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Hello! This survey is being conducted by the Athens City County Health Department because of a concern of reported illness following the Indonesian Night Dinner on February 27, 2015. We are working to identify the source of this illness, so we can prevent additional illness. We understand that you are one of the people who attended this event. We would like to ask you some questions about the event and foods that you ate at Indonesian Night whether you became ill or not. Your survey responses will be strictly confidential and data from this survey will be reported only in the aggregate. If you have questions about the survey or the investigation, you may contact Tonya McGuire at 740-441-2964 or by emailing [email protected].
Thank you very much for your time and help! Please start with the survey now by clicking on the Continue button below. |
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* Did you attend the Indonesian Night Dinner on February 27, 2015? |
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* If necessary, may we contact you again? |
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* What is your date of birth? |
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Month | Day | Year | | | |
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* Which buffet serving table did you eat from the first time you prepared your plate? |
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* What time did you first eat from the buffet table? |
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Hrs. | Mins. | AM/PM | | | |
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* Please mark the foods you ate from your first trip to the buffet table? (Mark all that apply.) |
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* Did you have multiple servings? (Seconds, go back for more) |
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What time did you last eat from the buffet? |
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Hrs. | Mins. | AM/PM | | | |
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Which buffet table did you eat from when you went back for more? |
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What foods/beverages did you have when you returned to the buffet? (Mark all that apply.) |
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* Did you become ill with any gastrointestinal symptoms after attending Indonesian Night? |
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IF you experience vomiting or diarrhea, which did you have FIRST? |
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What date and time did you first experience vomiting or diarrhea (best guess)? |
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Month | Day | Year | Hrs. | Mins. | AM/PM | | | | | | |
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Date of last time experiencing vomiting or diarrhea? |
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Month | Day | Year | Hrs. | Mins. | AM/PM | | | | | | |
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Please mark ALL symptoms you had in association with this illness? |
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What date and time did you first experience ANY of these symptoms? |
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Month | Day | Year | Hrs. | Mins. | AM/PM | | | | | | |
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What date and time did you last experience ANY of these symptoms? |
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Month | Day | Year | Hrs. | Mins. | AM/PM | | | | | | |
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| If you sought healthcare, where did you go? | | |
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Did any of your close contacts or other household members become ill with similar symptoms after you were ill? |
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