<p>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</p><p>I Last name First / MI H P</p><p>A Address City Zip R G    O County State Phone number(s) M</p><p>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</p><p>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</p><p>L U C Hospitalized? Y N Treated? Y N Treatment: U U</p><p>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: </p><p>) Occupation: (check all that apply): child student volunteer unemployed retired L A C</p><p>I Y N U If yes to any, list details for each: G</p><p>O Food handler? L ▪ facility name(s) O I Healthcare worker?</p><p>M ▪ location(s) E</p><p>D Group living? I ▪ supervisor name(s) P E</p><p>( Day care association? ▪ phone number(s) K S</p><p>I Attend or work in a school?</p><p>R ICP contacted if appropriate -</p><p>H Pool employee (lifeguard, swim instructor)? G I</p><p>H If yes to any above, did patient work/attend while ill? Dates/notes: </p><p>Reported by: G Reporter name: Phone: N</p><p>I hospital/ICP clinic/MD office T</p><p>R Date results reported to clinician: Date reported to Public Health: </p><p>O lab other: P E</p><p>R Received by whom at LHD: LHD open date: LHD Investigator: </p><p>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</p><p>E Visit/swim/play/work in natural waterway (e.g. R</p><p>U lake)? S O</p><p>P Have any other recreational water exposure (e.g. X E</p><p> water play table in daycare)?</p><p>Swim/play/work in any recreational water while ill or in the 2 weeks after diarrhea ended?</p><p>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 </p><p>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</p><p>I LHD interview date: Interviewed: Client Parent/Guardian Significant other HC provider Friend Other: T A</p><p>R Unable to contact/interview LHD Reviewer: LHD closed date: Date submitted to UDOH: T S I N</p><p>I Notes: M D A CRYPTOSPORIDIOSIS Name ______NETSS ID ______</p><p>- 2 -</p>