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 & Contact person
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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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Did you experience any of the following?
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Fever
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Date of onset?
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Nausea?
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Date of onset?
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Vomiting?
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Date of onset
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Abdominal pain?
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Date of onset
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Lethargy?
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Date of onset
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Headache?
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Date of onset
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Diarrhoea?
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Date of onset
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Bloody stools?
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Date of onset
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Watery stools?
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Date of onset
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Did you experience any other symptoms?
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What other symptoms did you experience.
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Date of onset
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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 onset of illness, has the case had contact with a family member with a similar illness?
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If yes, provide details - Name, Relationship, Address & phone (if different), Occupation/Childcare/school
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In the week prior to illness has the case 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 & was a faeces culture collected (Y/N)
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Could illness in the case be linked to illness in any others (Interviewer to conduct interviews on others if possible link)
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If yes, provide details & if possible link, conduct interviews on those other persons.
Environmental Risk Factors - in the week prior to illness did any of the following apply?
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Have you travelled within Tasmania or internationally in the week prior to illness?
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Place/s visited & type of accommodation
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Date of departure
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Date of return
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Airline & flight number
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Have you had close contact with farm animals (including petting zoos)?
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Specify type of animal, date/ s and location
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Do you live on a rural property?
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Have you had contact with with native animals?
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Have you had contact with with pets (including fish & reptiles)?
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Type of pet
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Has the pet been ill?
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Have you been bush walking or camping?
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Location where you went bush walking or camping.
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Describe water supply.
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Have you drunk water from a private water supply?
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Specify the type of water and location.
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Was the water treated?
- Yes
- No
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Did you drink from a public water supply?
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If yes, what was the location of the public water supply?
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Did you drink any bottled water?
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Specify the brand and how often you drink it.
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Have you had trouble with sewage disposal at home?
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Specify the type of problem and the type of system.
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Have you had contact with potting mix or manure while doing gardening?
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Specify the type of potting mix or manure.
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Have you participated in swimming or water sports?
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What was the type, the location and the date of the activity.
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Are there any other known risk factors ( eg occupational exposure).
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Specify the type of risk factor.
Food History - where do you normally obtain following (name & address of premises)
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Where do you or the household normally obtain meat & smallgoods
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Where do you or the household normally obtain chicken & other poultry?
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Where do you or the household normally obtain groceries ?
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Where do you or the household normally obtain fruit & vegetables (including roadside stalls & home grown)?
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Where do you or the household normally eggs (brand name & type of eggs) ?
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Where do you or the household normally obtain fish & seafood ?
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Have you tried any new or different foods recently?
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If so specify types of food.
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Have you been on any specific diets lately?
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If so specify.
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Was the case able to adequately recall a detailed 3-day (question for interviewer - if not administer the food checklist).
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Was the case able to adequately recall a detailed 3-day food history (if not, administer the food checklist).
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In the week prior to illness did you eat or buy food from cafè/restaurants?
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Name & address of premises. What was eaten?
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In the week prior to illness did you eat or buy food from bakeries or bakery products?
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Name & address of premises. What was eaten?
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In the week prior to illness did you eat or buy food from takeaway outlets?
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Name & address of premises. What was eaten?
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In the week prior to illness did you eat or buy food at parties or functions with family or friends?
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Name & address of premises. What was eaten?
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In the week prior to illness did you eat or buy food at festivals or commercial public gatherings (eg fetes, club social events, markets).
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Name & address of premises. What was eaten?
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In the week prior to illness did you eat or buy food at a continental deli or specialty grocer (rg Asian supermarket).
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Name & address of premises. What was eaten?
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In the week prior to illness did you eat or buy food at farms or growers (farm gate sales or consumption of unprocessed products).
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Name & address of premises. What was eaten?
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Were any other attendees at these meals/functions ill with gastro symptoms.
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If yes, provide details.
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What do you think was the cause of your illness.
Follow up actions
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We're food samples collected for the investigation?
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If yes, what was the type of food collected, date collected & result of analysis.
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Is a food premises implicated?
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If a food premises is implicated, advise the name & address of food premises.
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Has the food premises that has been implicated been inspected?
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Is the implicated food premises in another Local Council area?
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If yes, has the relevant Local Council been informed?
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Provide any details relevant.
Additional Investigation Factors
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Add any additional factors.
Education
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Hygiene precautions transmission & prevention discussed?
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Salmonellosis information sheets provided?
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Child/children in child care - have you discussed exclusions with parent or guardian?
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Child care worker - have you discussed exclusion?
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Is the affected person a food handler - have you discussed exclusion with affected person?
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If the person is a health care worker have you discussed exclusion with them?
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If the person is a resident of an institution (eg aged care/residential care), have you discussed exclusion with the person?
Signature
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Name & title of interviewer
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Date/time of interview
