Background
Employee's Name: (last)___________________, (first) __________________
Age: _____
Gender: _____
Home address: (city)____________________, (zip)__________________
Race/Ethnicity (circle all that apply):
African American, Asian, Caucasian, Latino/Hispanic, Native American, Pacific Islander, Other
Are you currently taking any oral steroid medications?: Yes / No
On what date did you first become ill?: ____ /____ /____
How many days were you ill?: _______
Was anyone else in your family ill?: Yes / No
If Yes, who? ______________________________________
What symptoms did they have? ______________________________
Since ___________, have any of your family, friends, or coworkers been diagnosed with pneumonia?:
Yes / No. If Yes, who? __________________________, (relationship)____________________
Work Exposure
(During the 10 days prior to your illness)
Job Description: ________________________________________________
Primary work area: ______________________________________________
List all areas in _______ building where you spent any time:
Area
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
|
Hours per week
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
|
Did you shower at work?: Yes / No
If Yes, where and how may times per week?: _________________
List all places you eat lunch: ____________________________________
List all places where you take a break: ____________________________
List all restrooms you use: ________________________________________
Do you smoke in the restrooms (or spend "extra" time, i.e., if a lounge is present): Yes / No
If Yes, which restroom(s)?: _______________________________
Did you attend any training courses outside of the building?: Yes / No
If Yes, where were they held? _______________________________
Do you have a second job?: Yes / No
If Yes, what job and where:
____________________________________________________________________
Any other places that you have not mentioned where you spent time while on the job?:
____________________________________________________________________
Community Exposure
(During the two weeks prior to your illness)
Did you use any health clubs?: Yes / No
If Yes, which ones?: ________________________________________
How many times?: ______________________________________________
Did you use any hot tubs (whirlpool spas)?: Yes / No
If Yes, list which hot tubs and when used:
_____________________________________________________________
Did you attend any churches?: Yes / No
If Yes, where ________________________________________________
How many times? ____________
Have you had any dental work performed?: Yes / No
If Yes, where _________________________________________
How many times? ____________
Which grocery stores did you go to?: _____________________________
How often? __________________
Did you go to the movies?: Yes / No
If Yes, which one? ________________________________
How often? ____________
Did you go to any shopping malls?: Yes / No
If Yes, which one(s)? __________________________
Did you go to any other public places which you feel might be significant (i.e. public meetings, schools etc.)?: Yes / No
If Yes, where? ___________________________________________
Did you engage in any activities that exposed you to water sprays or mists?: Yes / No
If yes, which one(s)?__________________________________________________________
How often? ___________________________
Did you travel or stay overnight somewhere other than usual residence?: Yes / No
If yes, give cities, dates, and lodging.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
|
Newsletter
RSS Feeds
Print This Page
Text Size
