Listeriosis Investigation Form
Participant Information
Please complete the following questions pertaining to the individual the illness has affected (i.e., you, your child) to the best of your ability.
Please identify if you are taking the survey for yourself or another person.
I am the person this survey is about
I am taking this survey for a person (i.e., a child) with their permission
First and last name
First Name
Last Name
Are you experiencing homelessness?
Yes
No
County of residence
Residential address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
Please enter a valid phone number.
Email
Date of birth
 -
Month
 -
Day
Year
Date
Age
Sex
Female
Male
Nonbinary
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race (check all that apply)
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other
Occupation or Grade in School
Employer/Worksite or School/Childcare Center Name
Clinical Information
What date did you first feel sick?
 -
Month
 -
Day
Year
Date
What date were you diagnosed?
 -
Month
 -
Day
Year
Date
Are you still sick?
Yes
No
Unsure
How many days were you sick for?
Did you take any antibiotic/treatment for this illness?
Yes
No
Unsure
Please provide the antibiotic name/treatment you received for this illness.
Signs and Symptoms
The most common symptoms for people who are sick with Listeriosis are fever, muscle aches, chills, and diarrhea.
Did you experience fever?
Yes
No
Unsure
Did you experience chills?
Yes
No
Unsure
Did you experience diarrhea?
Yes
No
Unsure
What was the maximum number of stools in 24 hours?
Did you experience vomiting?
Yes
No
Unsure
Did you experience preterm labor?
Yes
No
Unsure
Did you experience muscle aches?
Yes
No
Unsure
Did you experience headaches?
Yes
No
Unsure
Did you experience a stiff neck?
Yes
No
Unsure
Did you experience an altered mental status?
Yes
No
Unsure
Please list any other symptoms you experienced not previously mentioned.
Hospitalization
Were you hospitalized for this illness?
Yes
No
Unsure
Please provide the name of the hospital you stayed overnight at.
Date of admission
 -
Month
 -
Day
Year
Date
Date of discharge
 -
Month
 -
Day
Year
Date
Pregnancy Association
Was the Listeria infection associated with pregnancy?
Yes
No
Unsure
What was the outcome of the pregnancy?
Still pregnant
Delivery (live birth)
Fetal death (miscarriage or stillbirth)
Other
How many weeks of gestation?
What illnesses was associated with the infant (check all that apply)?
Bacteremia/sepsis
Meningitis
Pneumonia
None
Unsure
Other
Where was the infant delivered?
Hospital
Home
Other
Please provide name of the hospital.
Please provide the admit or birth date of infant.
 -
Month
 -
Day
Year
Date
Please provide the discharge date. Leave blank if still hospitalized.
 -
Month
 -
Day
Year
Date
Was the infant hospitalized for Listeriosis?
Yes
No
Unsure
Predisposing Conditions
Do you have an underlying illness?
Yes
No
Unsure
Please specify your underlying illness(es).
Clinical Findings
Did you experience any of these illnesses as a result of the Listeria infection (check all that apply)?
Bloodstream infection/sepsis
Meningitis
Meningoencephalitis
Brain abscess
Rhombencephalitis
Peritonitis
Pneumonia
Wound infection
Joint infection/septic arthritis
Bone infection/osteomyelitis
I did not experience any of these illnesses
Unsure
Other
Infection Timeline
For the remainder of the survey, we will ask you questions about the 4 weeks BEFORE your illness/delivery date to understand how you might have gotten ill. For example, if you first noticed symptoms on July 29th, we would like to know about July 1st to the 29th, since this is the time period when you probably caught the illness. Some people have an easier time remembering if they have a calendar nearby that they can refer to.
Travel Exposure
The next few questions will ask you about your recent travel. Listeriosis causes illness all over the world, and many people get sick while traveling.
During the 4 weeks before you became ill/delivery date, did you spend any time outside the state (domestic travel)?
Yes
No
Unsure
Please provide the dates and states you visited.
During the 4 weeks before you became ill/delivery date, did you spend any time outside the U.S. (international travel)?
Yes
No
Unsure
Please provide the dates and countries you visited.
Food Exposure
Listeriosis infection can be spread through food and drinks. The following questions will ask about the specific foods you consumed. If you are unsure if you ate or drank something, please make your best guest or select "unsure."
During the 4 weeks before you became ill/delivery date, were you on any kind of special or restricted diet for medical, weight loss, religious or other reasons?
Yes
No
Unsure
Please describe the foods you avoid.
During the 4 weeks before you became ill/delivery date, did you follow a vegetarian or vegan diet?
Vegetarian
Vegan
Unsure
I did not follow a vegetarian or vegan diet
During the 4 weeks before you became ill/delivery date, did you have any allergies that prevent you from eating certain foods?
Yes
No
Unsure
Please specify the foods you are allergic to (check all that apply).
Milk
Other dairy
Eggs
Peanuts
Tree nuts
Fish
Soy
Wheat
Shellfish
Other
Food Purchase History
Sources of Food at Home
The following questions are about where the food came from that you ate at home in the 4 weeks before your illness began.
During the 4 weeks before you became ill/delivery date, what were your sources of food (check all that apply)?
Grocery store or supermarkets
Warehouse stores (e.g. Costco, Sam's Club)
Small markets, mini marts & convenience stores
Ethnic specialty markets (Mexican, Asian or Indian)
Farmer's markets
Online stores or foods received by mail
Other
Please list the stores/retail names and locations you shop at.
Would you be willing to release your shopper card information so we can get an exact list of your foods and when they were purchased?
Yes
No
None available
Please provide the store name and the shopper card # associated.
Restaurants
These following questions are about restaurants where you might have eaten at 4 weeks before your illness began.
During the 4 weeks before you became ill/delivery date, did you eat foods from any of these places (check all that apply)?
Buffet-style (where you serve yourself)
Sandwich shops or delis
Ethnic restaurants that are not fast-food (e.g., Mexican, Italian, Chinese)
Fast-food (drive-up or pay at counter)
I did not eat at any restaurants
Other
Please specify the dates, restaurants/schools/facility names and locations, and the foods eaten.
Other Locations
These following questions are about food purchased or obtained from any other locations you might have eaten the 4 weeks before your illness began.
During the 4 weeks before you became ill/delivery date, did you purchase food from any of these locations (check all that apply)?
Salad bars (in grocery stores)
Cafeterias
Food trucks
Picnics
Potlucks
Concession stands
Institutions (e.g., hospital food)
Local farms or dairies
Special events (i.e., weddings, parties)
I did not eat or purchase food from any other locations
Other
Please specify the dates, names, locations, and foods eaten.
Specific Food Exposures: Cheese
During the 4 weeks before you became ill/delivery date, did you consume feta cheese?
Yes
No
Unsure
Please provide details of the feta cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the feta cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume goat cheese?
Yes
No
Unsure
Please provide details of the goat cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the goat cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume blue-veined cheese (gorgonzola, bleu)?
Yes
No
Unsure
Please provide details of the blue-veined cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the blue-veined cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume brie or camembert?
Yes
No
Unsure
Please provide details of the brie or camembert (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the brie or camembert cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume gouda cheese?
Yes
No
Unsure
Please provide details of the gouda (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the gouda made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume prepackaged, shredded cheese?
Yes
No
Unsure
Please provide details of the prepackaged, shredded cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the prepackaged, shredded cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fresh mozzarella, sold in water?
Yes
No
Unsure
Please provide details of the fresh mozzarella (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the mozzarella made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume cottage cheese?
Yes
No
Unsure
Please provide details of the cottage cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cottage cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume ricotta cheese?
Yes
No
Unsure
Please provide details of the ricotta cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the ricotta cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other gourmet, fancy, or artisanal cheese?
Yes
No
Unsure
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume any cheese sliced at a deli counter?
Yes
No
Unsure
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume Middle Eastern-style cheese (e.g., akawi, nabulsi)?
Yes
No
Unsure
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume Mexican- or Latin-style cheese (e.g., queso fresco)?
Yes
No
Unsure
What type of Mexican- or Latin- style cheese did you consume?
Queso fresco
Queso blanco
Queso casero
Cuajada
Asadero
Cotija
Panella
Queso ranchero
Requeson
Oaxaca
Unsure
Other
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other soft cheese (not cream, cottage, or ricotta)?
Yes
No
Unsure
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume any cheese from raw/unpasteurized milk?
Yes
No
Unsure
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume any other cheese not previously asked?
Yes
No
Unsure
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the cheese made from raw milk?
Yes
No
Unsure
Please provide place of purchase or consumption.
Specific Food Exposures: Other Dairy
During the 4 weeks before you became ill/delivery date, did you consume dairy milk?
Yes
No
Unsure
What type of milk did you consume (check all that apply)?
Whole
2%
1%
Skim
Other
Please provide details of the cheese (e.g., type, variety, brand, packaging, shape/size, how prepared).
Was the milk raw (unpasteurized)?
Yes
No
Unsure
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume non-dairy milk (e.g., soy, almond)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume frozen yogurt?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume yogurt?
Yes
No
Unsure
Was the yogurt raw (unpasteurized)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume yogurt drinks?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume butter (not margarine or other butter substitute)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume cream or half-and-half?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume icream bars, milkshakes, or frozen dairy dessert items?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume ice cream?
Yes
No
Unsure
Was any of the ice cream soft serve?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume sour cream or crema?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Seafood
During the 4 weeks before you became ill/delivery date, did you consume precooked shrimp?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume precooked shellfish (e.g., crab, mussels, clams)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume refrigerated smoked or cured fish that was not from a can (e.g., smoked salmon)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume any raw fish or seafood, including sushi?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume frozen processed seafood (e.g., fish sticks or breaded fish)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Dips and Spreads
During the 4 weeks before you became ill/delivery date, did you consume hummus?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume refrigerated, fresh salsa or pico de gallo (not from a jar or can)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume guacamole?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other dips or spreads?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Fruits
During the 4 weeks before you became ill/delivery date, did you consume apples, including apple slices?
Yes
No
Unsure
Were the apples pre-sliced?
Yes
No
Unsure
How were the apples consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume caramel apples?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume grapes?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume raisins?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pears?
Yes
No
Unsure
How were the pears consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume peaches?
Yes
No
Unsure
How were the peaches consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume nectarines?
Yes
No
Unsure
How were the nectarines consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume apricots?
Yes
No
Unsure
How were the apricots consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume plums?
Yes
No
Unsure
How were the plums consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume strawberries?
Yes
No
Unsure
How were the strawberries consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume raspberries?
Yes
No
Unsure
How were the raspberries consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume blueberries?
Yes
No
Unsure
How were the blueberries consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume blackberries?
Yes
No
Unsure
How were the blackberries consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume cherries?
Yes
No
Unsure
How were the cherries consumed?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume honeydew melon?
Yes
No
Unsure
Were the items purchased pre-sliced?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume cantaloupe?
Yes
No
Unsure
Were the items purchased pre-sliced?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume watermelon?
Yes
No
Unsure
Were the items purchased pre-sliced?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pineapple?
Yes
No
Unsure
Were the items purchased pre-sliced?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume mango?
Yes
No
Unsure
How were the mangos purchased?
Fresh
Frozen
Dried
Other
Were the items purchased pre-sliced?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume papaya?
Yes
No
Unsure
How were the papayas purchased?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume avocados (including homemade guacamole)?
Yes
No
Unsure
How were the avocados purchased?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fruit salad (including pre-cut cubes of a single fruit)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other fruits?
Yes
No
Unsure
How were the other fruits purchased?
Fresh
Frozen
Dried
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fruit sorbet?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Deli Meats
During the 4 weeks before you became ill/delivery date, did you consume ham?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume bologna?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide the place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume turkey breast?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume chicken deli meat (NOT fresh or rotisserie chicken)?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume roast beef?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pastrami or corned beef?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume liverwurst or braunschweiger?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pate or meat spread that was not canned?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume head cheese?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pepperoni?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume any other Italian-style meat?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other deli/luncheon meat?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume anything from a deli area where meat is sliced?
Yes
No
Unsure
Was this item sliced at a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Other Meat/Poultry
During the 4 weeks before you became ill/delivery date, did you consume precooked sausage?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume precooked chicken (whole or parts, including rotisserie)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other precooked meat?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume cured or dried meat (e.g., jerky)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume hot dogs?
Yes
No
Unsure
How were the hot dogs consumed?
Heated before being eaten
Not heated before being eaten (eaten directly out of package)
Unsure
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume frozen processed poultry (e.g., chicken nuggets or turkey pot pie)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume ground chicken or turkey?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Vegetables and Other Produce
During the 4 weeks before you became ill/delivery date, did you consume sprouts?
Yes
No
Unsure
Which of the following types of sprouts did you eat (check all that apply)?
Alfafa
Bean (e.g., mung, soybean)
Clover
Radish
Broccoli
Mixed
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume cucumbers?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pea pods/snap peas/snow peas?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume sweet peppers (green, red, orange, or yellow bell peppers)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume hot chili peppers such as jalapenos or seranos?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume green onions or scallions?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume celery?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume mini-carrots?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fresh mushrooms?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pre-cut raw vegetables or vegetable mixes (e.g., celery, onions)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fresh basil?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fresh cilantro?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fresh parsley?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other fresh herbs (sage, thyme, dill, etc.)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume fresh tomatoes?
Yes
No
Unsure
What type of tomatoes (check all that apply)?
Red round
Roma
Cherry/grape
Vine-ripe, sold on vine
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume lettuce?
Yes
No
Unsure
Was any of the lettuce prepackaged?
Yes
No
Unsure
What type of lettuce (check all that apply)?
Iceberg
Romaine
Mesclun ("spring mix")
Radish
Other
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other prepackaged leafy green (e.g., kale, spinach)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume premade green salad that includes other ingredients besides greens (e.g., cobb, Caesar salads)?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other produce?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Deli Salads
During the 4 weeks before you became ill/delivery date, did you consume potato salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume pasta salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume egg salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume tuna salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume chicken salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume bean salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume seafood salad?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume coleslaw?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume other ready-to-eat meat or vegetable salad not made at home?
Yes
No
Unsure
Was this purchased from a deli counter?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume anything from a salad bar?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Specific Food Exposures: Other Foods
During the 4 weeks before you became ill/delivery date, did you consume freshly-made smoothie with fresh or frozen fruit or produce?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume tahini?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume tofu, tempeh, or seitanr?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume rice noodles?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume sandwiches from a refrigerated case or vending machine?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume peanut butter or other nut butters or nut cheeses?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume nuts, including peanuts, almonds, cashews?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume seeds, including chia, hemp, flax, or sunflower?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
During the 4 weeks before you became ill/delivery date, did you consume food brought here from another country?
Yes
No
Unsure
Please provide details (e.g., type, variety, brand, packaging, shape/size, how prepared).
Please provide place of purchase or consumption.
Please provide details on any other seasonal foods or special foods you ate during the last 4 weeks.
Please provide any other food items you ate that we didn't talk about already.
Animal Exposure
A wide variety of animals can carry Listeriosis. These next few questions will ask you what animals you came into contact with prior to your illness.
During the 4 weeks before you became ill/delivery date, did you spend time at any of these locations (check all that apply)?
Petting zoo
Farm
Other venue with livestock (cattle, sheep, goats, etc.)
I did not spend time at any of these locations
Please specify the animal(s) you came into contact with.
Please provide the place of animal contact or purchase.
During the 4 weeks before you became ill/delivery date, did you feed a cat or dog raw pet food (i.e., pet food marketed as raw)?
Yes
No
Unsure
Please specify the type of pet food.
Please provide the place of contact or purchase.
During the 4 weeks before you became ill/delivery date, did you feed a cat or dog refrigerated, frozen, or freeze-dried pet treats?
Yes
No
Unsure
Please specify the type of pet food.
Please provide the place of contact or purchase.
School and Work
These following questions will ask you about the 5 days BEFORE your symptoms started until NOW.
In the time period between 5 days before you became ill and now, have you worked/volunteered as a food worker?
Yes
No
Unsure
Please provide the name/location of the food establishment you worked/volunteered at.
Since becoming ill, have you prepared food for public or private gatherings (e.g., potlucks, receptions)?
Yes
No
Unsure
In the time period between 5 days before you became ill and now, have you worked/volunteered as a health care worker?
Yes
No
Unsure
In the time period between 5 days before you became ill and now, have you worked/volunteered in child care or a preschool?
Yes
No
Unsure
In the time period between 5 days before you became ill and now, did you attend a child care or preschool?
Yes
No
Unsure
Are you living with a household member or have a close contact who works/volunteers in a sensitive occupation or setting (e.g., healthcare worker, child care, food)?
Yes
No
Unsure
Thank you for your participation.
Please include additional comments you would like to provide to the local health department below.
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