This form should be completed in full for each laboratory-confirmedlisteria case
INTERVIEWER DETAILS
Name / Surname
Contact number / Date investigation initiated / dd/mm/yyyy
Date investigation completed / dd/mm/yyyy
LABORATORY INFORMATION
Laboratory name / Laboratory specimen no.
Specimen type / Blood ⎕ / CSF ⎕ / Other ⎕ / Specify other
SOURCE(S) OF INFORMATION
Interview / Yes ⎕ No ⎕ / Medical record review / Yes ⎕ No ⎕
Person(s) interviewed / Relative⎕ / Parent⎕ / Caregiver⎕ / Guardian⎕ / Patient⎕ / Partner⎕
Telephonic interview / Yes ⎕ No ⎕ / Telephone number
DEMOGRAPHIC DETAILS
Name / Surname / Date of birth / dd/mm/yyyy
Age / Age units / D / M / Y / Age unknown⎕ / Gender (M/F/U) / Contact number
Race / Black⎕ / Coloured⎕ / Indian⎕ / White⎕ / Other⎕ / Specify other
Homeaddress
Code / District / Province
Occupation / Place of employment
Identity number / Unknown⎕
Has patient lived in South Africa for the last month? / Yes ⎕ No ⎕ Unknown⎕ / State country
CLINICAL DETAILS
Symptomatic? (Y/N/U) / If symptomatic date of onset of symptoms
If symptomatic, tick all the listed symptoms below that the person experienced:
Fever⎕ / Confusion⎕ / Headaches⎕ / Abdominal cramps ⎕ / Flu-like illness ⎕
Muscle aches ⎕ / Convulsions ⎕ / Loss of balance⎕ / Neck-stiffness ⎕ / Diarrhoea/vomiting ⎕
Other ⎕ / Specify other
Temperature(°C) / Unknown⎕ / Blood pressure / Unknown⎕
Mechanical ventilation / Yes ⎕ No ⎕ Unknown⎕ / Cardiac arrest / Yes ⎕ No ⎕ Unknown⎕
GCS / /15 / Unknown⎕ / Mental status / Unknown⎕
Patient diagnosis / Bacteraemia/Sepsis ⎕ / Meningitis ⎕ / Pneumonia ⎕
Granulomatosis infantiseptica⎕ / Other ⎕ / Specify other
HOST RISK FACTORS
Alcohol dependency ⎕ / Chronic liver disease ⎕ / Chronic renal disease (incl. Fanconi’s anaemia) ⎕
Pregnancy ⎕ / Malignancy ⎕ / Metabolic diseases (incl. diabetes mellitus) ⎕
Prematurity: age at birth⎕ / Advanced age (≥65 years) ⎕ / Immunosuppression treatment (steroids/chemo) ⎕
List any other
ADMISSION DETAILS
Admitted?(Y/N/U) / Previous admissions in the last year? (Y/N) / Number of previous admissions
Date of current admission / dd/mm/yyyy / Hospital name / Hospital number
Ward / Outcome / Still admitted ⎕ / Died⎕ / Discharged⎕ / UNK/RHT⎕
Adult ward / Paediatric ward / Adult ward⎕ / Paediatric ward ⎕
Hospital number / Outcome date / dd/mm/yyyy
Was patient referred? (Y/N/U) / Name of referring facility
Date of referral / dd/mm/yyyy / Date of first presentation / dd/mm/yyyy
Was patient transferred to another hospital? (Y/N/U) / Date of transfer / dd/mm/yyyy
HIV INFORMATION
HIV status on presentation / Positive⎕ / Negative⎕ / Unknown⎕
If positive when was the diagnosis made? / dd/mm/yyyy / Unknown⎕
Source of HIV status / Verbal ⎕ / Medical records⎕ / RTHC ⎕ / Specify other
If negative when was the last test done? / dd/mm/yyyy / Unknown⎕
HIV status now / Positive⎕ / Negative⎕ / Unknown⎕
For child <18 months: Was HIV PCR done? / N/A⎕Yes ⎕ No ⎕ Unknown⎕ / Date PCR done / dd/mm/yyyy
For child ≤5 years: What was the mother’s HIV status during pregnancy?
Positive⎕ / Negative⎕ / Unknown⎕
Source of HIV status / Verbal ⎕ / Medical records⎕ / RTHC ⎕ / Specify other
If mother was HIV positive during pregnancy, which ARVs were given?
HAART ⎕ / AZT only ⎕ / None ⎕ / Unknown ⎕ / Specify other
Date mother started on ARV therapy / dd/mm/yyyy / Unknown ⎕
Mother’s CD4 count in pregnancy / Unknown ⎕
Patient’s most recent CD4 count / N/A or not done ⎕
Patient’s most recent viral load / N/A or not done ⎕
Any antiretroviral use / N/A ⎕ / Current ⎕ / Previous ⎕ / Perinatal ⎕ / Unknown ⎕
If ARVs use is Current what was the date of initiation? / dd/mm/yyyy / Unknown ⎕
NEONATE ONLY (≤29 DAYS OLD) RELATED QUESTIONS
Did the mother have gastrointestinal illness during pregnancy / Yes ⎕ / No ⎕ / Unknown⎕
If yes, how long (weeks) into the pregnancy when the illness occurred? / Unknown⎕
Did the mother receive treatment for the illness? / Yes ⎕ / No ⎕ / Unknown⎕
Did the mother visit a traditional healer prior to illness? / Yes ⎕ / No ⎕ / Unknown⎕
Outcome of the baby / Alive and well ⎕ / Stillborn ⎕ / Alive with complications ⎕ / Died within 7 days ⎕
RESIDENTIAL INFORMATION – ALL PATIENTS
How long has the patient lived at the home address provided?
How many people live in the home? / How many rooms in the home?
Type of housing / Flat ⎕ / Townhouse ⎕ / Hostel ⎕ / RDP ⎕ / Informal ⎕
Water source / Piped ⎕ / Communal tap⎕ / Other ⎕ / Specify other
Sanitation / Toilet in home ⎕ / Communal toilet outside home ⎕ / Specify other
Does the home have a formal kitchen? / Yes ⎕ No ⎕ Unknown⎕ / Does the home have refrigerated food storage? / Yes ⎕ No ⎕ Unknown⎕
FOOD EXPOSURE RELATED INFORMATION – ALL PATIENTS
Where did the patient purchase his/her food in the 3 months prior to onset of illness?
Shop name / 1. / Location / 1.
Shop name / 2. / Location / 2.
Shop name / 3. / Location / 3.
Did the patient eat at take-away shops, restaurants or fast-food stores in the 3 months prior to onset of illness?
Yes ⎕ / No ⎕ / Unknown⎕
Restaurant / 1. / Location / 1.
Restaurant / 2. / Location / 2.
Restaurant / 3. / Location / 3.
Did the patient purchase food from an informal trader/vendor a month prior to onset of illness?
Yes ⎕ / No ⎕ / Unknown⎕
Name of trader/vendor / Location
Does the patient grow or produce his/her own food items?
Yes ⎕ / No ⎕ / Unknown⎕
If yes, list:
Did the patient consume the following food items a month prior to onset of illness?
Unpasteurised milk ⎕ / Eggs ⎕ / Fruit ⎕
Root vegetables ⎕ / Cured/smoked seafood ⎕ / Chicken/poultry ⎕
Processed meat (biltong, sausage) ⎕ / Meat spreads (Pate, paste, brawn) ⎕ / Cold meats (ham, polony)⎕
Ready-to-eat meals ⎕ / Ready-to-eat-salads ⎕ / Raw vegetable ⎕
Soft cheeses (cream cheese) ⎕ / Hard cheeses ⎕ / Sandwich spreads/Dips ⎕
Cream/Ice cream ⎕ / Yoghurt/Buttermilk/Amasi⎕ / Mayonnaise ⎕
ENVIRONMENTAL EXPOSURE INFORMATION – ALL PATIENTS
Did the patients seek treatment from a traditional healer in the 3 months prior to onset of illness?
Yes ⎕ / No ⎕ / Unknown⎕
If yes, patient to provide name and location of traditional healer:
Name of traditional healer / Location of healer
DATA CAPTURE INFORMATION
Data capture date / dd/mm/yyyy / Data capturer name / Database record number
ATTACH COPY OF LABORATORY FORM TO THIS CIF AND SUBMIT TO THE NICD –
Listeria Investigation Form Version 1.0, Updated September 2017