Utah Public Health

Utah Public Health LHD name LHD address line 1 GIARDIASIS LHD address line 2 Phone: (xxx) xxx-xxxx Confidential Case Report Confidential fax: (xxx) xxx-xxxx Date finalized Please fill in the blanks or check the answer for each field DEMOGRAPHIC INFORMATION NETSS ID Last name First / MI Address City Zip County State Phone number(s)    Date of birth Age Gender M F Parent/Contact Race White Black/Af. Am Amer. Indian Asian Alaska Native Native Hawaiian/Pacific Islander Other Unk Ethnicity Hispanic Non-Hispanic Unk Refugee or recent immigrant? Y N U If yes, how long has the patient been in the USA?

CLINICAL INFORMATION none nausea vomiting Onset date: Symptoms: abdominal pain diarrhea loss of appetite bloating Date resolved: ongoing fatigue weight loss Are symptoms (check all that apply): chronic intermittent Y N U Details Seen by physician (including ED)? Physician/ED: Phone: Date: Health facility: Medical Record Number: Hospitalized? From: To: Died? Date of death: Pregnant? N/A Due date: Treated? Treatment: Start: End Not finished : Immunocompromised? If yes, explain: Co-infected? If yes, disease:

LABORATORY INFORMATION Lab name/phone: Test type: O&P DFA ELISA/EIA other: Lab result: pos neg pres. pos inconcl. pending Specimen source: stool other: Collection date:

HIGH-RISK OCCUPATIONS / SETTINGS (EPIDEMIOLOGICAL) Occupation: (check all that apply): child student volunteer unemployed retired Y N U If yes to any, list details for each: Food handler? ▪ facility name(s) Healthcare worker? ▪ location(s) ▪ supervisor name(s) Group living? ▪ phone number(s) Day care association? Attend or work in a school? ICP contacted if appropriate Pool employee (lifeguard, swim instructor)? If yes to any above, did patient Dates/notes: work/attend while ill?

REPORTING INFORMATION Reported by: Reporter name: Phone: hospital/ICP clinic/MD office Date results reported to clinician: Date reported to public health: lab other: Received by whom at LHD: LHD open date: LHD Investigator:

Refugee cases skip to FOLLOW-UP ACTIONS on pg 3. All other cases, continue investigation on pg 2. GIARDIASIS Name ______NETSS ID ______

EXPOSURE PERIOD Have patient answer questions on following pages for the exposure period only: Date 25 days before disease onset: Date 3 days before disease onset: For cases with intermittent symptoms and/or unknown onset dates, ask about last exposure (water, outdoor, animal)

ILL CONTACT MANAGEMENT Y N Name/ & list Does case’s infection appear secondary to another person’s infection? NETSS: below. U Any contacts ill with similar symptoms? Y N If yes, list below. If no, skip to TRAVEL HISTORY. U  Last name: First / MI: Age: Sex: M F Relationship to case: Onset date: New case initiated?  NETSS ID: Contact info same as case? Y N Phone: Address: Food handler Healthcare Group living Day care Pool employee Not high-risk If high-risk, follow-up done? Y N  Last First / MI: Age: Sex: M F name: Relationship to case: Onset date: New case initiated?  NETSS ID: Contact info same as case? Y N Phone: Address: Food handler Healthcare Group living Day care Pool employee Not high-risk If high-risk, follow-up done? Y N

 Last name: First / MI: Age: Sex: M F Relationship to case: Onset date: New case initiated?  NETSS ID: Contact info same as case? Y N Phone: Address: Food handler Healthcare Group living Day care Pool employee Not high-risk If high-risk, follow-up done? Y N

 Last name: First / MI: Age: Sex: M F Relationship to case: Onset date: New case initiated?  NETSS ID: Contact info same as case? Y N Phone: Address: Food handler Healthcare Group living Day care Pool employee Not high-risk If high-risk, follow-up done? Y N

 Last name: First / MI: Age: Sex: M F Relationship to case: Onset date: New case initiated?  NETSS ID: Contact info same as case? Y N Phone: Address: Food handler Healthcare Group living Day care Pool employee Not high-risk If high-risk, follow-up done? Y N

TRAVEL HISTORY (3-25 days before onset) Travel outside USA? Y N U Travel outside Utah, but inside USA? Y N U Travel outside county, but inside Utah? Y N U If case answered yes to any of above travel questions, then fill in boxes below. If no, skip to WATER EXPOSURE.

Travel location: From: To: Mode of travel: plane car cruise ship Others in group ill? Y N U If yes, list above. other: List other details including: . Flight number / other identifiers . Accommodations & dates . Sources of food/water while traveling . Other relevant details

Skip to FOLLOW-UP ACTIONS on page 3 if patient was outside the country for entire exposure period.

- 2 - GIARDIASIS Name ______NETSS ID ______

WATER EXPOSURE (3-25 days before onset, or last exposure) Source of drinking water at home: municipal/public water bottled well (check all that apply) commercial delivery (e.g. Mount Olympus) other (specify): Source of drinking water at work/school: municipal/public water bottled well (check all that apply) commercial delivery (e.g. Mount Olympus) other (specify): Have recent plumbing/construction work Y N U Specify done on water system? dates/details: Drink from, swim/play in or have exposure to any of the following water sources: well secondary/irrigation water (e.g. canal) natural water (e.g. river, lake, stream, pond, spring) hose/sprinkler fountain/splash pad/interactive water feature bathtub/bathwater in which animals/pets have bathed pool/water park water table/water play at a daycare other (specify): none If none, skip to OUTDOOR EXPOSURE. If yes, details of any water exposure (dates, locations, etc):

OUTDOOR EXPOSURE (3-25 days before onset, or last exposure) Have been: hiking camping fishing hunting doing yard work/composting/gardening (w/manure and/or fertilizer) other (specify): none If none, skip to ANIMAL EXPOSURE. If yes, details of any outdoor exposure (dates, locations, water use, etc):

ANIMAL EXPOSURE (3-25 days before onset, or last exposure) Visit a: farm zoo petting zoo county/state fair rodeo none Specify Have contact with animal waste/manure? Y N Specify dates/details: Have contact with any animals (including farm animals, pets)? Y N U If yes, answer questions below. If no, proceed to FOLLOW-UP ACTIONS. Check all that apply: cat dog farm animal other (specify): Any of above animals sick with diarrhea? Y N U Specify dates/details: Details of any animal exposure: new pet?

FOLLOW-UP ACTIONS Date Action Provide client education (see disease plan). Notify Epidemiology of any high-risk occupations/settings and/or exposures likely to cause additional illness. Restrict/exclude case in high-risk occupations/settings if symptomatic (see disease plan); notify case’s supervisor if necessary. Notify case’s ICP or Employee Health Nurse if appropriate (case does direct patient care). Complete follow-up stool testing if needed. Consider restricting/excluding symptomatic contacts in high-risk occupations/settings. Release case/contacts back to high-risk occupations/settings if case/contacts have been restricted/excluded. Notify daycare as needed, to identify source or spread, if case is a child in daycare. Notify school nurse as needed, to identify source or spread, if case is a child in school. Notify Environmental Health if facility inspection is warranted. Notify UDOH if suspect exposure occurred outside health district or if potential cluster/outbreak situation exists. Complete CDC outbreak form, if appropriate. Other follow-up:

ADMINISTRATIVE LHD status: Confirmed Probable Suspect Not a case Carrier Pending UDOH status: Confirmed Probable Suspect Not a case Carrier Pending Did this case occur as part of an outbreak? Y N U (Two or more cases of Giardiasis associated by time & place) Outbreak name: LHD interview date: Interviewed: Client Parent/Guardian Sig. oth. HC provider Friend Other: Unable to contact/interview LHD Reviewer: LHD closed date: Date submitted to UDOH: