Information
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Officer(s)
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Location
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Conducted on
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This is a:
Demographic Data
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Surname/Family name
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Other names
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Residential Street Address
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Suburb/Town and Postcode
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Telephone
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Date of Birth
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Sex
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Aboriginal or Torres Straight Islander Origin
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Country of Birth
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Language Spoken at Home
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Occupations (if child list parental occupations)
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Name/Address of Employer or School or Child Care Attended
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Date last attended
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High Risk occupational group?
Treating Doctor/Hospital
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Name of Treating Dr
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Did the case present to hospital?
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Name of hospital
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Was the case admitted to hospital?
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Date of admission
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Date of discharge/death
Illness (Summary)
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First symptom
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Onset date of first symptom
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Time of onset of first symptom
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Maximum stools in 24 hours
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 10+
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Duration of diarrhoea (days/hours)
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Total duration of illness (days)
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History of Illness:
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Was the case given antibiotics to treat the illness?
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If yes, what antibiotics?
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Is the case still taking antibiotics?
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What date did the case last take antibiotics?
Contact Data
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In the week prior to the onset of illness, has the case:
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Had contact with a family member with a similar illness?
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Had contact with a friend or work/school colleague with a similar illness?
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If yes to the above questions, detail name, age, relationship, address, phone number, occupation/child care/school, onset date and if a faeces culture has been taken.
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Could illness in the case be linked to illness in any others
