*This questionnaire is an adaptation of a questionnaire developed by
Oregon Public Health Services, modified from the food exposure section
of the 2006-2007 FoodNet Population Survey. It can be used as a template
for foodborne outbreak investigations. Food exposure frequencies of
outbreak cases can be readily compared to food exposure frequencies in
the FoodNet population survey (available at
http://www.cdc.gov/foodnet/studies_pages/pop.htm). The first page is not
part of the FoodNet Population Survey but includes information that may
be routinely gathered as part of an outbreak investigation.*

Respondent was\...  self  parent  caretaker 
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Interviewed by \_\_\_\_\_\_ on
\_\_\_\_\_

Age \_\_\_\_\_ Sex  M  F onset of first symptoms (m/d)
\_\_\_\_/\_\_\_\_ first vomiting or diarrhea (m/d) \_\_\_\_/\_\_\_\_

+-------+--------------------------------------------------------------+
| **Y ? | **LEAD-IN QUESTIONS** \[BLOCK [^1]\]                         |
| N**   |                                                              |
|       | Was anyone in your household sick with diarrhea or vomiting  |
| *A*  | in the week before you got sick?  not applicable            |
|     |                                                              |
|       | Are you on any kind of special or limited diet? *If yes*,    |
| *B*  | describe:                                                    |
|     |                                                              |
|       | Did you spend any nights away from home in the XXX days      |
| *C*  | before you got sick?                                         |
|     |                                                              |
|       | Did you have any contact with dogs, cats, or other pets in   |
| *D*  | that period?                                                 |
|     |                                                              |
|       | Did you handle any pet treats like pig ears, rawhide         |
| *E*  | chews---at home or anywhere else?                            |
|     |                                                              |
|       | Did you have any contact with reptiles, including snakes,    |
| *F*  | iguanas or other lizards, and turtles?                       |
|     |                                                              |
|       | Do you have any underlying medical conditions such as        |
| *G*  | pregnancy, cancer, or diabetes that you have been told might |
|     | affect your immune system? *If yes*, specify :               |
|       | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}           |
+-------+--------------------------------------------------------------+

***First I\'d like to ask about the kinds of places where you might have
eaten food in the XXX*** days before you got sick. This may help you
remember specific food items, which I'll ask you about in a minute. Did
you eat anything at any\....

+-------+-----------------------------------+-------+----------------+
| **Y ? | **EATING AND SHOPPING VENUES**    | **Y ? | **RESTAURANT   |
| N**   | \[BLOCK [^2]\]                    | N**   | TYPES**        |
|       |                                   |       | \[[^3]\]       |
| *A*  | fast-food restaurants (specify)   | *A*  |                |
|     |                                   |     | Chinese        |
|       | sit-down restaurants(*if yes*,    |       |                |
| *B*  | specify type(s) in box at right)  | *B*  | Vietnamese     |
|     |                                   |     |                |
|       | grocery-store deli or other kind  |       | Thai           |
| *C*  | of deli                           | *C*  |                |
|     |                                   |     | Japanese       |
|       | bakery                            |       |                |
| *D*  |                                   | *D*  | Indian/South   |
|     | coffee shop (e.g., Starbucks)     |     | Asian          |
|       |                                   |       |                |
| *E*  | street vendor/push cart/kiosk?    | *E*  | other Asian    |
|     |                                   |     |                |
|       | event concession stands (like at  |       | Mexican        |
| *F*  | a sporting event or a concert)    | *F*  |                |
|     |                                   |     | Italian        |
|       | gas station or similar mini-mart  |       |                |
| *G*  |                                   | *G*  | C              |
|     | tavern or bar                     |     | uban/Caribbean |
|       |                                   |       |                |
| *H*  | free samples anywhere (e.g.,      | *H*  | Greek          |
|     | grocery store, Costco, farmer's   |     |                |
|       | market)                           |       | Other          |
| *I*  |                                   | *I*  | "              |
|     | cafeteria/dining room (e.g.,      |     | international" |
|       | worksite, hospital, school)       |       |                |
| *J*  |                                   | *J*  | vegetarian     |
|     | nursing home/ALC dining facility  |     |                |
|       |                                   |       | barb eque      |
| *K*  | hotel room service                | *K*  |                |
|     |                                   |     | seafood        |
|       | child-care facility               |       |                |
| *L*  |                                   | *L*  | breakfast      |
|     | potluck-type private events       |     | place          |
|       |                                   |       |                |
| *M*  | catered private gatherings (e.g., | *M*  | dine           |
|     | weddings, parties)                |     | r/neighborhood |
|       |                                   |       | cafe           |
| *N*  | any food at a church social or    | *N*  |                |
|     | similar gathering or "coffee"     |     | a              |
|       | hour                              |       | ll-you-can-eat |
| *O*  |                                   | *O*  | buffet         |
|     | food brought in to school         |     |                |
|       | classes, offices, or work place   |       | other          |
| *P*  |                                   | *P*  |                |
|     |                                   |     |                |
|       |                                   |       |                |
| *Q*  |                                   | *Q*  |                |
|     |                                   |     |                |
|       |                                   |       |                |
| *R*  |                                   | *R*  |                |
|     |                                   |     |                |
+-------+-----------------------------------+-------+----------------+

***Now I'd like to ask about where the food came from that you ate at
home in those XXX days. In other words, this isn't necessarily where you
shopped in those days, but where the food that you ate during that time
came from. OK? Did any of it come from\...***

+--------+-------------------------------------------------------------+
| **Y ?  | **SOURCES OF FOOD AT HOME** \[[^4]\]                        |
| N**    |                                                             |
|        | grocery stores/supermarkets (*specify*)                     |
| *A*   | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}            |
|      | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}            |
|        | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}            |
| *B*   |                                                             |
|      | food warehouse stores (Costco, Sams,etc.)                   |
|        | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}            |
| *C*   | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}            |
|      | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}            |
|        |                                                             |
| *D*   | mini-marts (e.g., 7-11, AM/PM)                              |
|      |                                                             |
|        | ethnic specialty markets                                    |
| *E*   |                                                             |
|      | delicatessens                                               |
|        |                                                             |
| *F*   | bakeries                                                    |
|      |                                                             |
|        | farmer's markets                                            |
| *G*   |                                                             |
|      | fish or meat shops                                          |
|        |                                                             |
| *H*   | home delivery services (e.g., Schwan\'s, Meals-on-Wheels)   |
|      |                                                             |
|        | home-grown produce                                          |
| *I*   |                                                             |
|      | home-slaughtered meat                                       |
|        |                                                             |
| *J*   | other private households (friends, family, etc)             |
|      |                                                             |
|        | other (specify)                                             |
| *K*   |                                                             |
|      |                                                             |
|        |                                                             |
| *L*   |                                                             |
|      |                                                             |
|        |                                                             |
| *M*   |                                                             |
|      |                                                             |
+--------+-------------------------------------------------------------+

Food exposures (Section 1)

Now I'd like to ask you about a long list of food items, and for each
one my question will be "Did you eat it in the past 7 days?" The lists
are organized into categories, like eggs and dairy foods, vegetables and
fruits, and so on. For each item, give me a "yes" or "no" if you
remember eating or even tasting it in the past 7 days. Some of the
questions might seem a little repetitive, but please try and answer each
question individually, even if you think it was already covered. Unless
I specify otherwise, I'm interested in whether you ate these items at
home or away from home---either one, OK?

+-------+--------------------------+-------+--------------------------+
| **Y ? | **DAIRY AND EGGS**       | **Y ? | **MEAT & POULTRY**       |
| N**   |                          | N**   |                          |
|       | eggs {anything anywhere  |       | any chicken prepared at  |
| *A*  | from fresh eggs} *If     | *A*  | home {i.e., not          |
|     | yes, \...*               |     | take-out}                |
|       |                          |       |                          |
| *B*  | any eggs at home         | *B*  | anything prepared at     |
|     |                          |     | home from a "whole"      |
|       | any eggs away from home  |       | chicken                  |
| *C*  |                          | *C*  |                          |
|     | any eggs anywhere that   |     | *if yes*, was that       |
|       | were runny               |       | chicken *frozen* when    |
| *D*  |                          | *D*  | you got it?              |
|     | anything that had eggs   |     |                          |
|       | that were still raw in   |       | anything prepared at     |
| *E*  | it {e.g., dough, sauces, | *E*  | home from pre-cut        |
|     | homemade ice cream,      |     | chicken parts            |
|       | mayo}                    |       |                          |
| *F*  |                          | *F*  | *if yes*, was that       |
|     | any egg substitutes      |     | chicken *frozen* when    |
|       | {Egg-Beaters, etc.}      |       | you got it?              |
| *G*  |                          | *G*  |                          |
|     | butter {real butter; not |     | any chicken prepared or  |
|       | margarine}               |       | eaten *away* from home   |
| *H*  |                          | *H*  |                          |
|     | buttermilk {fluid, not   |     | anything from ground     |
|       | powdered}                |       | chicken                  |
| *I*  |                          | *I*  |                          |
|     | sour cream               |     | ground turkey            |
|       |                          |       |                          |
| *J*  | whipped cream            | *J*  | any other turkey {whole  |
|     |                          |     | or parts}                |
|       | fresh or flavored        |       |                          |
| *K*  | store-bought yogurt      | *K*  | duck or game hen         |
|     |                          |     |                          |
|       | frozen yogurt            |       | pre-frozen hamburger     |
| *L*  |                          | *L*  | patties eaten at home    |
|     | ice cream                |     |                          |
|       |                          |       | *if yes*, were any       |
| *M*  | ice cream bars or frozen | *M*  | patties *pink on the     |
|     | dairy dessert items      |     | inside* when eaten?      |
|       |                          |       |                          |
| *N*  | any pasteurized          | *N*  | fresh {not store-frozen} |
|     | {"regular"} milk.        |     | hamburger patties at     |
|       |                          |       | home                     |
| *O*  | any unpasteurized {raw}  | *O*  |                          |
|     | milk                     |     | *if yes*, was it *pink   |
|       |                          |       | on the inside* when      |
| *P*  |                          | *P*  | eaten?                   |
|     |                          |     |                          |
|       |                          |       | anything else made with  |
|       |                          | *Q*  | ground beef at home      |
|       |                          |     |                          |
|       |                          |       | any other beef {steak,   |
|       |                          | *R*  | roasts, etc.} at home    |
|       |                          |     |                          |
|       |                          |       | veal                     |
|       |                          | *S*  |                          |
|       |                          |     | pork                     |
|       |                          |       |                          |
|       |                          | *T*  | ham                      |
|       |                          |     |                          |
|       |                          |       | lamb                     |
|       |                          | *U*  |                          |
|       |                          |     | any kind of game         |
|       |                          |       | {venison, pheasant,      |
|       |                          |       | etc.---\                 |
|       |                          |       | fresh, frozen, or dried} |
+-------+--------------------------+-------+--------------------------+
| **Y ? | **CHEESE**               | **Y ? | **COOKED OR PROCESSED    |
| N**   |                          | N**   | MEATS**                  |
|       | cream cheese             |       |                          |
| *A*  |                          | *A*  | smoked or dried fish     |
|     | cottage cheese           |     | {e.g., lox}              |
|       |                          |       |                          |
| *B*  | Ricotta                  | *B*  | any pre-packaged sliced  |
|     |                          |     | deli meats               |
|       | any "string" cheese      |       |                          |
| *C*  |                          | *C*  | any other sliced deli    |
|     | any cheese sold as or    |     | meats {i.e., *not*       |
|       | cut from solid blocks    |       | pre-packaged}            |
| *D*  | {"typical"}              | *D*  |                          |
|     |                          |     | corn dogs                |
|       | any cheese on a          |       |                          |
| *E*  | deli-type sandwich       | *E*  | hot dogs                 |
|     |                          |     |                          |
|       | any cheese spread        |       | bologna                  |
| *F*  |                          | *F*  |                          |
|     | American {processed)     |     | bacon                    |
|       | cheese                   |       |                          |
| *G*  |                          | *G*  | breakfast sausage        |
|     | cheddar                  |     |                          |
|       |                          |       | any other                |
| *H*  | Swiss                    | *H*  | sausage/bratwurst etc.   |
|     |                          |     |                          |
|       | uncooked mozzarella      |       | pepperoni/salami         |
| *I*  | {e.g., *not* cooked on   | *I*  |                          |
|     | pizza}                   |     | store-bought beef        |
|       |                          |       | sticks/jerky             |
| *J*  | any Parmesan or Romano   | *J*  |                          |
|     |                          |     | **SEAFOOD**              |
|       | any blue-veined cheese   |       | *\-\-\-\-\-\-\-          |
| *K*  | {Bleu, gorgonzola,\...}  | *K*  | \-\-\-\-\-\-\-\-\-\-\-\- |
|     |                          |     | \-\-\-\-\-\-\-\-\-\-\--* |
|       | feta                     |       |                          |
| *L*  |                          | *\-\- | {store-bought} fresh     |
|     | any cheese made from     | \-\-\ | fish                     |
|       | goat or sheep milk       | -\-\- |                          |
| *M*  |                          | \-\-\ | crab                     |
|     | any fancy imported       | -\-\- |                          |
|       | cheese                   | \-\-\ | shrimp/prawns            |
| *N*  |                          | -\-\- |                          |
|     | homemade Mexican-style   | \-\-\ | oysters                  |
|       | {*queso fresco, q.       | -\--* |                          |
| *O*  | blanco*}                 |       | *if yes,* were the       |
|     |                          | *A*  | oysters raw when eaten?  |
|       | store-bought             |     |                          |
| *P*  | Mexican-style {*queso    |       | other shellfish          |
|     | fresco, q. blanco*}      | *B*  |                          |
|       |                          |     | *if yes*, were the       |
| *Q*  | any cheese made from     |       | shellfish *raw* when     |
|     | unpasteurized milk       | *C*  | eaten?                   |
|       | {often homemade or sold  |     |                          |
| *R*  | off-the-farm or          |       | sushi, sashimi, or       |
|     | door-to-door}            | *D*  | ceviche made with raw    |
|       |                          |     | fish or shellfish        |
| *S*  |                          |       |                          |
|     |                          | *E*  |                          |
|       |                          |     |                          |
|       |                          |       |                          |
|       |                          | *F*  |                          |
|       |                          |     |                          |
|       |                          |       |                          |
|       |                          | *G*  |                          |
|       |                          |     |                          |
|       |                          |       |                          |
|       |                          | *H*  |                          |
|       |                          |     |                          |
+-------+--------------------------+-------+--------------------------+

+-------+--------------------------+-------+--------------------------+
| **Y ? | **FRESH VEGETABLES {Not  | **Y ? | **FRESH VEGETABLES {Not  |
| N**   | frozen}**                | N**   | frozen}**                |
|       |                          |       |                          |
| *A*  | celery                   | *A*  | cabbage                  |
|     |                          |     |                          |
|       | mini-carrots in sealed   |       | potatoes                 |
| *B*  | bag                      | *B*  |                          |
|     |                          |     | yams or sweet potatoes   |
|       | loose or bagged carrots  |       |                          |
| *C*  | {full size}              | *C*  | alfalfa sprouts          |
|     |                          |     |                          |
|       | cucumbers                |       | bean sprouts             |
| *D*  |                          | *D*  |                          |
|     | broccoli                 |     | any other sprouts        |
|       |                          |       | {clover, mixed,          |
| *E*  | cauliflower              | *E*  | broccoli, etc}           |
|     |                          |     |                          |
|       | green bell peppers       |       | any salad mix that came  |
| *F*  |                          | *F*  | in a sealed bag          |
|     | red bell peppers         |     |                          |
|       |                          |       | mesclun lettuce {"spring |
| *G*  | asparagus                | *G*  | mix"}                    |
|     |                          |     |                          |
|       | fresh corn               |       | any other iceberg        |
| *H*  |                          | *H*  | lettuce                  |
|     | snow peas {eaten in pod} |     |                          |
|       |                          |       | any romaine lettuce      |
| *I*  | fresh beans              | *I*  |                          |
|     |                          |     | any other leaf lettuce   |
|       | brussel sprouts          |       |                          |
| *J*  |                          | *J*  | any lettuce on           |
|     | eggplant                 |     | sandwiches or burgers    |
|       |                          |       |                          |
| *K*  | zucchini or other        | *K*  | any tomatoes on          |
|     | \"soft\" squash          |     | sandwiches or burgers    |
|       |                          |       |                          |
| *L*  | any \"hard" squash       | *L*  | fresh spinach {not       |
|     | {pumpkin, acorn, etc.}   |     | frozen}                  |
|       |                          |       |                          |
| *M*  | white or yellow onions   | *M*  | other greens {collard,   |
|     |                          |     | mustard, etc}            |
|       | green onions {scallions} |       |                          |
| *N*  |                          | *N*  | fresh basil              |
|     | leeks                    |     |                          |
|       |                          |       | fresh parsley            |
| *O*  | avocado {or guacamole}   | *O*  |                          |
|     |                          |     | fresh cilantro           |
|       | any homegrown fresh      |       |                          |
| *P*  | tomatoes {eaten raw}     | *P*  | other fresh herbs        |
|     |                          |     |                          |
|       | any store-bought fresh   |       | fresh garlic             |
| *Q*  | tomatoes eaten at home   | *Q*  |                          |
|     | {raw}                    |     | fresh mushrooms          |
|       |                          |       |                          |
| *R*  |                          | *R*  | beets, turnips, or       |
|     |                          |     | radishes                 |
|       |                          |       |                          |
| *S*  |                          | *S*  | any "organic" produce    |
|     |                          |     |                          |
|       |                          |       |                          |
| *T*  |                          | *T*  |                          |
|     |                          |     |                          |
|       |                          |       |                          |
| *U*  |                          | *U*  |                          |
|     |                          |     |                          |
|       |                          |       |                          |
| *V*  |                          | *V*  |                          |
|     |                          |     |                          |
|       |                          |       |                          |
|       |                          | *W*  |                          |
|       |                          |     |                          |
+-------+--------------------------+-------+--------------------------+
| **Y ? | **FRESH FRUIT** *{Not    | **Y ? | **FRESH FRUIT** *{Not    |
| N**   | frozen or cooked}*       | N**   | frozen or cooked}*       |
|       |                          |       |                          |
| *A*  | apples                   | *A*  | cherries                 |
|     |                          |     |                          |
|       | pears                    |       | plums                    |
| *B*  |                          | *B*  |                          |
|     | peaches                  |     | any kind of grapes *if   |
|       |                          |       | yes...*                  |
| *C*  | nectarines               | *C*  |                          |
|     |                          |     | green grapes             |
|       | apricots                 |       |                          |
| *D*  |                          | *D*  | red grapes               |
|     | oranges                  |     |                          |
|       |                          |       | bananas                  |
| *E*  | tangerines               | *E*  |                          |
|     |                          |     | plantains                |
|       | grapefruit               |       |                          |
| *F*  |                          | *F*  | cantaloupe               |
|     | lemon                    |     |                          |
|       |                          |       | honeydew                 |
| *G*  | lime                     | *G*  |                          |
|     |                          |     | watermelon               |
|       | strawberries             |       |                          |
| *H*  |                          | *H*  | kiwi                     |
|     | raspberries              |     |                          |
|       |                          |       | pineapple                |
| *I*  | blueberries              | *I*  |                          |
|     |                          |     | mango                    |
|       | blackberries             |       |                          |
| *J*  |                          | *J*  | papaya                   |
|     |                          |     |                          |
|       |                          |       |                          |
| *K*  |                          | *K*  |                          |
|     |                          |     |                          |
|       |                          |       |                          |
| *L*  |                          | *L*  |                          |
|     |                          |     |                          |
|       |                          |       |                          |
| *M*  |                          | *M*  |                          |
|     |                          |     |                          |
|       |                          |       |                          |
| *N*  |                          | *N*  |                          |
|     |                          |     |                          |
+-------+--------------------------+-------+--------------------------+

+-------+--------------------------+-------+--------------------------+
| **Y ? | **PREMADE AND DRIED      | **Y ? | **MISCELLANY**           |
| N**   | FOODS**                  | N**   |                          |
|       |                          |       | chips {potato, corn,     |
| *A*  | store-bought fruit salad | *A*  | Fritos, etc}             |
|     |                          |     |                          |
|       | store-bought pasta salad |       | any *fresh* salsa        |
| *B*  |                          | *B*  |                          |
|     | store-bought potato      |     | taco shells              |
|       | salad                    |       |                          |
| *C*  |                          | *C*  | tortillas                |
|     | store-bought egg salad   |     |                          |
|       |                          |       | bulk chocolate {not      |
| *D*  | store-bought cole slaw   | *D*  | wrapped candy}           |
|     |                          |     |                          |
|       | peanuts {loose or in     |       | any apple juice/cider    |
| *E*  | shell}                   | *E*  |                          |
|     |                          |     | any apple juice/cider    |
|       | peanut butter            |       | that is freshly pressed  |
| *F*  |                          | *F*  | and not pasteurized      |
|     | any fresh-ground         |     |                          |
|       | "natural" peanut butter  |       | any orange juice         |
| *G*  |                          | *G*  |                          |
|     | almonds                  |     | any fresh squeezed       |
|       |                          |       | orange juice that {not   |
| *H*  | walnuts                  | *H*  | from a carton or         |
|     |                          |     | concentrate}             |
|       | cashews                  |       |                          |
| *I*  |                          | *I*  | any juice that is not    |
|     | pistachios               |     | pasteurized and not from |
|       |                          |       | a concentrate {often     |
| *J*  | sunflower seeds          | *J*  | bought from farms or     |
|     |                          |     | orchards, but may be     |
|       | raisins                  |       | sold commerically with a |
| *K*  |                          | *K*  | label saying it is       |
|     | any pre-made pudding or  |     | unpasteurized and may    |
|       | custard {not a mix}      |       | contain bacteria}        |
| *L*  |                          | *L*  |                          |
|     |                          |     | tofu                     |
|       |                          |       |                          |
| *M*  |                          | *M*  | baby formula bought as a |
|     |                          |     | liquid in a can          |
|       |                          |       |                          |
| *N*  |                          | *N*  | baby formula bought as a |
|     |                          |     | powder                   |
|       |                          |       |                          |
| *O*  |                          | *O*  | store-bought puréed baby |
|     |                          |     | food {e.g., Gerbers}     |
|       |                          |       |                          |
|       |                          | *P*  | commercially bottled     |
|       |                          |     | water                    |
|       |                          |       |                          |
|       |                          | *Q*  | cold breakfast cereals   |
|       |                          |     | {e.g., Cheerios, Raisin  |
|       |                          |       | Bran}                    |
|       |                          | *R*  |                          |
|       |                          |     | granola                  |
|       |                          |       |                          |
|       |                          |       | hot breakfast cereals    |
|       |                          |       | {oatmeal, etc.}          |
+-------+--------------------------+-------+--------------------------+
| **Y ? | **FROZEN FOODS**         | **Y ? | **SPECIFIC FOODS EATEN   |
| N**   |                          | N\    | OUT\                     |
|       | frozen dinners/entrees   | **    | ***These refer to food   |
| *A*  |                          |       | eaten or prepared away   |
|     | frozen vegetables in a   | *A*  | from home*               |
|       | box                      |     |                          |
| *B*  |                          |       | Any burgers or ground    |
|     | frozen vegetables in a   | *B*  | beef at a fast-food      |
|       | bag                      |     | place                    |
| *C*  |                          |       |                          |
|     | frozen berries           | *C*  | any other burger/ground  |
|       |                          |     | beef away from home      |
| *D*  | frozen vegetarian stuff  |       |                          |
|     | {e.g., Gardenburgers}    | *D*  | any other beef away from |
|       |                          |     | home                     |
| *E*  | frozen fish products     |       |                          |
|     |                          | *E*  | any deli-type sandwich   |
|       | frozen chicken strips or |     |                          |
| *F*  | nuggets {at home}        |       | any sandwich with        |
|     |                          | *F*  | sprouts on it            |
|       | any other frozen chicken |     |                          |
| *G*  | products                 |       | any sandwich or burger   |
|     |                          | *G*  | garnished with lettuce   |
|       | frozen pizza             |     |                          |
| *H*  |                          |       | any sandwich or burger   |
|     | frozen Mexican-style     | *H*  | garnished with tomato    |
|       | items                    |     |                          |
| *I*  |                          |       | anything from a salad    |
|     | frozen shrimp, frog      | *I*  | bar                      |
|       | legs, lobster, crab,     |     |                          |
| *J*  | other seafood            |       | any kind of salad made   |
|     |                          | *J*  | with lettuce or greens   |
|       |                          |     |                          |
| *K*  |                          |       | anything with raw        |
|     |                          | *K*  | tomatoes                 |
|       |                          |     |                          |
|       |                          |       | pizza from a pizzeria    |
|       |                          | *L*  | {not frozen}             |
|       |                          |     |                          |
|       |                          |       | any kind of burrito or   |
|       |                          |       | "wrap"                   |
+-------+--------------------------+-------+--------------------------+

Animal Contact (Section 4)

IN THE PAST 7 DAYS did {you/your child} have any contact with any of the
following?

+-----------+----------------------------------------------------------+
| **Y ? N   | Bird                                                     |
| R**       |                                                          |
|           | Kitten                                                   |
| *A*     |                                                          |
|       | Cat                                                      |
|           |                                                          |
| *B*     | Chicken                                                  |
|       |                                                          |
|           | Baby chicks                                              |
| *C*     |                                                          |
|       | Cow/bull/steer                                           |
|           |                                                          |
| *D*     | Calf                                                     |
|       |                                                          |
|           | Puppy {\<6 months old}                                   |
| *E*     |                                                          |
|       | Dog                                                      |
|           |                                                          |
| *F*     | Goat, Sheep, or Lamb                                     |
|       |                                                          |
|           | Horse                                                    |
| *G*     |                                                          |
|       | Pig                                                      |
|           |                                                          |
| *H*     | Reptile {including snakes, iguanas or other lizards, and |
|       | turtles}                                                 |
|           |                                                          |
| *I*     | Amphibian {such as frogs}                                |
|       |                                                          |
|           | Turkey                                                   |
| *J*     |                                                          |
|       | Tropical fish                                            |
|           |                                                          |
| *K*     |                                                          |
|       |                                                          |
|           |                                                          |
| *L*     |                                                          |
|       |                                                          |
|           |                                                          |
| *M*     |                                                          |
|       |                                                          |
|           |                                                          |
| *N*     |                                                          |
|       |                                                          |
|           |                                                          |
| *O*     |                                                          |
|       |                                                          |
|           |                                                          |
| *P*     |                                                          |
|       |                                                          |
+-----------+----------------------------------------------------------+
| **Y ? N   | IN THE PAST 7 DAYS did {you/your child} handle any dog   |
| R**       | treats like pig ears, rawhide chews -- at home or        |
|           | anywhere else?                                           |
| **A**   |                                                          |
|       | IN THE PAST 7 DAYS did {you/your child} visit a petting  |
|           | zoo or farm?                                             |
| **B**   |                                                          |
|       | IN THE PAST 7 DAYS did {you/your child} visit a state,   |
|           | county or local fair at which there were animals?        |
| **C**   |                                                          |
|       | IN THE PAST 7 DAYS did {you/your child} visit any other  |
|           | events at which there were animals present such as       |
| **D**   | festivals, animal shows, exhibits, swap meets, sales,    |
|       | etc.?                                                    |
+-----------+----------------------------------------------------------+

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