Environmental Engineering Reference
In-Depth Information
became ill (Figure 1.6). The sanitary survey is important to the interpretation of
an environmental sample and determining a sound course of action and should
include a study of all environmental factors that might be the cause or may be
contributing to the cause of the disease outbreak. These should include water
supply, food, housing, sewage disposal, bathing, insects, rodents, pesticide use,
food handlers and other workers, practices, procedures, and any other relevant
factors. Each should be considered responsible for the illness until definitely ruled
DEPARTMENT OF
HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
CENTERS FOR DISEASE CONTROL
CENTER FOR INFECTIOUS DISEASES
ATLANTA, GEORGIA 30333
1. Where did the outbreak occur?
Form Approved
OMB No. 920-0004
INVESTIGATION OF A WATERBORNE OUTBREAK
2. Date of outbreak : (Date of onset of 1st case)
______________________(1-2)
City or Town _______________
Country _________
_________________________________ (3-8)
3. Indicate actual (a) or estimated
(a) numbers :
4. History of exposed persons :
5. Incubation period (hours):
Shortest ____ (40-42) Longest ____ (43-45)
Persons exposed _______ (9-11)
Persons ill _____________ (12-14)
Hospitalized __________ (15-16)
Fatal cases ____________ (17)
No., histories obtained _______________ (18-20)
No. persons with symptoms ___________ (21-23)
Nauses _______ (24-26) Diarrhea______ (33-35)
Vomiting ______ (27-29)
Cramps _______ (30-32)
Other, specify (39) ________________________
Median _______ (46-48)
Fever ________ (36-38)
Shortest ____ (49-51) Longest ____ (52-54)
Median _______ (55-57)
7. Epidemiologic date (e.g., attack rates (number ill / number exposed) for persons who did not eat or drink specific food items or water,
attack rate by quantity of water consumed, anacdotal information) * (58)
NUMBER OF PERSONS WHO ATE OR
DRANK SPECIFIED FOOD OR WATER
NUMBER WHO DID NOT EAT OR DRINK
SPECIFIED FOOD OR WATER
ITEMS SERVED
NOT
ILL
PERCENT
ILL
NOT
ILL
PERCENT
ILL
ILL
TOTAL
ILL
TOTAL
8. Vehicle responsible (item incriminated by epidemiologic evidence) : (59-60)
9. Water supply characteristics
____________________________________________________
(A) Type of water supply** (61)
Municipal or community supply (Name ___________________ )
Individual household supply
Semi-public water supply
Institution, school, church
Camp, recreational area
Other, ___________________________________________
Botteled water
(B) Water source (
check all applicable
):
(C) Treatment provided (
circle treatment of each source checked in B
):
a. no treatment
b. disinfection only
c. purification plant - coagulation, settling, filtration,
disinfection (
circle those applicable
)
d. other ___________________________________________
Well
a
b
c
d
Spring
a
b
c
d
Lake, pond
a
b
c
d
River, stream
a
b
c
d
10. Point where contamination occurred: (66)
Raw water source
Treatment plant
Distribution system
*See CDC 52.13 (Formerly 4.245) Investigation of a Foodborne Outbreak, Item 7.
**Municipal or community water supplies are public or investor owned utilites, Individual water supplies are wells or springs used by single residences.
Semipublic water systems are individual-type water supplies serving a group of residences or locations where the general public is likely
to have access to drinking water. These locations include schools, camps, parks, resorts, hotels, industries, subdivisions, trailer parks,
etc., that do not obtain water from a municipal water system but have developed and maintain their own water supply.
CDC 52.12 (f. 4.461)
Rev. 7-81
This report is authorized by law (Public Health Service Act, 42 USC 241)
While your response is voluntary, your cooperation is necessary for the understanding and control of the disease.
FIGURE 1.6
Investigation of waterborne outbreak.
