Call Log. Please track calls like this:
to be filled in ahead of time to make piping work
We are investigating reports of possible gastrointestinal illness and are interviewing people who _________________________________, to help us __________________________.
For your protection, before beginning an interview, we are required to give you the following information regarding your participation in this investigation and your right to privacy.
We are collecting this information to determine what the cause of this reported illness may be. All information we collect about your health is private; the only persons who will have access to this information will be public health staff from the Minnesota Department of Health and staff from local public health agencies who work on this investigation.
Under no conditions will your name be released to anyone else without your permission.
You are under no obligation to participate in this investigation.
There is no penalty if you choose not to participate in this investigation. However, your participation may help us identify an outbreak of illness, identify its cause, and prevent further illness.
* must provide value
Yes
No
Now M-D-Y H:M
Thank them for their time, and give them your phone number to call back if they change their mind or have questions. Â
Â
First Name: Last Name: Age: Gender: Street: City: ZIP:
Phone:
County:
First Name
* must provide value
Last Name
* must provide value
Female Male Non-binary Unknown
Include Area Code
Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon McLeod Mahnomen Marshall Martin Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Ottertail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau St. Louis Scott Sherburne Sibley Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine Non-MN Resident
Enter state
Did you/your child attend ______ ?
Yes No Unknown
What date did you/your child visit ______ ?
M-D-Y
What date did you/your child visit ______ ?
M-D-Y
What date did you/your child visit ______ ?
M-D-Y
What date did you/your child visit ______ ?
M-D-Y
What date did you/your child visit ______ ?
M-D-Y
Yes
Additional Visit Date Info
Visit Date 1 Visit Date 2 Visit Date 3 Visit Date 4 Visit Date 5 Visit Date Unknown Add'l info
Have you been sick with diarrhea or vomiting since attending ______ or since DATE?
or
Have you been sick with diarrhea or vomiting since DATE?
* must provide value
Yes No
First symptom  Onset date Onset time  Recovery date Recovery time Illness Dates Still sick? Vomiting:
Vomiting recov Diarrhea:
Diarrhea recov Max # of stools/24 hrs Length of time diarrhea time units Bloody Stool Cramps Fever: Temp: Other Symptoms
Â
Today M-D-Y MM/DD/YYYY
Now H:M
Yes No Unknown
Today M-D-Y MM/DD/YYYY. If you're still sick, leave blank.
Now H:M If you're still sick, leave blank.
What was your first symptom?
Yes No
What date did the diarrhea start?
Today M-D-Y MM/DD/YYYY
What time did the diarrhea start?
Now H:M
What date did the diarrhea stop?
Today M-D-Y MM/DD/YYYY. If you're still sick, leave blank
What time did the diarrhea stop?
Now H:M If you're still sick, leave blank.
How many days did the diarrhea last?
days
Days Hours
When the diarrhea was at its worst, how many stools were you having in a 24 hour period?
1-2 stools 3-5 stools 6-9 stools 10+ stools
Yes No Unknown
Yes No
What date did the vomiting start?
Today M-D-Y MM/DD/YYYY
What time did the vomiting start?
Now H:M
What date did the vomiting stop?
Today M-D-Y MM/DD/YYYY
What time did the vomiting stop?
Now H:M MM/DD/YYYY
Yes No Unknown
Yes No Unknown
in degrees F
Called provider: Visited provider: Type of visit: Date of Visit: Provider Name Clinic Name Hospitalized: Hospital Name: Admit: Discharge: Submitted stool sample: Result of test:
Did you call a health care provider?
Yes No Unknown
Did you visit a health care provider?
Yes No
What type of visit was it?
Office Emergency room
Today M-D-Y
Health care facility name/Location
Yes No
Today M-D-Y MM/DD/YYYY
Today M-D-Y MM/DD/YYYY
Did you submit a stool sample to your health care provider?
Yes No
What were the results of the stool test?
Are you willing to submit a stool kit to MDH for laboratory testing?
Yes No
Check the address to make sure it's not a PO Box. We can't send kits to PO boxes, so we need a physical address.
Yes No
Yes No
What barns did you visit at ______ ?
modify choices for each outbreak
What animals were present in those barns?
Did you have contact with any of the animals' environments (i.e. pens, fencing, bedding, feed) in the barns?
Yes No Unknown
Explain this contact. What did you touch? What animals were you near? Was it dirty-looking?
Did you have direct contact (such as petting, holding or feeding) with any of the animals in the animal barns?
Yes No Unknown
What animals did you touch/pet/feed/hold? Â
What type of poultry/birds?
What other animals did you contact?
Explain this contact. Did you pet, feed, etc?
Did you have any contact with animals outside of the barns or anywhere else at the fair?
Yes No Unknown
What animals, where were they located and type of contact?
Did you eat or drink anything inside any animal barns?
Yes No Unknown
What food/drink and which barn?
Did you eat before or after visiting the animal barns? (put with food section and have it triggered on barns = yes, or leave here where its sep or move to health behav section??)
Yes No Unknown
What areas did you visit at _________________?
What animals were present at ______________?
Did you have contact with any of the animals' environments (i.e. pens, fencing, bedding, feed) in the barns?
Yes No Unknown
Explain this contact. What did you touch, near what animals, etc.?
Did you have direct contact (such as petting, holding or feeding) with any of the animals in the animal barns?
Yes No Unknown
What animals did you touch/pet/feed/hold? Â
What type of poultry/birds?
What other animals did you contact?
Explain this contact. Did you pet, feed, etc?
Did you have any contact with animals outside of the_________ or anywhere else at the venue?
Yes No Unknown
What animals, where were they located and type of contact?
Did you eat or drink anything inside the animal areas?
Yes No Unknown
What food/drink? Which animal area?
Did you eat before or after visiting the animal areas? (put with food section and have it triggered on barns = yes, or leave here where its sep or move to health behav section??)
Yes No Unknown
Where you notified about which animals they might visit?
Yes No Unknown
Did you receive any information about possible disase risks from animals?
Yes No Unknown
How did the student get to __________________
Did you child change shoes or clothes after visiting ______________?
Yes No Unknown
What animals were present at ______________?
Did you have contact with any of the animals' environments (i.e. pens, fencing, bedding, feed) in the barns?
Yes No Unknown
Explain this contact. What did you touch, near what animals, etc.?
Did you have direct contact (such as petting, holding or feeding) with any of the animals in the animal barns?
Yes No Unknown
What animals did you touch/pet/feed/hold? Â
What type of poultry/birds?
What other animals did you contact?
Explain this contact. Did you pet, feed, etc?
Did you have any contact with animals outside of the_________ or anywhere else at the venue?
Yes No Unknown
What animals, where were they located and type of contact?
Did you eat or drink anything inside the animal areas?
Yes No Unknown
What food/drink? Which animal area?
Did you eat before or after visiting the animal areas? (put with food section and have it triggered on barns = yes, or leave here where its sep or move to health behav section??)
Yes No Unknown
Did you participate in a visit to ____________ on ____________?
Yes No Unk
Did you get manure on uncovered skin (e.g. face, hands)?
Yes No Unknown
Did you have any ungloved contact with any environmental object on the farm?
Yes No Unknown
What type of object (e.g. bedding, fence)?
Did you change or wash your gloves and/or boot covers between working with individual animals?
Yes No Unknown
Regarding the clothes you were wearing to the farm field trip, when did you change out of those clothes?
Before drive back from farm After leaving the farm but before going home on the bus on the way home After arriving home Not until end of day Other Unk
Did you work at ____________ during _____________?
Yes No Unknown
How long have you worked at ____________________?
< 1 month 1+ to 3 months 3 months to 1 year > 1 year
decide on some time categories for dripdown
Do you help care for animals?
Yes No Unknown
What are your animal-related job duties?
could do free text instead?
Do enter the animal pens when working?
Yes No Unknown
Do you use any of the following personal protective equipment when workig with the animals?
Did you receive any training on diseases people can get from animals?
Yes No Unknown
Did you receive any training on PPE use?
Yes No Unknown
Did you eat or drink anything during or soon after caring for the animals?
Yes No Unknown
Do you routinely wash your hands after working with the animals?
Yes No Unknown
Do you visit the animals or their area when working?
Yes No Unknown
Did you wash your hands with soap and water after visiting the animals at ______ ?
Yes No Used only water Unknown
How did you dry your hands?
paper towels air blower On clothes Other Unknown
Why did you not wash your hands?
sink not available sink too far away line too long used sanitizer instead sink too dirty "just didn't" other
Did you use hand sanitizer?
Yes No Unknown
Did you take any steps to reduce/remove dust or dirt from the animal environment, such as change shoes or clothes when you got home?
took off shoes changed clothes both no
alt version: Did you remove shoes when home? Next question: did you change clothes when home?
Yes No Unknown
Do you remember signs in the animal area of ______ reminding you to wash your hands?
Yes No Unknown
Did you see any signs with education about disease risk from animals?
Yes No Unknown
What food did you eat at ______ ?
Have you gone swimming since your symptoms started?
Yes No Unknown
Cryptosporidium can be spread easily through water, and people who have symptoms of cryptosporidiosis should not go swimming or use hot tubs or bathe with other people while they have diarrhea and for 2 weeks following the resolution of symptoms.
I ackknowledge that I/my child should not go swimming, use hottubs, or bathe with others whil ill and for 2 weeks after recovery.
Did you attend or work at a childcare facility WHILE ill?
Yes No
Did you attend or work at a childcare facility FOLLOWING your illness?
Yes No
Name of Childcare Director
Our colleages may contact the child care provider to determine if other children have been ill and to provide information and recommendations to prevent the spread of illness. Do you have concern about disclosing your/your child's name to the child care facility
Yes, I have concerns. Do not disclose names.
No, I have no concerns.
Additionally, because Crypto can easilyspread in childcare settings, children shoud not attend preschool or childcare until they are diarrhea-free for 24 hours. Employees of preschools or childcares shoud also not work until they are diarhrea-free for 24 hours. If you have questions about these restrictions, please call an epidemiologist in the Waterborne Diseases Unit at 651-201-5414.
I ackknowledge my child shoud lnmot attend/I should not work at preschool or chlidcare until they are diarrhea free fro 24 hours.
Have you worked or volunteered at Wild and Free Animal Rehab since July 24, 2023?
Yes No Unknown
volunteer intern full-time staff
How long have you worked at Wild and Free Animal Rehab?
< 1 month 1+ to 3 months 3 months to 1 year > 1 year
decide on some time categories for dripdown
How many hours per week do you work at Wild and Free?
< 5 hours 5-10 hours 10-20 hours 20-40 hours >40 hours
Do you help care for animals?
Yes No Unknown
What are your animal-related job duties?
could do free text instead?
Since mid-July, what animals have you worked with?
Since mid-July, did any animals have vomiting or diarrhea?
Did you help with the fawn release on August 3?
Did you enter the animal pens when working?
Yes No Unknown
Did you have any ungloved contact with any environmental objects (e.g. bedding, fence?)
Yes No Unknown
Since mid-July, did you use any of the following personal protective equipment when working with the animals?
Did you change or wash your gloves and/or boot covers between working with individual animals?
Yes No Unknown
Have you received any training on PPE use?
Yes No Unknown
Since mid-July, did you eat or drink anything during or soon after caring for the animals?
Yes No Unknown
Did you routinely wash your hands with soap and water after working with animals at Wild and Free?
Yes No Used only water Unknown
How did you routinely dry your hands?
paper towels air blower On clothes Other Unknown
Why did you not wash your hands?
sink not available sink too far away line too long used sanitizer instead sink too dirty "just didn't" other
Did you routinely use hand sanitizer?
Yes No Unknown
Did you routinely take any steps to reduce/remove dust or dirt from the animal environment, such as change shoes or clothes when you got home?
took off shoes changed clothes both no
Are there signs in the animal area of Wild and Free reminding you to wash your hands?
Yes No Unknown
Did you see any signs with education about disease risk from animals?
Yes No Unknown
Have you received any training on diseases people can get from animals?
Yes No Unknown
Any additional notes on interview.
Confirmed Probable Case Not a Case