D02 2015 10 Eoe Standard 5 Day Infectious Gastroenteritis Questionnaire V3

IN STRICT CONFIDENCE EAST OF ENGLAND LOCAL INFECTIOUS GASTROENTERITIS AUTHORITY INVESTIGATION QUESTIONNAIRE LOGO STANDARD – 5 DAY EXPOSURE FOR OFFICIAL USE ONLY ORGANISM: Investigating Officer: ID Number:

INSTRUCTIONS FOR COMPLETING THIS FORM This questionnaire should be answered by, or for the person who is ill with food poisoning type symptoms. Please use black or dark blue biropen to complete the questionnaire. If the person suffering from symptoms is a child (under 16 years), a parent or responsible adult should complete the questionnaire on the child’s behalf. If the child is not old enough to eat solid food, please complete the form as best you can. Please read each question carefully before you answer it and try to answer every section as far as possible. Questions should be answered by ticking boxes or writing in the spaces provided. ‘No’ answers are as important as ‘Yes’ answers. If you leave a blank we cannot interpret your intended answer. Names and addresses (including postcode) of identified locations are particularly important to us as a means of identifying common links. However, if the name of a location crops up more than once as you complete the questionnaire, you do not need to repeat address details if you have already given it once. Any personally identifiable information returned in this questionnaire will remain CONFIDENTIAL to the investigation team.

NAME OF PERSON COMPLETING FORM If completing this form on behalf of another person, please also state relationship to ill person

Surname: Forename: Relationship to ill person: Date completed: / / (dd/mm/yy) WHEN COMPLETED, PLEASE RETURN THIS The above organisation/s are registered under FORM IN THE PRE-PAID ENVELOPE/ OR TO: the Data Protection Act 1998 for the purpose of processing personal data in the performance of «Address» its legitimate business. Any information held will be processed in compliance with the eight principles of the Act. Further information relating to your rights under the Data Protection Act can be sent to you on request SECTION A: GENERAL DETAILS This section asks for some basic information about you, the ill person/child 1. PERSONAL DETAILS

Surname: Forename:

Date of birth: / / (dd/mm/yy) Sex: Male Female

Telephone: Home: Daytime:

Mobile: Email: GP Practice name: Telephone:

EoE Standard GI Questionnaire Final Oct 2015 1 IN STRICT CONFIDENCE 2. DETAILS OF OCCUPATION OR CHILD’S SCHOOL/NURSERY 2.1 If you are the person with symptoms, please provide details of your occupation or main activities (including part-time work, voluntary and other activities) OR if the person with symptoms is your child, please provide details of their school/nursery. Details of workplace/school/nursery. If retired or not in employment please tick box Occupation Name and address of workplace/school/nursery Postcode

2.2 Do you do any work or activities that involve the following. Please tick all that apply. Pre-school/nursery child Food handler Contact with patients/clients in health/social care setting Caring for/teaching children Work with animals Other (please specify)

SECTION B: CLINICAL DETAILS 3. ILLNESS 3.1 Did/do you have any of the following symptoms? Please tick all that apply. Diarrhoea or loose stools Nausea or vomiting Abdominal pain/stomach cramps Other (please specify). Blood in stools Fever 3.2 Did you consult your GP or another doctor or visit A&E as a result of this illness? No Yes 3.3 Were you admitted to hospital for one or more nights as a result of this illness?

If YES, how many nights were you admitted for? nights

3.4 When did you first start to feel unwell? Date: (dd/mm/yy) / / 3.5 Do you still have any symptoms? YES NO If NO, when did they end? Date: (dd/mm/yy) / / 4. Was anyone else in your household ill with similar symptoms in the 5 days before No Yes you became ill?

SECTION C: EXPOSURE IN THE 5 DAYS BEFORE SYMPTOMS STARTED This section asks for details of certain activities which may have resulted in your illness 5. TRAVEL ABROAD AND IN UK

5.1 In the 5 days before your symptoms started did you travel OUTSIDE of the UK? No Yes (holidays or business trips; staying at friends or relatives, hotels, etc) If NO, please go to Q5.2. If YES, please give details below Departure Name of hotel, B&B, guesthouse, Arrival date Country Town or Resort date campsite, cruise liner, etc (dd/mm/yyyy) (dd/mm/yyyy

/ / / /

5.2 In the 5 days before your symptoms started did you spend any nights away from home No Yes

EoE Standard GI Questionnaire Final Oct 2015 2 IN STRICT CONFIDENCE WITHIN the UK? (holidays or business trips; staying at friends or relatives, hotels, campsites, etc) If NO, please go to Q6. If YES, please give details below Departure Name and location of hotel, B&B, guesthouse, campsite, Arrival date Town or resort date etc (dd/mm/yyyy) (dd/mm/yyyy

/ / / /

6. CONTACT WITH ANIMALS 6.1 In the 5 days before your symptoms started, have you been in a household (your own or someone else’s) with pets or had contact with any pets? If YES, please give details No Yes below of the types of pets e.g. dogs, cats, rabbits, reptiles, etc

6.2 In the 5 days before your symptoms started, have you stayed in or visited a place where there were animals? This will include visits to a farm, petting zoo, stables, etc. If YES, No Yes please give details below. Date of visit Name Location /Address Postcode (dd/mm/yy)

7. EXPOSURE TO WATER 7.1 In the 5 days before your symptoms started, did you take part in any water-based activity which could have led to any accidental swallowing of water? If NO, please go to Q7.2. No Yes If YES, please tick below all that apply and give relevant details. Activity Site name Location/Address Postcode

Swimming/

paddling pool

Theme park

water ride

Sailing/canoeing

Other, please state below & give details

7.2 What is the source of your drinking water at home? Please tick all that apply

Please specify Mains water company

Private Please give details

Other Please give details (e.g bottled water)

EoE Standard GI Questionnaire Final Oct 2015 3 IN STRICT CONFIDENCE SECTION D: FOODS EATEN This section asks for details of foods eaten, inside or outside the home and locations.

8. In the 5 days before you became ill, did you eat any of the foods below? Please tick NO or YES at home and/or YES outside home against each and give details as relevant. If, for any location named below, you have already given the address and postcode once, you do not need to detail them again. The list of foods below is a general one and will include items that you may not eat for religious or cultural reasons. Please tick the NO box for any such foods. Yes at Yes If eaten outside the home, please detail where eaten Food item No outside home home Names and location/addresses of places where eaten Postcodes Sliced meats (cured/pre-cooked) e.g. salami, cold ham, chicken, etc

Barbecued food

Sausages or burgers (incl pork, beef, lamb or poultry)

Chicken (casseroles, roast, etc)

Other poultry (turkey, duck, goose, pheasant, etc)

Beef (incl roast, mince, steak)

Lamb (incl roast, mince, steak, chops)

Pork (incl roast, mince, chops, pies)

Bacon or Gammon (incl roast, steaks, chops)

Paté (any)

Fish/shellfish (fish, crab, prawns, mussels, oysters, etc)

Food item No Yes at Yes If eaten outside the home, please detail where eaten

EoE Standard GI Questionnaire Final Oct 2015 4 IN STRICT CONFIDENCE outside home Names and location/addresses of places where eaten Postcodes home Eggs (raw, boiled, fried, scrambled, etc) or egg products (e.g. egg fried rice, mousses, etc) Pre-prepared salads and vegetables (in a bag, ready to eat)

Other salad vegetables, not pre- prepared (e.g. lettuce)

Pre-prepared fruit salad, ready to eat

Pre-prepared sandwiches

Iced cakes & pastries

Unpasteurised milk (incl in tea, coffee, cereal, etc) or milk products (e.g. yoghurt, cheese, etc)

9. In the 5 days before your symptoms started, did you eat any meals or snacks at any outside function, e.g. at any party, reception, or buffet? No Yes If NO, please go to Q10. If YES, please give details below. Date Type of function Venue name and location/address Postcode (dd/mm/yyyy)

/ / 10. In the 5 days before your symptoms started, did you eat any meals or snacks from any restaurant, café, etc or fast food outlet e.g. sandwich bar, pizza outlet, hot dog stand, No Yes kebab shop, etc. If NO, please go to Section E. If YES, please give details below. Date Restaurant/outlet name Location/address Postcode (dd/mm/yyyy)

EoE Standard GI Questionnaire Final Oct 2015 5 IN STRICT CONFIDENCE SECTION E: ADDITIONAL INFORMATION

Please give any additional information relevant to this illness that you think might be useful to us.

Thank you for taking the time to fill in this questionnaire, any information you have given will be most helpful.

EoE Standard GI Questionnaire Final Oct 2015 6