Cryptosporidium Report Form 
  INTRODUCTION
The North Central Health District and the Georgia Department of Public Health are investigating people who have become infected with Cryptosporidium in the summer of 2018. Please complete one questionnaire for each person with Cryptosporidium.

If the sick person is a child, please work with her/him to complete the questionnaire as thoroughly as possible. All information provided to public health will remain confidential in accordance with HIPAA.

If you have any questions, please call or email Bill Johnson at the North Central Health District at (478) 751-6550 or bill.johnson@dph.ga.gov.

When you have completed your 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
Please complete the following information for the sick person.
1 . Last Name
2 . First Name
3 . Address
4 . City
5 . State
6 . Zip Code
7 . County
8 . Gender
9 . Date of Birth//
10 . Age
11 . Phone Number--
12 . Email Address
13 . Parent/Guardian Names
(if sick person is a child)
  ILLNESS AND SYMPTOMS
1 . When did your symptoms start?//
2 . Please check ALL of the following symptoms you experienced during your illness. (Please answer yes, no, or not sure to each one.)
 Yes   No   Not Sure 
Fever
Diarrhea
Bloody Diarrhea
Abdominal Pain
Nausea
Vomiting
Headache
Fatigue
Body Aches
Chills
Other
3 . Other symptoms.
4 . Do you feel better? In other words, have your symptoms resolved?Yes No 
5 . IF you're feeling better, how long did your symptoms last? days
6 . Did you visit a healthcare provider for this illness?Yes No 
7 . IF YES, what type of healthcare provider? (please check any and all types of providers you saw)
       Primary Care Physician
       Health Clinic
       Hospital Emergency Department (did not stay overnight)
       Hospital (stayed at least one night)
8 . IF you sought any medical care for this illness, please provide details, including the date, location, and any doctor's names you saw while you were there.
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?
11 . Do you know of anyone else with an illness similar to yours?Yes No Not Sure 
12 . IF YES, please provide any details you can on those sick people and if you were around them either before or after your illness. (A public health employee may be in touch with you or the sick person to get more information.)
  TRAVEL
1 . Did you travel internationally in the 2 weeks (14 days) prior to illness?Yes No Not Sure 
2 . If yes, what country/countries did you travel to?
3 . If yes to international travel, what date did you leave home?//
4 . If yes to international travel, what date did you return home?//
5 . Did you travel domestically in the 2 weeks (14 days) before illness?Yes No Not Sure 
6 . If yes, did you travel inside Georgia, outside Georgia, or both?
       Inside Georgia
       Outside Georgia
7 . If yes, what cities/states did you travel to?
8 . If yes to domestic travel, what date did you leave home?//
9 . If yes to domestic travel, what date did you return home?//
  WATER CONTACT BEFORE ILLNESS
Please indicate if you did or did not swim, wade, or enter in each of the following types of water in the 2 weeks (14 days) before your illness started.
Please select yes, no, or not sure to each one and provide details ONLY on those you said YES to.
1 . Ocean?Yes No Not Sure 
2 . Ocean Details (locations, dates):
3 . Natural hot spring?Yes No Not Sure 
4 . Hot spring details (locations, dates):
5 . Lake, pond, river, or stream?Yes No Not Sure 
6 . Lake, pond, river, or stream details (locations, dates):
7 . Waterpark?Yes No Not Sure 
8 . Waterpark details (locations, dates):
9 . Swimming Pool?Yes No Not Sure 
10 . Swimming Pool details (locations, dates)
11 . Kiddie/Wading pool?Yes No Not Sure 
12 . Kiddie/Wading pool details (locations dates):
13 . Water playground, interactive fountain, splash pad, or spray park?Yes No Not Sure 
14 . Water playground, interactive fountain, splash pad, or spray park details (locations, dates)
15 . Hot tub, spa, whirlpool, or Jacuzzi?Yes No Not Sure 
16 . Hot tub, spa, whirlpool, or Jacuzzi details (locations, dates):
17 . Other recreational water?Yes No Not Sure 
18 . Other recreational water details (locations, dates):

Did you consume any of the following types of water in the 2 weeks (14 days) before your illness started.
Please select yes, no, or not sure to each one and provide details ONLY on those you said YES to.
19 . Municipal/public supply (i.e., do you receive water bill from public or private utility)?Yes No Not Sure 
20 . Municipal/public supply details:
21 . Private well (e.g., used by 1 household)?Yes No Not Sure 
22 . Private well details:
23 . Common well (e.g., used by >1 household)?Yes No Not Sure 
24 . Common well details:
25 . Bottled water?Yes No Not Sure 
26 . Bottled water details:
27 . Spring, lake, creek, river, stream, or cistern (i.e., untreated surface water)?Yes No Not Sure 
28 . Spring, lake, creek, river, stream, or cistern details:
29 . Other drinking water?Yes No Not Sure 
30 . Other drinking water details:
  ANIMAL CONTACT BEFORE ILLNESS
Please indicate if you came in contact with any of the following types of animals or environments in the 2 weeks (14 days) before your illness started.
Please select yes, no, or not sure to each one and provide details at the bottom ONLY on those you said YES to.
1 . Did you come into contact with any of the following live animals in the 2 weeks (14 days) before your illness started?
Please answer yes, no, or unknown (unk) to each animal.
 Yes   No   Unk 
Cow?
Calf?
Sheep?
Lamb?
Goat?
Kid (baby goat)?
Horse?
Foal (baby horse)?
Cat?
Kitten?
Dog?
Puppy?
Squirrel?
Mouse?
Raccoon?
Chipmunk?
Chicken?
Chick (baby chicken)?
Turkey?
Poult (baby turkey)?
Other animal, including other birds or wild animals?
2 . Did you visit, work, or live on a farm, ranch, petting zoo, or other setting that has farm animals?Yes No Not Sure 
3 . Did you have contact with animal manure, pet feces, or compost?Yes No Not Sure 
4 . Did you do any of the following:camping, hiking, hunting, fishing, gardening, or farm work?Yes No Not Sure 
5 . Please provide details on any question you said YES to in this ANIMAL section.
  FOODS BEFORE ILLNESS
1 . Did you eat/drink any of the following food items in the 2 weeks (14 days) before your illness started? Please answer yes, no, or unknown (unk) to each question.
 Yes   No   Unk 
Unpasteurized dairy products, (e.g. raw milk or cheese made from raw milk)?
Raw/unpasteurized fruit or vegetable juice or cider?
Attend large gatherings where food was served (e.g. weddings, party/picnic, festival/fair, or sports event)?
Eaten raw fruits or vegetables?
Eaten food from a restaurant?
2 . Please provide details (locations, dates, food specifics) on any question you said YES to in this FOOD BEFORE ILLNESS section.
  WATER CONTACT AFTER ILLNESS
Please refer to TIME YOU WERE SICK and the 2 WEEKS AFTER YOU FELT BETTER for these questions.
1 . Did you swim, play, or wade in any bodies of water (e.g. pools, lakes, oceans, waterparks, etc.) while you were sick or in the 2 weeks (14 days) after you felt better?Yes No Not Sure 
2 . IF YES, please indicate which types of water you could have swam, played, waded, or entered in during your illness or in the 2 weeks after you felt better.
Please answer yes, no, or unknown (unk) to each type of water.
 Yes   No   Unk 
Ocean?
Natural hot spring?
Lake, pond, river, or stream?
Swimming Pool?
Waterpark?
Kiddie/Wading pool?
Water playground, interactive fountain, splash pad, or spray park?
Hot tub, spa, whirlpool, or Jacuzzi?
Other recreational water?
3 . Please provide details (locations, dates) on any question you said YES to in this WATER AFTER ILLNESS section.
  ADDITIONAL INFORMATION
1 . Do any of the following pertain to you? (Please select all that apply.)
       Attend daycare
       Attend school
       Work in daycare
       Work in healthcare
       Work in food service
       Currently pregnant
       Have an immunosupressive disease
       Reside in a nursing home or long-term care facility
Cryptosporidium is a parasite that can cause diarrhea and abdominal cramping in addition to other symptoms. People with compromised or suppressed immune systems can be more susceptible to this illness. For more information on Cryptosporidium, please visit the CDC website at: https://www.cdc.gov/parasites/crypto/index.html.

Cryptosporidium is tolerant of chlorine and can stay in a properly chlorinated pool for over 1 week.

Public Health recommends that all people diagnosed with Cryptosporidium do NOT swim for 2 weeks following recovery to prevent the spread of Cryptosporidium to others.
  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 your illness. 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.
In general, 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.
  PUBLIC HEALTH USE ONLY
1 . Patient ID
2 . Incident ID
3 . Response ID
  PUBLIC HEALTH USE ONLY 2
1 . Public Health Placeholder