of  | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
| appetite        |     |     |      |       |       |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **e.**          | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
| Abdominal       |     |     |      |       |       |     |        |
| cramps          |     |     |      |       |       |     |        |
| (non-menstrual) |     |     |      |       |       |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **f.**          | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
| Gas/Bloating    |     |     |      |       |       |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **g.**          | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
| Body/Muscle     |     |     |      |       |       |     |        |
| aches           |     |     |      |       |       |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **h.**          | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
| Ti              |     |     |      |       |       |     |        |
| redness/Fatigue |     |     |      |       |       |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+
| **i**. Fever or | 0   | 1   | 2    | 6     | 14    | 77  | 99     |
| felt feverish   |     |     |      |       |       |     |        |
|                 |     |     |      |       |       |     |        |
| **IF YES, GO TO |     |     |      |       |       |     |        |
| A10,**          |     |     |      |       |       |     |        |
|                 |     |     |      |       |       |     |        |
| **IF NO GO TO   |     |     |      |       |       |     |        |
| A11.**          |     |     |      |       |       |     |        |
+-----------------+-----+-----+------+-------+-------+-----+--------+

> **A10.** **If yES TO fever,** What was the highest temperature
> measured?

a.  **NUMBER** \|\_\_\|\_\_\|\_\_\| **.** \|\_\_\| **degrees F**

> **OR**
>
> **b. NUMBER** \|\_\_\|\_\_\|\_\_\| **.** \|\_\_\| **degrees C**
>
> Felt warm/feverish, but temperature not measured ....222.2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...........................\...\....777.7
>
> REFUSED\...\...\...\...\...\...\...\...\...................................
> 999.9
>
> **A11**. Have you experienced any weight loss as a result of your
> symptoms?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(GO TO A13)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77 **(GO TO A13)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A13)**
>
> **A12**. **IF YES TO A11,** Approximately how many pounds did you
> lose?
>
> **\|\_\_\|\_\_\| POUNDS**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99
>
> **A13**. Did you seek health care for any symptoms?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(GO TO A16)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...77 **(GO TO A16)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A16)**
>
> **A14.** Once your diarrhea began, how long were you ill before you
> contacted or visited a doctor, nurse, or other healthcare provider?
>
> **NUMBER \|\_\_\|\_\_\|\_\_\|** **days**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...777
>
> REFUSED...\...\...\...\...\...\...\...\...\...\...\...\...\...\...999
>
> **A15**. The following questions are about treatment for your illness.
>
> **(CHECK ALL THAT APPLY)** Y N U R
>
> **A15a.** Was a healthcare provider consulted over the phone? 1 2 77
> 99
>
> **A15b.** Did you visit a healthcare provider's office? 1 2 77 99
>
> **A15c.** Did you visit an Emergency Room? 1 2 77 99
>
> **A15d.** Were you hospitalized for more than 24 hours? 1 2 77 99
>
> **A15e**. **IF YES**, How long were you hospitalized? \|\_\_\|\_\_\|
> **DAYS**
>
> UNKNOWN\...\...77
>
> REFUSED\...\...\....99
>
> **A16**. What treatment did you use for your symptoms?
>
> **(CHECK ALL THAT APPLY)**:
>
> **Y N U R**
>
> A16a. Nothing **\[IF YES GO TO A17\]** 1 2 77 99
>
> A16b. OTC antidiarrheal medications (i.e. Peptobismol) 1 2 77 99
>
> A16c. Herbal remedies 1 2 77 99
>
> A16d. Antibiotics/Antiparasitics 1 2 77 99
>
> A16e. Any prescription medications 1 2 77 99
>
> A16f. Dehydration medications (Pedialyte) 1 2 77 99
>
> A16g. Drank more fluids 1 2 77 99
>
> A16h. Received intravenous fluids 1 2 77 99
>
> A16i. Fever/Pain reliever 1 2 77 99
>
> A16j. Other (specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 1 2 77 99
>
> **A17.** When your illness began, were you employed -- meaning you had
> a paid job performed either outside or inside the home?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
> **(GO TO A20)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\....77 **(GO TO A20)**
>
> REFUSED...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A20)**
>
> **A18.** **IF YES TO A17**, During your illness, did you miss any time
> from work, for example because you called in sick or took time off to
> see a doctor?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
> **(GO TO A20)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\....77 **(GO TO A20)**
>
> REFUSED...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A20)**
>
> **A19. If yes TO A18,** How many days were you unable to work for all
> or part of the day? \|\_\_\_\|\_\_\_\| **days**
>
> **(IF IN HOURS, i.e. \<1 DAY, THEN CODE** **AS ZERO)**
>
> UNKNOWN .......................77
>
> REFUSED........................\...99
>
> **A20.** Did this illness prevent you from performing daily activities
> such as school, recreation, or vacation activities, or working within
> the home?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
> **(GO TO A22)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\....77 **(GO TO A22)**
>
> REFUSED...\...\...\...\...\...\...\...\...\...\...\... 99 **(GO TO
> A22)**
>
> **A21.** **If yes TO A20**, How many days were you unable to perform
> your usual
>
> daily activities for part or all of the day? \|\_\_\_\|\_\_\_\| **days
> (IF IN HOURS, i.e. \<1 DAY, THEN CODE AS ZERO)**
>
> UNKNOWN..............................77
>
> REFUSED.................................99
>
> **A22.** Did you continue to do water activities (swimming, water
> parks, etc.) while you had diarrhea?
>
> YES....................................1
>
> NO.....................................2
>
> UNKNOWN..........................77
>
> REFUSED............................99
>
> **A23.** Did you prepare food for others while you had diarrhea?
>
> YES....................................1
>
> NO.....................................2
>
> UNKNOWN..........................77
>
> REFUSED............................99
>
> **A24.** Did you participate in water activities (pool, water parks,
> etc.) within the 2 week period after your diarrhea ended?
>
> YES......................................1
>
> NO....................................\...2
>
> UNKNOWN........................\....77
>
> REFUSED..............................99
>
> **A25.** Are you aware of anyone in your immediate household or social
> group that had diarrhea a week or two ***[before]{.underline}*** your
> symptoms began?
>
> YES.....................................1
>
> NO......................................2
>
> UNKNOWN........................\...77
>
> REFUSED...........................\...99
>
> **A26.** Are you aware of anyone in your immediate household or social
> group that had diarrhea ***[while]{.underline}*** you had your
> symptoms?
>
> YES.....................................1
>
> NO......................................2
>
> UNKNOWN........................\...77
>
> REFUSED.............................99
>
> **A27.** Are you aware of anyone in your immediate household or social
> group that had diarrhea during the 2 weeks ***[after]{.underline}***
> your symptoms began?
>
> YES.....................................1
>
> NO......................................2
>
> UNKNOWN........................\...77
>
> REFUSED.............................99
>
> **A28.** Do you have a weakened immune system? Conditions such as
> cancer, HIV, organ transplant and/or receiving steroid treatment can
> cause a weakened immune system. This does not include inhaled steroids
> for asthma therapy.
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\....77
>
> REFUSED...\...\...\...\...\...\...\...\...\...\...\... 99
>
> **A29.** Do you have any long lasting or chronic illness or condition
> in which diarrhea or vomiting is a major symptom, such as irritable
> bowel syndrome, ulcerative colitis, partial removal of the stomach or
> intestines, stomach or esophagus problems, or Crohn's disease?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\....77
>
> REFUSED...\...\...\...\...\...\...\...\...\...\...\... 99
>
> **[SECTION B.]{.underline} PERSON-TO-PERSON CONTACT AND CHILDCARE
> INFORMATION**
>
> **read:** NOW I WOULD LIKE TO ASK ABOUT THE ADULTS (18 YEARS OF AGE OR
> OLDER) IN YOUR HOUSE.
>
> **B1.** What are the adult's sexes and did they have diarrhea during
> the 2 weeks before you became ill? **(QUESTION A2)**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> **TO**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|

+--------------------+------+--------+--------+--------+--------+------+
| **ADULT**          | What |        | Had    |        |        |      |
|                    | sex? |        | dia    |        |        |      |
|                    |      |        | rrhea? |        |        |      |
|                    | **(1 |        |        |        |        |      |
|                    | =MAL |        | **YES  |        |        |      |
|                    | E,** |        | NO UNK |        |        |      |
|                    |      |        | REF**  |        |        |      |
|                    | *    |        |        |        |        |      |
|                    | *2=F |        |        |        |        |      |
|                    | EMAL |        |        |        |        |      |
|                    | E)** |        |        |        |        |      |
+--------------------+------+--------+--------+--------+--------+------+
| **ADULT 1**        | 1    | 2      | 1      | 2      | 77     | 99   |
+--------------------+------+--------+--------+--------+--------+------+
| **ADULT 2**        | 1    | 2      | 1      | 2      | 77     | 99   |
+--------------------+------+--------+--------+--------+--------+------+
| **ADULT 3**        | 1    | 2      | 1      | 2      | 77     | 99   |
+--------------------+------+--------+--------+--------+--------+------+
| **ADULT 4**        | 1    | 2      | 1      | 2      | 77     | 99   |
+--------------------+------+--------+--------+--------+--------+------+
| **ADULT 5**        | 1    | 2      | 1      | 2      | 77     | 99   |
+--------------------+------+--------+--------+--------+--------+------+
| **ADULT 6**        | 1    | 2      | 1      | 2      | 77     | 99   |
+--------------------+------+--------+--------+--------+--------+------+

> **read:** Now I would now like to ask you a few questions about your
> contact with children younger than 18 years of age and with persons
> with diarrhea during the 2 weeks before you became ill **(QUESTION
> A2)**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> **TO**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> **B2.** Do you have children (younger than 18 years old) living in
> your home?
>
> **IF INTERVIEWING AN ADOLESCENT:** Do you have children (younger than
> 18 years old) -- ***[other than yourself]{.underline}*** - living in
> your home?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\........\....
> 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\........\...
> 2 **(GO TO B10)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 77 **(GO TO B10)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.........\.....
> 99 **(GO TO B10)**
>
> **B3. IF YES TO B2,** How many children live in your house?
>
> **IF INTERVIEWING AN ADOLESCENT:** How many children - ***[other than
> yourself]{.underline}*** **--** live in your house?
>
> **NUMBER OF CHILDREN** \|\_\_\|\_\_\|
>
> UNKNOWN...................... 77
>
> REFUSED........................ 99
>
> **B4. IF YES TO B2,** What are the children's age(s) in years, their
> sexes, and did they have diarrhea in the 2 weeks before your diarrhea
> began?
>
> **IF INTERVIEWING AN ADOLESCENT: *[Other than
> yourself]{.underline}***, what are the children's age(s) in years,
> their sexes and did they have diarrhea in the 2 weeks before your
> diarrhea began?

+---------+---------+---------+----+-----+----+-----+-----+--------+
| **      | AGE?    | Does    | Wh |     | H  |     |     |        |
| CHILD** |         | the     | at |     | ad |     |     |        |
|         | **(I    | child   | se |     | di |     |     |        |
|         | NDICATE | wear    | x? |     | ar |     |     |        |
|         | YRS OR  | d       |    |     | rh |     |     |        |
|         | MO      | iapers? | ** |     | ea |     |     |        |
|         | NTHS)** |         | (1 |     | in |     |     |        |
|         |         | **Y N** | =M |     | t  |     |     |        |
|         |         |         | AL |     | he |     |     |        |
|         |         |         | E, |     | *  |     |     |        |
|         |         |         | ** |     | ** |     |     |        |
|         |         |         |    |     | [2 |     |     |        |
|         |         |         | *  |     | w  |     |     |        |
|         |         |         | *2 |     | ee |     |     |        |
|         |         |         | =F |     | ks |     |     |        |
|         |         |         | EM |     | ]{ |     |     |        |
|         |         |         | AL |     | .u |     |     |        |
|         |         |         | E) |     | nd |     |     |        |
|         |         |         | ** |     | er |     |     |        |
|         |         |         |    |     | li |     |     |        |
|         |         |         |    |     | ne |     |     |        |
|         |         |         |    |     | }* |     |     |        |
|         |         |         |    |     | ** |     |     |        |
|         |         |         |    |     | be |     |     |        |
|         |         |         |    |     | fo |     |     |        |
|         |         |         |    |     | re |     |     |        |
|         |         |         |    |     | yo |     |     |        |
|         |         |         |    |     | ur |     |     |        |
|         |         |         |    |     | di |     |     |        |
|         |         |         |    |     | ar |     |     |        |
|         |         |         |    |     | rh |     |     |        |
|         |         |         |    |     | ea |     |     |        |
|         |         |         |    |     | be |     |     |        |
|         |         |         |    |     | ga |     |     |        |
|         |         |         |    |     | n? |     |     |        |
|         |         |         |    |     |    |     |     |        |
|         |         |         |    |     | *  |     |     |        |
|         |         |         |    |     | *Y |     |     |        |
|         |         |         |    |     | ES |     |     |        |
|         |         |         |    |     | NO |     |     |        |
|         |         |         |    |     | U  |     |     |        |
|         |         |         |    |     | NK |     |     |        |
|         |         |         |    |     | R  |     |     |        |
|         |         |         |    |     | EF |     |     |        |
|         |         |         |    |     | ** |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 1**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 2**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 3**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 4**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 5**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 6**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 7**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 8**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 9**     |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 10**    |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 11**    |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 12**    |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 13**    |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 14**    |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+
| **CHILD |         | 1 2     | 1  | 2   | 1  | 2   | 77  | 99     |
| 15**    |         |         |    |     |    |     |     |        |
+---------+---------+---------+----+-----+----+-----+-----+--------+

> **B5. IF YES TO B2,** Were any children in your household in childcare
> outside of your home at any time during the 2 weeks before you became
> ill?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> 2 **(GO TO B8)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 77 **(GO TO B8)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 99 **(GO TO B8)**
>
> **B6. IF YES TO B5,** Did *(he/she/they)* participate in any
> water-related activities, such as swimming, wading, or water table
> play at *(his/her)* childcare outside of your home?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> 2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 99
>
> **B7. IF YES TO B5,** Were any children at your child's childcare
> location ***[in diapers]{.underline}***?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 1
>
> > NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....2
>
> > UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> > 77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\... 99
>
> **B8. IF YES TO B2,** Were any children in your household in a ***[day
> camp]{.underline}*** during the 2 weeks before you became ill? By a
> day camp I mean a center with activities where children spend all or
> part of the day, often during the summer months when school is out. By
> comparison, a day care center is often for toddlers.
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....2
> **(GO TO B10)**
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\.....77
> **(GO TO B10)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...99
> **(GO TO B10)**
>
> **B9. IF YES TO B8,** Did *(he/she/they)* participate in any
> water-related activities, such as swimming, wading, or water tables at
> his or her ***[day camp]{.underline}***?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> 2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 99
>
> **B10.** During the 2 weeks before illness, did you
> ***[provide]{.underline}*** childcare in any of the following
> childcare settings? **\[Read THE LIST. cIRCLE ALL THAT APPLY\]**

+------------------------------+------+-------+----------+-----------+
| **SETTING**                  | **Y  | *     | **U      | **        |
|                              | ES** | *NO** | NKNOWN** | REFUSED** |
+------------------------------+------+-------+----------+-----------+
| a\. Out-of-home childcare    | 1    | 2     | 77       | 99        |
| center                       |      |       |          |           |
+------------------------------+------+-------+----------+-----------+
| b\. In-home childcare center | 1    | 2     | 77       | 99        |
+------------------------------+------+-------+----------+-----------+
| c\. Out-of-home babysitter   | 1    | 2     | 77       | 99        |
+------------------------------+------+-------+----------+-----------+
| d\. In-home babysitter       | 1    | 2     | 77       | 99        |
+------------------------------+------+-------+----------+-----------+
| e\. Other                    | 1    | 2     | 77       | 99        |
|                              |      |       |          |           |
| f\. Specify:                 |      |       |          |           |
+------------------------------+------+-------+----------+-----------+

**B11.** During the 2 weeks before illness, did you have contact with
any children in diapers?

> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\... 2 **(GO TO
> B13)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.... 77 **(GO TO B13)**
>
> REFUSED\...\...\...\...\...\...\...\...\... 99 **(GO TO B13)**
>
> **B12. If yes TO B11,** During the 2 weeks before illness, did
> ***[you]{.underline}*** change any diapers?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.........
> 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..........
> 2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.............
> 99
>
> **B13Number range CHAPTER.** During the 2 weeks before you became ill,
> did you come in contact with anyone who had diarrhea?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 2 **(GO TO B16)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...77 **(GO TO
> B16)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\.... 99 **(GO TO
> B16)**
>
> **B14Number range CHAPTER. IF YES TO B13,** Did they include:
>
> **\[Read THE LIST. cIRCLE ALL THAT APPLY\]**

  ------------------------------ --------- -------- ------------- -------------
                                 **YES**   **NO**   **UNKNOWN**   **REFUSED**

  a\. Children [\<]{.underline}  1         2        99            77
  3 years of age                                                  

  b\. Children 4 to \<13 years   1         2        99            77
  of age                                                          

  c\. Teenagers                  1         2        99            77
  [\>]{.underline}13 to \<18                                      
  years                                                           

  d\. Adults 18 years or older   1         2        99            77
  ------------------------------ --------- -------- ------------- -------------

> **B15. IF YES TO B13,** Did you provide direct care to a person with
> diarrhea?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\... 77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\... 99
>
> **B16.** Are you aware of anyone in your immediate household or social
> group that had diarrhea ***[while]{.underline}*** you had your
> symptoms?
>
> YES.....................................1
>
> NO......................................2
>
> UNKNOWN........................\...77
>
> REFUSED.............................99
>
> **B17.** Are you aware of anyone in your immediate household or social
> group that had diarrhea during the 2 weeks ***[after]{.underline}***
> your symptoms began?
>
> YES.....................................1
>
> NO......................................2
>
> UNKNOWN........................\...77
>
> REFUSED.............................99

**B18.** Did you prepare food for others while you had diarrhea?

YES....................................1

NO.....................................2

UNKNOWN..........................77

REFUSED............................99

**[SECTION C]{.underline}. DIETARY EXPOSURES**

> **read:** I WOULD LIKE TO TALK ABOUT YOUR DIET DURING THE [***2
> WEEKS*** ***BEFORE***]{.underline} YOUR DIARRHEA BEGAN **(QUESTION
> A2),** THAT WOULD BE THE PERIOD FROM
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> TO
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|.
>
> **C1.** During the 2 weeks before your diarrhea began, did you eat any
> of the following food items? **\[READ THE LIST. ENTER ALL THAT
> APPLY\]**

+-------------------------------------+------+------+--------+--------+
| **FOOD**                            | *    | *    | **U**  | **R**  |
|                                     | *Y** | *N** |        |        |
+-------------------------------------+------+------+--------+--------+
| **a.** Lettuce or garden salad      | 1    | 2    | 77     | 99     |
+-------------------------------------+------+------+--------+--------+
| **b.** Cold cuts, chicken salad,    | 1    | 2    | 77     | 99     |
| egg salad, or tuna salad            |      |      |        |        |
+-------------------------------------+------+------+--------+--------+
| **c.** Other cold salads (such as   | 1    | 2    | 77     | 99     |
|                                     |      |      |        |        |
| coleslaw, potato salad, or pasta    |      |      |        |        |
| salad)                              |      |      |        |        |
+-------------------------------------+------+------+--------+--------+
| **d.** Raw vegetables (such as      | 1    | 2    | 77     | 99     |
|                                     |      |      |        |        |
| carrots, tomatoes, cucumbers, green |      |      |        |        |
| onions)                             |      |      |        |        |
+-------------------------------------+------+------+--------+--------+
| **e.** Raw berries (such as         | 1    | 2    | 77     | 99     |
| strawberries and raspberries)       |      |      |        |        |
+-------------------------------------+------+------+--------+--------+
| **f.** Raw fruits                   | 1    | 2    | 77     | 99     |
| ***[with]{.underline}*** skin/peel  |      |      |        |        |
| (such as melons, apples)            |      |      |        |        |
+-------------------------------------+------+------+--------+--------+
| **g.** Cider or juice               | 1    | 2    | 77     | 99     |
+-------------------------------------+------+------+--------+--------+
| **h.** Raw shellfish                | 1    | 2    | 77     | 99     |
+-------------------------------------+------+------+--------+--------+
| **i.** Cooked shellfish             | 1    | 2    | 77     | 99     |
+-------------------------------------+------+------+--------+--------+

> **C2.** During the two weeks before your diarrhea began, did you
> consume any of the following ***[unpasteurized]{.underline}*** foods
> or drinks? Number range CHAPTERThis may include products supplied from
> health food stores, local farms, or imported from other countries.
>
> **\[Read THE LIST. ENTER ALL THAT APPLY\]**

+--------------------------+------+-------+-------------+-------------+
| **FOOD**                 | **Y  | *     | **UNKNOWN** | **REFUSED** |
|                          | ES** | *NO** |             |             |
+--------------------------+------+-------+-------------+-------------+
| **a.** Unpasteurized     | 1    | 2     | 77          | 99          |
| milk                     |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+
| **b**. Unpasteurized     | 1    | 2     | 77          | 99          |
| apple juice/cider        |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+
| **c.** Other             | 1    | 2     | 77          | 99          |
| unpasteurized juices     |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+
| **d.** Unpasteurized     | 1    | 2     | 77          | 99          |
| cheese                   |      |       |             |             |
|                          |      |       |             |             |
| (e.g. goat cheese,       |      |       |             |             |
| farmer's cheese, queso   |      |       |             |             |
| fresco)                  |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+
| **e.** Other             | 1    | 2     | 77          | 99          |
|                          |      |       |             |             |
| > Specify:               |      |       |             |             |
| >                        |      |       |             |             |
| \_\_\_\_\_\_\_\_\_\_\_\_ |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+

**[SECTION D]{.underline}. DRINKING WATER EXPOSURES**

> **read:** I WOULD LIKE TO TALK ABOUT YOUR EXPOSURE TO DRINKING WATER
> DURING THE ***[2 WEEKS BEFORE]{.underline}*** YOUR DIARRHEA BEGAN
> **(QUESTION A2),** THAT WOULD BE THE PERIOD FROM
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> TO
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|

**D1.** During the 2 weeks before your diarrhea began, did you drink
water from home?

> YES.....................................1
>
> NO......................................2 **(GO TO D3)**
>
> UNKNOWN........................\...77 **(GO TO D3)**
>
> REFUSED.............................99 **(GO TO D3)**
>
> **D2.** **IF YES TO D1,** What were your sources of drinking water
> ***[at home]{.underline}***?
>
> **\[Read THE LIST. ENTER ALL THAT APPLY\]**

+--------------------+-----------+-----------+-----------+-----------+
| **QUESTION**       | **YES**   | **NO**    | **        | **        |
|                    |           |           | UNKNOWN** | REFUSED** |
+--------------------+-----------+-----------+-----------+-----------+
| **a.** Municipal   | 1         | 2         | 77        | 99        |
| or city water      |           |           |           |           |
| direct from tap    |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| **b**. Municipal   | 1         | 2         | 77        | 99        |
| or city water with |           |           |           |           |
| additional         |           |           |           |           |
| filtration or      |           |           |           |           |
| treatment          |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| **c.**             | 1         | 2         | 77        | 99        |
| Refrigerator       |           |           |           |           |
| dispenser          |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| **d.** Private     | 1         | 2         | 77        | 99        |
| well water         |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| **e.** Private     | 1         | 2         | 77        | 99        |
| well water with    |           |           |           |           |
| additional         |           |           |           |           |
| filtration or      |           |           |           |           |
| treatment          |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| **f**.             | 1         | 2         | 77        | 99        |
| Commercially       |           |           |           |           |
| bottled water      |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| **g.** Other       | 1         | 2         | 77        | 99        |
|                    |           |           |           |           |
| > Specify:         |           |           |           |           |
| >                  |           |           |           |           |
| \_\_\_\_\_\_\_\_\_ |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+

> **D3.** During the 2 weeks before your diarrhea began, did you drink
> water ***[outside the home]{.underline}***, for example, at school, or
> work?
>
> YES.....................................1
>
> NO......................................2 **(GO TO D5)**
>
> UNKNOWN........................\...77 **(GO TO D5)**
>
> REFUSED.............................99 **(GO TO D5)**
>
> **D4**. **IF YES TO D3,** What were your sources of drinking water
> ***[outside the home]{.underline}***, for example, at school, or work?
> **\[Read THE LIST. ENTER ALL THAT APPLY.\]**

+---------------------------------+-----+-----+-----------+-----------+
| **QUESTION**                    | *   | **N | **        | **        |
|                                 | *YE | O** | UNKNOWN** | REFUSED** |
|                                 | S** |     |           |           |
+---------------------------------+-----+-----+-----------+-----------+
| **a.** Municipal or city water  | 1   | 2   | 77        | 99        |
| direct from tap (including a    |     |     |           |           |
| water fountain)                 |     |     |           |           |
+---------------------------------+-----+-----+-----------+-----------+
| **b**. Municipal or city water  | 1   | 2   | 77        | 99        |
| with additional filtration or   |     |     |           |           |
| treatment                       |     |     |           |           |
+---------------------------------+-----+-----+-----------+-----------+
| **c.** Refrigerator dispenser   | 1   | 2   | 77        | 99        |
+---------------------------------+-----+-----+-----------+-----------+
| **d**. Private well water       | 1   | 2   | 77        | 99        |
+---------------------------------+-----+-----+-----------+-----------+
| **e.** Private well water with  | 1   | 2   | 77        | 99        |
| additional filtration or        |     |     |           |           |
| treatment                       |     |     |           |           |
+---------------------------------+-----+-----+-----------+-----------+
| **f.** Commercially bottled     | 1   | 2   | 77        | 99        |
| water                           |     |     |           |           |
+---------------------------------+-----+-----+-----------+-----------+
| **g.** Brought water from home  | 1   | 2   | 77        | 99        |
+---------------------------------+-----+-----+-----------+-----------+
| **h**. Other                    | 1   | 2   | 77        | 99        |
|                                 |     |     |           |           |
| > Specify: \_\_\_\_\_\_\_\_\_   |     |     |           |           |
+---------------------------------+-----+-----+-----------+-----------+

**D5.** What was your usual source of ***[ice]{.underline}*** during the
2 weeks before your diarrhea began?

> **\[Read THE LIST. ENTER ALL THAT APPLY\]**

+----------------------------+------+------+------------+------------+
| **SOURCE**                 | **Y  | **   | *          | *          |
|                            | ES** | NO** | *UNKNOWN** | *REFUSED** |
+----------------------------+------+------+------------+------------+
| **a.** Do not use ice      | 1    | 2    | 77         | 99         |
| **(GO TO D6)**             |      |      |            |            |
+----------------------------+------+------+------------+------------+
| **b.** From home           | 1    | 2    | 77         | 99         |
+----------------------------+------+------+------------+------------+
| **c.** From outside the    | 1    | 2    | 77         | 99         |
| home                       |      |      |            |            |
+----------------------------+------+------+------------+------------+
| **d.** Commercially-bought | 1    | 2    | 77         | 99         |
| ice                        |      |      |            |            |
+----------------------------+------+------+------------+------------+
| **e**. Other               | 1    | 2    | 77         | 99         |
|                            |      |      |            |            |
| > Specify:                 |      |      |            |            |
| > \_\_\_\_\_\_\_\_\_       |      |      |            |            |
+----------------------------+------+------+------------+------------+

> **D6.** During the 2 weeks before your diarrhea began, did you drink
> any untreated water from a lake, river, or stream?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\.....99

**[SECTION E]{.underline}. RECREATIONAL WATER EXPOSURE**

> **read:** I WOULD LIKE TO TALK ABOUT YOUR EXPOSURE TO RECREATIONAL
> WATER. WE WILL FIRST FOCUS ON THE PERIOD [***2 WEEKS***
> ***BEFORE***]{.underline} YOUR DIARRHEA BEGAN **(QUESTION A2),** THAT
> WOULD BE THE PERIOD FROM
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> TO
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|.
>
> **E1Number range CHAPTER.** During the 2 weeks before your diarrhea
> began, did you swim or enter recreational water (which means water
> other than in a bathtub or shower)?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
> **(GO TO E28)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO E28)**
>
> REFUSED...\...\...\...\...\...\...\...\...\...\.....99 **(GO TO E28)**
>
> **E2Number range CHAPTER.** During the 2 weeks before the diarrhea
> began, which recreational water settings did you swim in, wade in, or
> enter? **\[Read THE LIST. enter ALL THAT APPLY\]**

+--------------+--------+----+--------+--------------+--------------+
| # IF YES, on |        | ** |        |              |              |
|  how many da |        | IF |        |              |              |
| ys did you s |        | YE |        |              |              |
| wim or enter |        | S, |        |              |              |
|  the water i |        | ** |        |              |              |
| n the 2 week |        | d  |        |              |              |
| s before you |        | id |        |              |              |
|  became ill? |        | y  |        |              |              |
|              |        | ou |        |              |              |
|              |        | p  |        |              |              |
|              |        | ut |        |              |              |
|              |        | yo |        |              |              |
|              |        | ur |        |              |              |
|              |        | fa |        |              |              |
|              |        | ce |        |              |              |
|              |        | u  |        |              |              |
|              |        | nd |        |              |              |
|              |        | er |        |              |              |
|              |        | t  |        |              |              |
|              |        | he |        |              |              |
|              |        | wa |        |              |              |
|              |        | te |        |              |              |
|              |        | r? |        |              |              |
+--------------+--------+----+--------+--------------+--------------+
| # Setting    | **Y N  |    | **     |              | **Y N U R**  |
|              | U R**  |    | Number |              |              |
|              |        |    | of     |              |              |
|              |        |    | d      |              |              |
|              |        |    | ays?** |              |              |
|              |        |    |        |              |              |
|              |        |    | **1    |              |              |
|              |        |    | 2-5    |              |              |
|              |        |    | 6-10   |              |              |
|              |        |    | \>11 U |              |              |
|              |        |    | R**    |              |              |
+--------------+--------+----+--------+--------------+--------------+
| **a.** Lake, | 1 2 77 |    | 1 2 3  |              | 1 2 77 99    |
| Pond, River  | 99     |    | 4 77   |              |              |
| or Stream    |        |    | 99     |              |              |
+--------------+--------+----+--------+--------------+--------------+
| **b**. Hot   | 1 2 77 |    | 1 2 3  |              | 1 2 77 99    |
| Tub, Spa,    | 99     |    | 4 77   |              |              |
| Whirlpool,   |        |    | 99     |              |              |
| Jacuzzi      |        |    |        |              |              |
+--------------+--------+----+--------+--------------+--------------+
| **c**.       | 1 2 77 |    | 1 2 3  |              | 1 2 77 99    |
| Recreational | 99     |    | 4 77   |              |              |
| Water Park   |        |    | 99     |              |              |
| other than   |        |    |        |              |              |
| swimming     |        |    |        |              |              |
| pools (*list |        |    |        |              |              |
| area         |        |    |        |              |              |
| examples, if |        |    |        |              |              |
| known*)      |        |    |        |              |              |
+--------------+--------+----+--------+--------------+--------------+

> **E3.** During the 2 weeks before your diarrhea began, did you swim,
> wade in, or enter a swimming pool?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
> **(GO TO E28)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO E28)**
>
> REFUSED...\...\...\...\...\...\...\...\...\...\.....99 **(GO TO E28)**
>
> **read:** THE FOLLOWING QUESTIONS ASK ABOUT TYPICAL SWIMMING
> ACTIVITIES DURING VISITS TO POOLS
>
> **E4.** On a typical visit during the 2 weeks before your diarrhea
> began, did you usually ***[wade or play]{.underline}*** in the water
> without swimming?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E5.** On a typical visit during the 2 weeks before your diarrhea
> began, did you get water ***[splashed in your face]{.underline}***?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E6.** On a typical visit during the 2 weeks before your diarrhea
> began, did you put your ***[face in the water]{.underline}***?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E7.** On a typical visit during the 2 weeks before your diarrhea
> began, did you get ***[any]{.underline}*** water in your
> ***[mouth]{.underline}***?
>
> YES.....................1
>
> NO....................\...2 **(GO TO E9)**
>
> UNKNOWN...\...\.....77 **(GO TO E9)**
>
> REFUSED.......\...\... 99 **(GO TO E9)**
>
> **E8. IF YES TO E7,** On a typical visit during the 2 weeks before
> your diarrhea began, did you ***[swallow]{.underline}*** any of this
> water?
>
> YES.......................1
>
> NO........................2
>
> UNKNOWN...\...\...\....77
>
> REFUSED..............99
>
> **E9.** On a typical visit during the 2 weeks before your diarrhea
> began, did you ***[dive or jump]{.underline}*** into the water?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E10.** On a typical visit during the 2 weeks before your diarrhea
> began, did you ***[use a slide]{.underline}*** to enter the water?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E11**. On a typical visit during the 2 weeks before your diarrhea
> began, did you ***[eat]{.underline}*** while visiting the pool?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E12**. On a typical visit during the 2 weeks before your diarrhea
> began, did you consume any drink with ***[ice]{.underline}***, for
> example, ice tea or soda from the soda fountain?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E13**. On a typical visit during the 2 weeks before your diarrhea
> began, did you drink from the ***[water fountain]{.underline}*** at
> the swimming pool?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **E14**. On a typical visit during the 2 weeks before your diarrhea
> began, did you go to the restrooms at the swimming pool to...

+--------------------------+------+-------+-------------+-------------+
| **SOURCE**               | **Y  | *     | **UNKNOWN** | **REFUSED** |
|                          | ES** | *NO** |             |             |
+--------------------------+------+-------+-------------+-------------+
| **a.** Change diapers    | 1    | 2     | 77          | 99          |
+--------------------------+------+-------+-------------+-------------+
| **b.** Wash hands        | 1    | 2     | 77          | 99          |
+--------------------------+------+-------+-------------+-------------+
| **c.** Urinate           | 1    | 2     | 77          | 99          |
+--------------------------+------+-------+-------------+-------------+
| **d.** Have bowel        | 1    | 2     | 77          | 99          |
| movements                |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+
| **e.** Shower            | 1    | 2     | 77          | 99          |
+--------------------------+------+-------+-------------+-------------+
| **e**. Other             | 1    | 2     | 77          | 99          |
|                          |      |       |             |             |
| > Specify:               |      |       |             |             |
| > \_\_\_\_\_\_\_\_\_     |      |       |             |             |
+--------------------------+------+-------+-------------+-------------+

> **E15**. On a typical visit during the 2 weeks before your diarrhea
> began, did you touch or play on the playground equipment at a
> playground near the swimming pool?
>
> YES..................\....1
>
> NO......................2
>
> UNKNOWN\...\...\...\....77
>
> REFUSED...\...\...\...\....99
>
> **read:** NOW I WOULD LIKE TO ASK YOU ABOUT THE SWIMMING POOLS YOU
> VISITED.
>
> **E16.** During the 2 weeks before your diarrhea began, please list
> the swimming pools that you swam in or entered **\[ENTER ALL THAT
> APPLY\]**

+---------+----+-----+---+---------+---+---------+---------+----------+
| ## **I  |    | *   |   | **(IF   | * |         |         |          |
| F YES,* |    | *IF |   | CANNOT  | * |         |         |          |
| * on ho |    | YES |   | RECALL  | I |         |         |          |
| w many  |    | ,** |   | EXACT   | F |         |         |          |
| days in |    | ple |   | D       | Y |         |         |          |
|  the 2  |    | ase |   | ATES,** | E |         |         |          |
| weeks b |    | l   |   | prompt  | S |         |         |          |
| efore y |    | ist |   | for     | , |         |         |          |
| ou beca |    | da  |   | ***     | * |         |         |          |
| me ill? |    | tes |   | [week]{ | * |         |         |          |
|         |    |     |   | .underl | d |         |         |          |
|         |    |     |   | ine}*** | i |         |         |          |
|         |    |     |   | of      | d |         |         |          |
|         |    |     |   | s       | y |         |         |          |
|         |    |     |   | wimming | o |         |         |          |
|         |    |     |   | in that | u |         |         |          |
|         |    |     |   | l       | p |         |         |          |
|         |    |     |   | ocation | u |         |         |          |
|         |    |     |   | and     | t |         |         |          |
|         |    |     |   | enter   | y |         |         |          |
|         |    |     |   | date of | o |         |         |          |
|         |    |     |   | *       | u |         |         |          |
|         |    |     |   | **[Wedn | r |         |         |          |
|         |    |     |   | esday]{ | f |         |         |          |
|         |    |     |   | .underl | a |         |         |          |
|         |    |     |   | ine}*** | c |         |         |          |
|         |    |     |   | of that | e |         |         |          |
|         |    |     |   | week    | u |         |         |          |
|         |    |     |   |         | n |         |         |          |
|         |    |     |   |         | d |         |         |          |
|         |    |     |   |         | e |         |         |          |
|         |    |     |   |         | r |         |         |          |
|         |    |     |   |         |   |         |         |          |
|         |    |     |   |         | t |         |         |          |
|         |    |     |   |         | h |         |         |          |
|         |    |     |   |         | e |         |         |          |
|         |    |     |   |         | w |         |         |          |
|         |    |     |   |         | a |         |         |          |
|         |    |     |   |         | t |         |         |          |
|         |    |     |   |         | e |         |         |          |
|         |    |     |   |         | r |         |         |          |
|         |    |     |   |         | ? |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| ## Pool | *  |     | * |         |   | ######  | ######  | **Y N U  |
|         | *Y |     | * |         |   | ## **Li | ## **Li | R**      |
|         | N  |     | N |         |   | st date | st date |          |
|         | U  |     | u |         |   | s (MM/D | s (MM/D |          |
|         | R  |     | m |         |   | D/YY)** | D/YY)** |          |
|         | ** |     | b |         |   |         |         |          |
|         |    |     | e |         |   |         |         |          |
|         |    |     | r |         |   |         |         |          |
|         |    |     | o |         |   |         |         |          |
|         |    |     | f |         |   |         |         |          |
|         |    |     | d |         |   |         |         |          |
|         |    |     | a |         |   |         |         |          |
|         |    |     | y |         |   |         |         |          |
|         |    |     | s |         |   |         |         |          |
|         |    |     | ? |         |   |         |         |          |
|         |    |     | * |         |   |         |         |          |
|         |    |     | * |         |   |         |         |          |
|         |    |     |   |         |   |         |         |          |
|         |    |     | * |         |   |         |         |          |
|         |    |     | * |         |   |         |         |          |
|         |    |     | 1 |         |   |         |         |          |
|         |    |     | 2 |         |   |         |         |          |
|         |    |     | - |         |   |         |         |          |
|         |    |     | 5 |         |   |         |         |          |
|         |    |     | 6 |         |   |         |         |          |
|         |    |     | - |         |   |         |         |          |
|         |    |     | 1 |         |   |         |         |          |
|         |    |     | 0 |         |   |         |         |          |
|         |    |     | \ |         |   |         |         |          |
|         |    |     | > |         |   |         |         |          |
|         |    |     | 1 |         |   |         |         |          |
|         |    |     | 1 |         |   |         |         |          |
|         |    |     | U |         |   |         |         |          |
|         |    |     | R |         |   |         |         |          |
|         |    |     | * |         |   |         |         |          |
|         |    |     | * |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| **a.**  | 1  |     | 1 |         |   |         |         | 1 2 77   |
| *(Pool  | 2  |     | 2 |         |   |         |         | 99       |
| A)*     | 77 |     | 3 |         |   |         |         |          |
|         | 99 |     | 4 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| **b.**  | 1  |     | 1 |         |   |         |         | 1 2 77   |
| *(Pool  | 2  |     | 2 |         |   |         |         | 99       |
| B)*     | 77 |     | 3 |         |   |         |         |          |
|         | 99 |     | 4 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| **c.**  | 1  |     | 1 |         |   |         |         | 1 2 77   |
| *(Pool  | 2  |     | 2 |         |   |         |         | 99       |
| C)*     | 77 |     | 3 |         |   |         |         |          |
|         | 99 |     | 4 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| **d.**  | 1  |     | 1 |         |   |         |         | 1 2 77   |
| *(Pool  | 2  |     | 2 |         |   |         |         | 99       |
| D)*     | 77 |     | 3 |         |   |         |         |          |
|         | 99 |     | 4 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| **e.**  | 1  |     | 1 |         |   |         |         | 1 2 77   |
| *(Pool  | 2  |     | 2 |         |   |         |         | 99       |
| E)*     | 77 |     | 3 |         |   |         |         |          |
|         | 99 |     | 4 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 7 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+
| **f.**  | 1  |     | 1 |         |   |         |         | 1 2 77   |
| Other   | 2  |     | 2 |         |   |         |         | 99       |
|         | 77 |     | 3 |         |   |         |         |          |
| S       | 99 |     | 4 |         |   |         |         |          |
| pecify: |    |     | 7 |         |   |         |         |          |
| \_\_\   |    |     | 7 |         |   |         |         |          |
| _\_\_\_ |    |     | 9 |         |   |         |         |          |
|         |    |     | 9 |         |   |         |         |          |
+---------+----+-----+---+---------+---+---------+---------+----------+

**IF THE PERSON DID NOT SWIM AT *\[POOL OF INTEREST\]*, GO TO E28**

> **READ:** NOW I WOULD LIKE TO ASK YOU ABOUT YOUR ACTIVITIES AT THE
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*POOL OF INTEREST*) **(THESE
> QUESTIONS WILL NEED TO BE TAILORED TO THE SPECIFICS OF THE POOL)**
>
> **E17.** Regarding your activities at the \_\_\_\_\_\_\_\_\_\_\_*(the
> pool of interest)* during the 2 weeks before your diarrhea began did
> you swim in or enter the ***[wading pool]{.underline}***?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **E18.** Did you swim in or enter the ***[main pool]{.underline}***
> *(if applicable)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO E23)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO E23)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> E23)**
>
> **E19. IF YES TO E18,** When you were in the main pool did you ever
> use the ***[water slide]{.underline}** (if applicable)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **E20. IF YES TO E18,** When you were in the main pool did you ever
> use the ***[frog slide]{.underline}** (if applicable)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **E21. IF YES TO E18,** When you were in the main pool did you ever go
> under the ***[raindrop tree]{.underline}*** *(if applicable)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **E22. IF YES TO E18,** When you were in the main pool did you ever
> use the ***[diving boards]{.underline}*** *(if applicable)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **E23.** During the 2 weeks before your diarrhea began did you swim at
> a swim meet at the \_\_\_\_\_\_\_\_\_\_\_*(the pool of interest)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO E25)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO E25)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> E25)**
>
> **E24. IF YES TO E23,** What date?
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> MM DD YY
>
> **E25.** When the \_\_\_\_\_\_\_\_\_\_\_*(the pool of interest)*
> closed, the period between
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> to
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|,
> did you enter the water or swim at any other facility or recreational
> area?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO E27)** UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO
> E27)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> E27)**
>
> **E26.** **IF YES TO E25,** What pool/recreational area(s) did you
> swim in while the *(the pool of interest)* was closed
> (\|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> to
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|)?
>
> **(WRITE IN NAME OF POOL/RECREATIONAL AREA)**
>
> [Name of Pool/Recreational Area]{.underline}
>
> a.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> b.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> c.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> d.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######## **E27**. During the 2 weeks before your diarrhea began, did you participate as a member of any of the following groups at the \_\_\_\_\_\_\_\_\_\_\_(the pool of interest)? **\[READ ALL AND ENTER ALL THAT APPLY\] (THIS QUESTION WILL NEED TO BE TAILORED TO THE SPECIFICS OF THE POOL)**

> Swimming/diving team.........................\.......1
>
> Swimming lessons......................\................2
>
> Water aerobics.......................................\...3
>
> UNKNOWN...........................\...\...\...\...\...\.....77
>
> OTHER................................................88
>
> If Other, specify: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> REFUSED.............................................99
>
> **E28.** Are you a member of the \_\_\_\_\_\_\_\_\_\_\_*(the pool of
> interest)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **READ:** NOW WE WILL FOCUS ON YOUR RECREATIONAL WATER EXPOSURE DURING
> THE ***[ONE MONTH SINCE]{.underline}*** YOUR DIARRHEA
> ***[BEGAN]{.underline}***.
>
> **E29.** During the ***[one month since]{.underline}*** your diarrhea
> began, did you swim or enter recreational water (other than in a
> bathtub or shower)?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...2
> **(GO TO SECTION F)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO SECTION
> F)**
>
> REFUSED...\...\...\...\...\...\...\...\...\...\.....99 **(GO TO
> SECTION F)**
>
> **E30Number range CHAPTER.** During the ***[one month
> since]{.underline}*** your diarrhea began, which recreational water
> settings did you swim in, wade in, or enter? **\[Read THE LIST. enter
> ALL THAT APPLY\]**
>
> **E31.** During the ***[one month since]{.underline}*** your diarrhea
> began, did you swim, wade in, or enter a swimming pool?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO SECTION F)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO SECTION
> F)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> SECTION F)**

######## **E32.** During the **[one month since]{.underline}** your diarrhea began, please list the swimming pools that you swam in or entered. **\[ENTER ALL THAT APPLY\]**

########  **IF THE PERSON DID NOT SWIM AT THE** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **(POOL OF INTEREST), GO TO SECTION F.**

> **READ:** NOW I WOULD LIKE TO ASK YOU ABOUT YOUR ACITIVITIES AT THE
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*POOL OF INTEREST*)
>
> **E33.** During the ***[one month since]{.underline}*** your diarrhea
> began, did you participate as a member of any of the following groups
> at the \_\_\_\_\_\_\_\_\_\_\_*(the pool of interest)*? **\[READ ALL
> AND ENTER ALL THAT APPLY\]**
>
> Swimming/ diving team.........................\.......1
>
> Swimming lessons......................\............ ....2
>
> UNKNOWN........................\...\...\...\...\...\...\...\.....77
>
> OTHER .................................................88
>
> If Other, specify \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> REFUSED..............................................99
>
> **E34.** During the ***[one month since]{.underline}*** your diarrhea
> began, did you swim in or enter the **[*wading pool*]{.underline}**
> *(if applicable)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **E35.** During the ***[one month since]{.underline}*** your diarrhea
> began, did you swim in or enter the ***[main pool]{.underline}***?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99

**[SECTION F.]{.underline} EVENTS**

> **READ:** NOW I WOULD LIKE TO TALK TO YOU ABOUT THE EVENTS THAT YOU
> ATTENDED DURING THE \_\_\_\_\_\_\_\_\_\_\_\_ *(specify time period)*
> BEFORE YOUR DIARRHEA BEGAN.
>
> **F1.** During the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*specify time
> period*) before your diarrhea began, did you attend any large social
> gatherings with 50 or more persons present, such as picnics, county
> fairs, or other events?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO F3)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO F3)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> F3)**
>
> **F2. IF YES TO F1,** Please list the event(s) that you attended:
>
> **\[CIRCLE THOSE MENTIONED\]**
>
> **\[If specific events are in question, list here. If not, use general
> questions\]**
>
> *Event A (*
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> *date)*................01
>
> *Event B (*
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> *date)*................02
>
> *Event C (*
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> *date)*................03
>
> *Event D (*
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> *date)*................04
>
> *Event E (*
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> *date)*................ 05
>
> Other - please specify: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 06
>
> **F3.** Did you attend any events/parties/potlucks held at the
> \_\_\_\_\_\_\_\_\_\_\_*(the pool of interest)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 (**GO
> TO F5**)
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 (**GO TO F5**)
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 (**GO TO
> F5**)
>
> **F4.** **IF YES TO F3,** Please name the events/parties/potlucks?
>
> **[Name]{.underline} [Date (MM/DD/YY)]{.underline}**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> **F5.** Did you attend any events/parties/potlucks in
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*indicate time period*) at any
> other pool other than the \_\_\_\_\_\_\_\_\_\_\_*(the pool of
> interest)*?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 (**GO
> TO F7**)
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 (**GO TO F7**)
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 (**GO TO
> F7**)
>
> **F6.** **IF YES TO F5,** Please name the events/parties/potlucks?
>
> **[Name]{.underline} [Date (MM/DD/YY)]{.underline}**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> **F7.** While attending ***[any]{.underline}*** of these events, did
> you drink any beverage made with water, such as ice tea, lemonade, or
> other powdered or concentrated drink mix?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 (**GO
> TO F9**)
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 (**GO TO F9**)
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 (**GO TO
> F9**)
>
> **F8.** **IF YES TO F7,** Please name the events/parties/potlucks?
>
> **[Name]{.underline} [Date (MM/DD/YY)]{.underline}**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> **F9.** While attending at ***[any]{.underline}*** of these events,
> did you eat any food that was not commercially packaged?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 (**GO
> TO SECTION G**)
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 (**GO TO SECTION
> G**)
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 (**GO TO
> SECTION G**)
>
> **F10.** **IF YES TO F9,** Please name the events/parties/potlucks?
>
> **[Name]{.underline} [Date (MM/DD/YY)]{.underline}**
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|

####### **[SECTION G]{.underline}. TRAVEL HISTORY**

> **READ:** NOW I WOULD LIKE TO TALK TO YOU ABOUT YOUR TRAVEL HISTORY
> DURING THE ***[2 WEEKS BEFORE]{.underline}*** YOUR DIARRHEA BEGAN
> **(QUESTION A2),** THAT WOULD BE THE PERIOD FROM
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> TO
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|.
>
> **G1.** During the 2 weeks before illness, did you travel within the
> state?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.... 2
> **(GO TO G3)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\..... 8 **(GO TO G3)**
> UNKNOWN\...\...\...\...\...\...\...\...\...\..... 9 **(GO TO G3)**
>
> **G2.** **IF YES TO G1,** Please tell me where you went within the
> state:
>
> **(WRITE IN LOCATION)**
>
> LOCATION CODE
>
> A\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> B\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> C\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> **G3.** During the 2 weeks before illness, did you travel to another
> state within the United States?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.... 2
> **(GO TO G5)** REFUSED\...\...\...\...\...\...\...\...\...\...\..... 8
> **(GO TO G5)** UNKNOWN\...\...\...\...\...\...\...\...\...\..... 9
> **(GO TO G5)**
>
> **G4.** **IF YES TO G3,** Please tell me the name of the cities and
> states that you traveled to: **(WRITE IN LOCATION)**
>
> CITY/STATE CODE
>
> A\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> B\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> C\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> **G5.** During the two weeks before illness, did you travel to another
> country?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.... 2
> **(GO TO G7)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\..... 8 **(GO TO G7)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\..... 9 **(GO TO G7)**
>
> > **G6.** **IF YES TO G5,** Please tell me which country or countries
> > you traveled to:
>
> **(WRITE IN LOCATION)**
>
> COUNTRY CODE
>
> A\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> B\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> C\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \|\_\_\|\_\_\|
>
> **G7.** During the 2 weeks before your diarrhea began, did you travel
> to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (*name of specific location*)?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO SECTION H)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO SECTION
> H)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> SECTION H)**

## 

## **FOLLOW THIS QUESTION WITH QUESTIONS ABOUT SPECIFIC ACTIVITIES, IF APPLICABLE** 

## **[SECTION H]{.underline}. ANIMAL CONTACT** 

> **READ:** NOW I WOULD LIKE TO TALK TO YOU ABOUT YOUR CONTACT WITH
> ANIMALS DURING THE ***[2 WEEKS BEFORE]{.underline}*** YOUR DIARRHEA
> BEGAN **(QUESTION A2),** THAT WOULD BE THE PERIOD FROM
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|
> **TO**
> \|\_\_\|\_\_\|-\|\_\_\|\_\_\|-\|[\_\_]{.underline}\|[\_\_]{.underline}\|**.**
>
> **H1**. During the 2 weeks before your diarrhea began, did you have
> contact with any animals (at home, on a farm, at a zoo, at a fair,
> festival or other event)?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\..... 1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2 **(GO
> TO H3)**
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77 **(GO TO H3)**
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99 **(GO TO
> H3)**
>
> **H2.** **IF YES TO H1,** To which of the following animals?
>
> **Read THE LIST. ENTER AND ASK THE CORRESPONDING QUESTIONS.**

+---------------------------+--------------------+--------------------+
| **ANIMAL**                | Did you have       | Did this animal    |
|                           | contact with this  | have diarrhea?     |
|                           | animal (feeding,   |                    |
|                           | petting, playing)? | **Y N U R**        |
|                           |                    |                    |
|                           | **Y N U R**        |                    |
+---------------------------+--------------------+--------------------+
| a.  Kitten (\< 6 months)  | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| b.  Cat                   | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| c.  Puppy (\< 6 months)   | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| d.  Dog                   | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| e.  Calf                  | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| f.  Cow/Bull/Steer        | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| **g.** Deer               | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| **h.** Goat/Sheep/Lamb    | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| **i.** Horse              | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| **j.** Pigs               | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| **k.** Poultry            | 1 2 77 99          | 1 2 77 99          |
|                           |                    |                    |
| > (chicken, turkey, etc.) |                    |                    |
+---------------------------+--------------------+--------------------+
| **l.** Rabbit             | 1 2 77 99          | 1 2 77 99          |
+---------------------------+--------------------+--------------------+
| **m.** Amphibian/reptile  | 1 2 77 99          | 1 2 77 99          |
| Number range              |                    |                    |
| CHAPTER(frog, turtle,     |                    |                    |
| lizard, snake, etc.)      |                    |                    |
+---------------------------+--------------------+--------------------+
| **n.** Other              | 1 2 77 99          | 1 2 77 99          |
|                           |                    |                    |
| Specify:                  |                    |                    |
| \                         |                    |                    |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |                    |                    |
+---------------------------+--------------------+--------------------+

> **Number range CHAPTERH3.** During the 2 weeks before your diarrhea
> began, did you touch or shovel animal waste/ manure or walk through
> any area where animal waste/ manure was on the ground?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **H4.** Did you visit, work on, or live on a farm during the 2 weeks
> before your diarrhea began?
>
> YES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1
>
> NO\...\...\...\...\...\...\...\...\...\...\...\...\...\........2
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\.....77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...99
>
> **[SECTION I]{.underline} : DEMOGRAPHIC INFORMATION**
>
> **READ:** FINALLY, I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT
> YOURSELF.

**I1.** What is your ZIP code? \|\_\_\|\_\_\|\_\_\|\_\_\|\_\_\|

UNKNOWN............77777

REFUSED............\... 99999

**I2.** What is your age?

\|\_\_\_\|\_\_\_\|

Age (years)

**I3.** What is your gender?

MALE ................ 1

FEMALE ............ 2

UNKNOWN......\....77

REFUSED.........\....99

**I4**. What county do you live in?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**IF RESPONDENT ANSWERS "DON'T KNOW", ASK:**

**I5.** What city do you live
in?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> **I6.** What racial or ethnic group do you consider yourself part of ?
>
> **PROMPT IF NECESSARY:**
>
> WHITE, NON-HISPANIC\...\...\...\...\...\...\...\...\...\............ 1
>
> BLACK,
> NON-HISPANIC\...\...\...\...\...\...\...\...\...\...\...\...\..... 2
>
> WHITE,
> HISPANIC\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> 3
>
> BLACK,
> HISPANIC\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> 4
>
> AMERICAN INDIAN/ALASKAN NATIVE\...\...\...\... 5
>
> ASIAN/PACIFIC ISLANDER\...\...\...\...\...\...\...\...\...\...\...\...
> 6
>
> OTHER.......................................................7
>
> Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> UNKNOWN\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
> 77
>
> REFUSED\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
> 99

**END OF QUESTIONNAIRE:** This concludes our questionnaire. I would like
to thank you very much for your time, patience, and cooperation in
answering our questions. I would be happy to answer any questions you
may have at this point.

If you have any questions in the future please contact the
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** (*city/county health
department*) at \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(*phone number*).