The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

5C3AZfZPL99CG9N3Zrf4ow2g443r4RFJNopQ6VkRXNBA7eekx3BdqvmAvkRZ39Hfswx4oZ9J49SFGYdac3xNQdVbhCUjHuJF8rJR3

Raw Milk Interview

Please complete the survey below.

Thank you!

Call Log. Please track calls like this:
Call 1: Date, Time, Call Result, Your Name

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Please verify that you have read the above information and agree to be interviewed. (If you refuse, choose No.)

* must provide value

Yes

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Interviewer

Interview Date and Time

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.

First Name:	Last Name:	Age:	Gender:
Street:	City:	ZIP: State	Phone:

County:

MEDSS Event ID

Lab ID

Specimen Collection Date

M-D-Y

Pathogen

Serotype/Subtype

Did this case have a co-infection

Yes

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If yes, what other infection did they have?

Co-infection serotype info

Did you drink raw milk in the 14 days prior to your illness?

Yes No Unknown

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How often do you drink raw milk?

Where did you get your milk from?

What is the name of the farm, program, or store you get your milk from?

What drop site location do you use? Include city, address, and building location (e.g. Cub, Rock Elementary School)

What was the most recent date you got the milk?

How did you learn about getting milk from a drop site? How did you sign up for it?

What animal does the milk come from?

Does anyone else who lives with you drink raw milk?

Yes

Unknown

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If yes who?

Has anyone else you know been sick since drinking raw milk?

Yes

Unknown

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Who else has been sick?

Have you been sick with diarrhea or vomiting since consuming products from Healthy Harvest?

* must provide value

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

Weight loss?

Yes

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Pounds lost

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:

Are you willing to submit a stool kit to MDH for laboratory testing?

Yes No

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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.

Stool kit sent?

Yes No

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Stool kit returned?

Yes No

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Stool kit results

Stool kit comments (reason not sent, additional result details, etc.)

Any additional notes

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Case Defintion

Updated in MEDSS?

Yes

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Raw Milk Interview

Start of Interview

Thank them for their time, and give them your phone number to call back if they change their mind or have questions.

Contact Information

Lab Information

Raw Milk

Illness History

Health Care

MDH Stool Kit

Additional Questions/Comments

Admin/Epi Only

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