Georgia Tech Gastrointestinal Illness 
  INTRODUCTION
The Fulton County Department of Health and Wellness and the Georgia Department of Public Health is working with Georgia Tech Stamps Student Health Services to investigate an outbreak of gastrointestinal illnesses among students during October 2017.
Please complete the questionnaire even if you did not become ill. We will use the information you provide to try to determine what could have caused the illnesses by comparing activities and meals ill people report with those well people report.
All information provided to public health will remain confidential in accordance with HIPAA. If you have any questions, please call Shamim Khan at Fulton County Department of Health and Wellness at 404-613-1336.
When you have completed you questionnaire, please click on the "Save" button at the bottom. You will have an opportunity to review your entries and make changes, if needed.
  DEMOGRAPHIC INFORMATION
1 . Last Name
2 . First Name
3 . Gender
4 . Date of Birth//
5 . Age
6 . Phone Number--
7 . Email Address
8 . Do you live on or off campus?On Campus Off Campus 
9 . If you live on campus, what dorm are you in?
10 . What year are you?
  ILLNESS AND SYMPTOMS
1 . Did you experience any symptoms of diarrhea, vomiting, fever, or abdominal cramps beginning on or after Monday, October 9th?Yes No Not Sure 
If you have not experienced any symptoms of diarrhea, vomiting, fever, or abdominal cramps in the last 2 weeks, please move on to the section called Food On and Off Campus.
2 . On what date did your symptoms start?//
3 . Please check ALL of the following symptoms you experienced since October 9th. (Please answer yes, no, or not sure to each one.)
 Yes   No   Not Sure 
Fever
Nausea
Vomiting
Diarrhea
Bloody Diarrhea
Abdominal Cramps
Headache
Fatigue
Body Aches
Chills
Other
4 . Other symptoms.
5 . Have you recovered from this illness?Yes No 
6 . How long did your illness last? days
7 . Did you visit a healthcare provider for this illness?Yes No 
8 . IF YES, what type of healthcare provider? (please check any and all types of providers you saw)
       Student Health Services
       Primary Care Physician
       Health Clinic
       Hospital Emergency Department (did not stay overnight)
       Hospital (stayed at least one night)
9 . Did you submit any samples (stool, urine, blood, or other) for testing?Yes No Not Sure 
10 . Do you know the results of that testing? Or, did a healthcare practitioner give you a diagnosis and, if so, what was it?
  ILL CONTACTS
1 . In the week prior to the start of your illness, did you have contact with anyone with similar symptoms?
2 . If yes, please select the option that best describes that contact.
3 . If yes, please describe that person's symptoms as far as you know.
  FOOD ON AND OFF CAMPUS
1 . Did you eat at any of the following on-campus dining facilities on these dates?
 Mon, 10/9   Tues, 10/10   Wed, 10/11   Thur, 10/12   Fri, 10/13   Sat, 10/14   Sun, 10/15   Mon, 10/16   Tues, 10/17   Wed, 10/18   Thur, 10/19   Fri, 10/20   Did Not Eat There On These Dates 
Student Center Food Court (2nd Floor)

Student Center Commons (1st Floor)

Woodruff

Brittain

North Avenue

Bradley Building (Highland Bakery)

Starbucks in ULC

Freshens in CRC

Engineered Biosystems Building (Food Anatomy)

Food Trucks on Campus

Curran Parking Deck (Market or WingZone)
2 . If you ate in the Student Center (1st or 2nd floors), please indicate which restaurant(s) you ate from on which date(s).
 Mon, 10/9   Tues, 10/10   Wed, 10/11   Thur, 10/12   Fri, 10/13   Sat, 10/14   Sun, 10/15   Mon, 10/16   Tues, 10/17   Wed, 10/18   Thur, 10/19   Fri, 10/20   Did Not Eat There On These Dates 
1st Floor
Blue Donkey Coffee

Chick-fil-A

Panda Express

Subway

Taco bell

2nd Floor
Bhojanic

Dunkin Donuts

Essential Eats

Far East Fusion

Ray's Pizza Express

Simply Sustainable Salad Bar

Simply-to-Go (pre-packed salads)

Twisted Taco

Yahala Mediterranean
3 . Please leave any comments regarding on-campus dining here.
4 . Please select which days you ate off campus for any meals or snacks.
       Mon, 10/9
       Tues, 10/10
       Wed, 10/11
       Thurs, 10/12
       Fri, 10/13
       Sat, 10/14
       Sun, 10/15
       Mon, 10/16
       Tues, 10/17
       Wed, 10/18
       Thurs, 10/19
       Fri, 10/20
       I did not eat off campus on these dates
5 . Please provide any details regarding your off-campus meals or snacks that you remember.
  ON CAMPUS ACTIVITIES
1 . What is your class schedule? Please include building names and room numbers.
2 . Do you participate in any extracurricular activities, including Greek organizations, sports, or clubs? If so, please list them here.
3 . Do you spend time in any on campus buildings other than those where you have classes (ie for study groups or meals)? Please list those buildings here.
  THANK YOU
Thank you so much for taking the time to fill out this questionnaire! All of the answers you have provided will remain confidential. We hope your answers will help us determine what could have contributed to illnesses on campus. Please click the "Save" button below when you are finished. You will have an opportunity to review your responses before clicking "Finish" to submit your completed survey. Thank you again for your time.
1 . Please provide any other comments you have regarding your illness here.
Public Health recommends that people with fever, diarrhea, or vomiting stay home from daycare, school, or work until they are symptom free for 24 hours without the use of symptom-reducing medication.