Generated Narrative: Questionnaire CampylobacterEntericsDiseaseQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints CampylobacterEntericsDiseaseQuestionnaire Te Whatu Ora survey of Campylobacter Enterics Disease Symptoms and source locations Questionnaire https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/CampylobacterEntericsDiseaseQuestionnaire#1.0.0 #xD; PrivacyStatement Privacy statement 0..1 group #xD; Privacy1 We may need to share some of your personal information with other agencies for health purposes and to ensure we meet our legal obligations. We may also share information for statistical and research purposes, but no information will be published in a form that could reasonably be expected to identify any individual. To prevent the spread of disease, we may need to talk to your contacts, and information about where you’ve been and your movements while infectious may need to be shared with others. While we do everything we can to make sure that you remain anonymous, in certain situations more information may need to be given to contacts to prevent or reduce a serious threat to public health – this will always be discussed with you first. If you would like more information about how your personal information is managed, please go to the Te Whatu Ora website, and look for our 'privacy & security' webpage. Please note: If you are completing this questionnaire on behalf of someone else, (e.g. your child) the 'you/your' refers to the person who was unwell, not the person completing it. 0..1 display #xD; Privacy5 Please confirm that you understand the information in the privacy statement. 1..1 choice Options: 2 options #xD; Privacy6 Thank you for your time, we are unable to continue with the questionnaire at this time. Someone may be in touch with you to discuss your illness further. 0..1 display Enable When: Privacy5 = #xD; ContactDetails 1. Contact details 0..1 group Enable When: Privacy5 = #xD; ContactDetail1 What is the best phone number to contact you on? 0..1 string #xD; ContactDetail2 What is the best email address to contact you on? 0..1 string #xD; Occupation 2. Occupation 0..1 group Enable When: Privacy5 = #xD; Occupation1 What is your primary occupation? 0..1 string #xD; Occupation2 Does your work (outside of your home) or activities (e.g. volunteer work) involve any of the following: - Handling unwrapped food that will be eaten raw or without further cooking? - Providing direct, hands on care to unwell people in healthcare facilities? - Providing direct, hands on care to other people at increased risk due to age or disability? - An early childhood service or group, e.g. kindergarten, play centre or day care? 0..1 boolean #xD; Occupation3 Select all the high risk work / volunteer categories that apply: 0..* choice Enable When: Occupation2 = Options: 5 options #xD; Occupation4 Please avoid any high risk activities until free from all symptoms for 48 hours 0..1 display #xD; Symptoms 4. Symptoms 0..1 group Enable When: Privacy5 = #xD; Symptom1 Do you currently have or have you experienced any symptoms? 0..1 boolean #xD; Symptom2 Which of the following symptoms have you experienced? Select all that apply 0..* choice Enable When: Symptom1 = Options: 7 options #xD; Symptom4 Provide details of other symptoms 0..1 text Enable When: Symptom2 = #xD; Symptom5 What was your first symptom? 0..1 choice Enable When: Symptom1 = Options: 7 options #xD; Symptom6 What date did the first symptom appear? 0..1 date Enable When: Symptom1 = #xD; Symptom7 What date did the diarrhoea start? 0..1 date Enable When: Symptom2 = #xD; Symptom8 Has the diarrhoea stopped? 0..1 boolean Enable When: Symptom2 = #xD; Symptom9 What date did the diarrhoea stop? 0..1 date Enable When: Symptom8 = #xD; Symptom10 Have all your symptoms stopped? 0..1 boolean Enable When: Symptom1 = #xD; Symptom11 What date did your symptoms stop? 0..1 date Enable When: Symptom10 = #xD; ContactWithOthers 5. Source investigation - contact with others 0..1 group Enable When: Privacy5 = #xD; ContactWithOthers1 If you have not experienced any symptoms, use the date you produced the stool (poo) sample to answer all the following questions 0..1 display #xD; ContactWithOthers2 In the 1-10 days before you became unwell have you had contact with a confirmed case? 0..1 boolean #xD; ContactWithOthers3 What was their name? 0..1 string Enable When: ContactWithOthers2 = #xD; ContactWithOthers4 Do you know their date of birth or age? 0..1 string Enable When: ContactWithOthers2 = #xD; ContactWithOthers5 When did you first have contact with them? 0..1 date Enable When: ContactWithOthers2 = #xD; ContactWithOthers6 Where did you last have contact with them? 0..1 text Enable When: ContactWithOthers2 = #xD; ContactWithOthers7 Do you have a contact phone number for them? 0..1 string Enable When: ContactWithOthers2 = #xD; ContactWithOthers8 In the 1-10 days before you became unwell, have you had any contact with people with a similar illness? 0..1 boolean #xD; ContactWithOthers9 What was their name? 0..1 string Enable When: ContactWithOthers10 = #xD; ContactWithOthers10 In the 1-10 days before you became unwell have you been to any particular places where you might have been exposed to the illness? This might include an early childhood centre, a school or kura, a university, a hospital, doctors waiting room. 0..1 boolean Enable When: ContactWithOthers8 = #xD; ContactWithOthers11 Please provide details of the place / setting and date/s. 0..1 text Enable When: ContactWithOthers10 = #xD; ContactWithOthers12 In the 1-10 days before you became unwell, did you have any visitors from overseas? 0..1 boolean #xD; ContactWithOthers13 Please provide details of the visitors, including their country of origin and the nature of contact. 0..1 text Enable When: ContactWithOthers12 = #xD; InternationalAndDomesticTravel 6. Source investigation - international and domestic travel 0..1 group Enable When: Privacy5 = #xD; InternationalAndDomesticTravel1 In the 1-10 days before you became unwell, were you overseas? 0..1 boolean #xD; InternationalAndDomesticTravel2 If usually residing in New Zealand, what date did you leave? 0..1 date Enable When: InternationalAndDomesticTravel1 = #xD; InternationalAndDomesticTravel3 What date did you arrive in New Zealand? 0..1 date Enable When: InternationalAndDomesticTravel1 = #xD; InternationalAndDomesticTravel4 Last Country Visited (ISO 3166 list) 0..1 choice Enable When: InternationalAndDomesticTravel1 = Options: 2 options #xD; InternationalAndDomesticTravel5 What region/city did you visit in this country? 0..1 string Enable When: InternationalAndDomesticTravel1 = #xD; InternationalAndDomesticTravel7 What date did you enter this country? 0..1 date Enable When: InternationalAndDomesticTravel1 = #xD; InternationalAndDomesticTravel8 What date did you leave this country? 0..1 date Enable When: InternationalAndDomesticTravel1 = #xD; InternationalAndDomesticTravel9 Did you visit any other countries? 0..1 boolean Enable When: InternationalAndDomesticTravel1 = #xD; InternationalAndDomesticTravel10 2nd Last Country Visited (ISO 3166 list) 0..1 choice Enable When: InternationalAndDomesticTravel9 = Options: 2 options #xD; InternationalAndDomesticTravel11 What City/Region in that country? 0..1 text Enable When: InternationalAndDomesticTravel9 = #xD; InternationalAndDomesticTravel12 What date did you enter this country? 0..1 date Enable When: InternationalAndDomesticTravel9 = #xD; InternationalAndDomesticTravel14 What date did you leave this country? 0..1 date Enable When: InternationalAndDomesticTravel9 = #xD; InternationalAndDomesticTravel15 Did you visit any additional countries? 0..1 boolean Enable When: InternationalAndDomesticTravel9 = #xD; InternationalAndDomesticTravel16 3rd last Country Visited (ISO Country list) 0..1 choice Enable When: InternationalAndDomesticTravel15 = Options: 2 options #xD; InternationalAndDomesticTravel17 What City/Region in that country 0..1 text Enable When: InternationalAndDomesticTravel15 = #xD; InternationalAndDomesticTravel18 What date did you enter this country? 0..1 date Enable When: InternationalAndDomesticTravel15 = #xD; InternationalAndDomesticTravel19 What date did you leave this country 0..1 date Enable When: InternationalAndDomesticTravel15 = #xD; InternationalAndDomesticTravel20 Considering that the incubation period (the time between you being exposed to the illness and you developing symptoms) may be longer than 1-10 days in some situations, do you have a history of overseas travel that could explain this infection, even if the travel was not recent? 0..1 boolean #xD; InternationalAndDomesticTravel22 Please provide details of prior overseas travel 0..1 text Enable When: InternationalAndDomesticTravel20 = #xD; InternationalAndDomesticTravel23 In the 1-10 days before you became unwell, did you travel within New Zealand? 0..1 boolean #xD; InternationalAndDomesticTravel24 Please provide details of your travel within New Zealand 0..1 text Enable When: InternationalAndDomesticTravel23 = #xD; FoodAndDrinkingWater 7. Source investigation - food and drinking water 0..1 group Enable When: Privacy5 = #xD; FoodAndDrinkingWater1 In the 1-10 days before you became unwell, did you eat out e.g. any meals from a restaurant, cafe, event, street vendor, or other food establishment? 0..1 boolean #xD; FoodAndDrinkingWater2 Please provide details of the food you ate out and where it was purchased from 0..1 text Enable When: FoodAndDrinkingWater1 = #xD; FoodAndDrinkingWater3 In the 1-10 days before you became unwell, did you purchase, handle or eat any of the following products at home products at home? 0..1 group #xD; FoodAndDrinkingWater3_1 Raw or undercooked meats (with pink flesh or unclear juices)? 0..* open-choice Options: 9 options #xD; FoodAndDrinkingWater3_2 Raw or undercooked seafood? 0..* open-choice Options: 3 options #xD; FoodAndDrinkingWater3_3 Please provide details of the food products you ate at home 0..1 string #xD; FoodAndDrinkingWater5 In the 1-10 days before you became unwell, did you consume untreated/raw (unpasteurised) milk or products made with raw milk, e.g. cheese, yoghurt? 0..1 boolean #xD; FoodAndDrinkingWater6 Can you provide details of the untreated/raw (unpasteurised) milk or products you consumed? 0..1 text Enable When: FoodAndDrinkingWater5 = #xD; FoodAndDrinkingWater7 What is your usual drinking water supply at home? Tool tip: examples include: council supply, bore, rainwater etc 0..1 text #xD; FoodAndDrinkingWater8 In the 1-10 days before you became unwell, did you consume untreated water? E.g. untreated tank water 0..1 boolean #xD; FoodAndDrinkingWater9 Can you provide details of the untreated water you've consumed? 0..1 text Enable When: FoodAndDrinkingWater8 = #xD; RecreationalWater 8. Source investigation - recreational water 0..1 group Enable When: Privacy5 = #xD; RecreationalWater1 In the 1-10 days before you became unwell, did you have any recreational contact with water e.g. swimming, fishing, beach activities, kayaking, splash pad, spa pools 0..1 boolean #xD; RecreationalWater2 Please provide details of your recreational contact with water 0..1 text Enable When: RecreationalWater1 = #xD; ContactWithAnimals 9. Source investigation - contact with animals 0..1 group Enable When: Privacy5 = #xD; ContactWithAnimals1 In the 1-10 days before you became unwell, did you have any contact with animals or their faeces? This includes pets, birds, turtles/reptiles or farm animals 0..1 boolean #xD; ContactWithAnimals2 Please provide details of the contact you've had with animals or their faeces 0..1 text Enable When: ContactWithAnimals1 = #xD; ContactWithFaecalMatter 10. Source investigation - contact with faecal matter 0..1 group Enable When: Privacy5 = #xD; ContactWithFaecalMatter1 In the 1-10 days before you became unwell, have you had any contact with human sources of faeces e.g. nappy changing, dirty public toilets or sewage? 0..1 boolean #xD; ContactWithFaecalMatter2 Please provide details of the contact you've had with human sources of faeces 0..1 text Enable When: ContactWithFaecalMatter1 = #xD; OtherPotentialSources 11. Source investigation - other potential sources 0..1 group Enable When: Privacy5 = #xD; OtherPotentialSources1 Do you have any ideas about what you think might have made you unwell? 0..1 text #xD; ThankYouMessage Thank you for taking the time to answer these questions that help in the investigation of this disease. 0..1 display Enable When: Privacy5 = #xD; Documentation for this format Options Sets Answer options for Privacy5 https://standards.digital.health.nz/ns/enterics-answer-code#yes ("Yes") https://standards.digital.health.nz/ns/enterics-answer-code#no ("No") Answer options for Occupation3 null#option1 ("Food Handler") null#option2 ("Intellectually/physically impaired") null#option3 ("Healthcare/Rest Home worker") null#option4 ("Early Childhood Services/Groups") null#option5 ("Other high risk category") Answer options for Symptom2 null#option1 ("Diarrhoea") null#option2 ("Blood in stool (poo)") null#option3 ("Vomiting") null#option4 ("Nausea") null#option5 ("Stomach Cramps/Abdominal Pain") null#option6 ("Fever") null#option7 ("Other Symptoms") Answer options for Symptom5 null#option1 ("Diarrhoea ") null#option2 ("Blood in stool (poo)") null#option3 ("Vomiting") null#option4 ("Nausea") null#option5 ("Stomach Cramps/Abdominal Pain") null#option6 ("Fever") null#option7 ("Other Symptoms") Answer options for InternationalAndDomesticTravel4 null#option1 ("Option 1") null#option2 ("Option 2") Answer options for InternationalAndDomesticTravel10 null#option1 ("Option 1") null#option2 ("Option 2") Answer options for InternationalAndDomesticTravel16 null#option1 ("Option 1") null#option2 ("Option 2") Answer options for FoodAndDrinkingWater3_1 null#RawMeat1 ("Chicken or other poultry") null#RawMeat2 ("Lamb / Hogget / Mutton") null#RawMeat3 ("Pork or pork products") null#RawMeat4 ("Beef or beef products, e.g. mince, hamburger, cold beef") null#RawMeat5 ("Any home kill meats or game meat") null#RawMeat6 ("Liver, e.g. lamb's fry, chicken liver or other liver products (pate)") null#RawMeat7 ("Salami, pepperoni or other deli meats") null#RawMeat8 (" Offal, e.g. chicken livers") null#RawMeat9 ("Pet Food") Answer options for FoodAndDrinkingWater3_2 null#RawSeafood1 ("Shellfish, e.g. oysters, clams, crabs, shrimps or prawns") null#RawSeafood2 ("Sushi, sashimi, ceviche") null#RawSeafood3 ("Other seafood")
Campylobacter Enterics Disease Questionnaire
Te Whatu Ora survey of Campylobacter Enterics Disease Symptoms and source locations
We may need to share some of your personal information with other agencies for health purposes and to ensure we meet our legal obligations. We may also share information for statistical and research purposes, but no information will be published in a form that could reasonably be expected to identify any individual. To prevent the spread of disease, we may need to talk to your contacts, and information about where you’ve been and your movements while infectious may need to be shared with others. While we do everything we can to make sure that you remain anonymous, in certain situations more information may need to be given to contacts to prevent or reduce a serious threat to public health – this will always be discussed with you first. If you would like more information about how your personal information is managed, please go to the Te Whatu Ora website, and look for our 'privacy & security' webpage. Please note: If you are completing this questionnaire on behalf of someone else, (e.g. your child) the 'you/your' refers to the person who was unwell, not the person completing it.
Please confirm that you understand the information in the privacy statement.
Thank you for your time, we are unable to continue with the questionnaire at this time. Someone may be in touch with you to discuss your illness further.
What is the best phone number to contact you on?
What is the best email address to contact you on?
Does your work (outside of your home) or activities (e.g. volunteer work) involve any of the following: - Handling unwrapped food that will be eaten raw or without further cooking? - Providing direct, hands on care to unwell people in healthcare facilities? - Providing direct, hands on care to other people at increased risk due to age or disability? - An early childhood service or group, e.g. kindergarten, play centre or day care?
Select all the high risk work / volunteer categories that apply:
Please avoid any high risk activities until free from all symptoms for 48 hours
Do you currently have or have you experienced any symptoms?
Which of the following symptoms have you experienced? Select all that apply
5. Source investigation - contact with others
If you have not experienced any symptoms, use the date you produced the stool (poo) sample to answer all the following questions
In the 1-10 days before you became unwell have you had contact with a confirmed case?
When did you first have contact with them?
Where did you last have contact with them?
Do you have a contact phone number for them?
In the 1-10 days before you became unwell, have you had any contact with people with a similar illness?
In the 1-10 days before you became unwell have you been to any particular places where you might have been exposed to the illness? This might include an early childhood centre, a school or kura, a university, a hospital, doctors waiting room.
Please provide details of the place / setting and date/s.
In the 1-10 days before you became unwell, did you have any visitors from overseas?
Please provide details of the visitors, including their country of origin and the nature of contact.
6. Source investigation - international and domestic travel
In the 1-10 days before you became unwell, were you overseas?
If usually residing in New Zealand, what date did you leave?
What date did you arrive in New Zealand?
What region/city did you visit in this country?
2nd Last Country Visited (ISO 3166 list)
3rd last Country Visited (ISO Country list)
Considering that the incubation period (the time between you being exposed to the illness and you developing symptoms) may be longer than 1-10 days in some situations, do you have a history of overseas travel that could explain this infection, even if the travel was not recent?
Please provide details of prior overseas travel
In the 1-10 days before you became unwell, did you travel within New Zealand?
Please provide details of your travel within New Zealand
7. Source investigation - food and drinking water
In the 1-10 days before you became unwell, did you eat out e.g. any meals from a restaurant, cafe, event, street vendor, or other food establishment?
Please provide details of the food you ate out and where it was purchased from
In the 1-10 days before you became unwell, did you purchase, handle or eat any of the following products at home products at home?
Raw or undercooked meats (with pink flesh or unclear juices)?
Beef or beef products, e.g. mince, hamburger, cold beef
Liver, e.g. lamb's fry, chicken liver or other liver products (pate)
Shellfish, e.g. oysters, clams, crabs, shrimps or prawns
Please provide details of the food products you ate at home
In the 1-10 days before you became unwell, did you consume untreated/raw (unpasteurised) milk or products made with raw milk, e.g. cheese, yoghurt?
Can you provide details of the untreated/raw (unpasteurised) milk or products you consumed?
What is your usual drinking water supply at home? Tool tip: examples include: council supply, bore, rainwater etc
In the 1-10 days before you became unwell, did you consume untreated water? E.g. untreated tank water
Can you provide details of the untreated water you've consumed?
8. Source investigation - recreational water
In the 1-10 days before you became unwell, did you have any recreational contact with water e.g. swimming, fishing, beach activities, kayaking, splash pad, spa pools
Please provide details of your recreational contact with water
9. Source investigation - contact with animals
In the 1-10 days before you became unwell, did you have any contact with animals or their faeces? This includes pets, birds, turtles/reptiles or farm animals
Please provide details of the contact you've had with animals or their faeces
10. Source investigation - contact with faecal matter
In the 1-10 days before you became unwell, have you had any contact with human sources of faeces e.g. nappy changing, dirty public toilets or sewage?
Please provide details of the contact you've had with human sources of faeces
11. Source investigation - other potential sources
Do you have any ideas about what you think might have made you unwell?
Thank you for taking the time to answer these questions that help in the investigation of this disease.