Utah Public Health s1

Utah Public Health LHD name LHD address line 1 CRYPTOSPORIDIOSIS LHD address line 2 Phone: (xxx) xxx-xxxx Mini Confidential Case Report Confidential fax: (xxx) xxx-xxxx Date finalized Please fill in the blanks or check the answer for each field NETSS ID S C

I Last name First / MI H P

A Address City Zip R G    O County State Phone number(s) M

E Date of birth Age Gender M F Parent/contact D Race Wh Bl Am Ind Asian AK Native Native HI/Pac Isl Oth Ethnicity His Non-His Unk Unk

L Onset date: Symptoms: none nausea vomiting abdominal pain diarrhea fever loss of appetite A C I Y N N Date resolved: ongoing Died? Date of death: I

L U C Hospitalized? Y N Treated? Y N Treatment: U U

Lab name/phone: Test type: DFA ELISA/EIA other: B A L Lab result: pos neg pres. pos inconcl. pending Specimen source: stool other: Collection date:

) Occupation: (check all that apply): child student volunteer unemployed retired L A C

I Y N U If yes to any, list details for each: G

O Food handler? L ▪ facility name(s) O I Healthcare worker?

M ▪ location(s) E

D Group living? I ▪ supervisor name(s) P E

( Day care association? ▪ phone number(s) K S

I Attend or work in a school?

R ICP contacted if appropriate -

H Pool employee (lifeguard, swim instructor)? G I

H If yes to any above, did patient work/attend while ill? Dates/notes:

Reported by: G Reporter name: Phone: N

I hospital/ICP clinic/MD office T

R Date results reported to clinician: Date reported to Public Health:

O lab other: P E

R Received by whom at LHD: LHD open date: LHD Investigator:

In the 2 weeks before onset, did patient: Y N U If yes to any, list name, address and date for each: Visit/swim/play/work in a pool, hot tub, water park or interactive water feature? S

E Visit/swim/play/work in natural waterway (e.g. R

U lake)? S O

P Have any other recreational water exposure (e.g. X E

water play table in daycare)?

Swim/play/work in any recreational water while ill or in the 2 weeks after diarrhea ended?

Drink or have contact with any untreated water (e.g. Specify: well, river/lake, irrigation/secondary water)? Have contact with person(s) who were ill with If yes, who? family friends other Total number ill: similar symptoms? Similar exposure(s)? Y N U

Appropriate follow-up completed? Y N/A Specify: LHD status: Confirmed Probable Suspect Not a case Carrier Pending UDOH status: Confirmed Probable Suspect Not a case Carrier Pending E V

I LHD interview date: Interviewed: Client Parent/Guardian Significant other HC provider Friend Other: T A

R Unable to contact/interview LHD Reviewer: LHD closed date: Date submitted to UDOH: T S I N

I Notes: M D A CRYPTOSPORIDIOSIS Name ______NETSS ID ______