11 Example Forms for Field Investigation:
⬜ Developing Hypotheses
⬜ Sample Collection
🟩 Outbreak Investigation
⬜ Sequencing
⬜ Bioinformatics
⬜ Molecular Epidemiology
⬜ Public Health Implementation
11.1 Case Interview Form
1. Case Information
| Field | Response |
|---|---|
| Case ID | |
| Interview Date | |
| Interviewer Name | |
| Date of Symptom Onset | |
| Date of Testing | |
| Test Type | |
| Test Result |
2. Demographics
| Field | Response |
|---|---|
| Full Name | |
| Date of Birth | |
| Age | |
| Sex/Gender | |
| Address | |
| City | |
| County/Region | |
| Phone Number (Optional) |
3. Vaccination History
| Vaccine | Received? (Y/N) | Date (if known) |
|---|---|---|
| Influenza | ||
| COVID-19 | ||
| Other (specify) |
Clinical and Symptom History
| Symptom | Present? (Y/N) | Onset Date (if known) |
|---|---|---|
| Fever | ||
| Cough | ||
| Fatigue | ||
| Sore Throat | ||
| Muscle/Body Aches | ||
| Diarrhea | ||
| Other (specify) |
Exposure and Travel History
| Field | Response |
|---|---|
| Travel in last 14 days? | |
| Locations visited | |
| Date of Safari Zone Visit | |
| Animal Contact? (Y/N) | |
| Species Contacted | |
| Occupation/Work Role | |
| Contact with sick individuals? | |
| Household illness reported? |
Protective Measures and Behavior
| Field | Response |
|---|---|
| Mask Use (Y/N) | |
| Hand Hygiene Frequency | |
| Isolation Practiced? | |
| PPE Used at Work? | |
| Other Preventive Measures |
Additional Notes
| Notes | |
|---|---|
11.2 Animal Case Surveillance Form
Animal Identification
| Field | Response |
|---|---|
| Animal ID / Tag Number | |
| Species | |
| Breed (if applicable) | |
| Age Estimate (Years/Months) | |
| Sex | |
| Unique Markings or Features |
Location & Housing
| Field | Response |
|---|---|
| Location / Zone Name | |
| Enclosure Number or Area | |
| Facility or Safari Section | |
| Contact with Other Species? | |
| Contact with Trainers / Staff? |
Clinical Observations
| Symptom | Present? (Y/N) | Onset Date (if known) |
|---|---|---|
| Lethargy | ||
| Respiratory symptoms | ||
| Nasal discharge | ||
| Fever | ||
| Decreased appetite | ||
| Gastrointestinal symptoms | ||
| Neurological symptoms | ||
| Other (specify) |
Exposure History
| Field | Response |
|---|---|
| Contact with New Animals? | |
| Known Contact with Sick Humans? | |
| Recently Moved or Transferred? | |
| Part of a Group Showing Symptoms? | |
| Any Medical Procedures Recently? |
Sample Collection
| Sample Type | Collected? (Y/N) | Date Collected | Notes |
|---|---|---|---|
| Nasal swab | |||
| Oral swab | |||
| Rectal swab | |||
| Blood sample | |||
| Fecal sample | |||
| Other (specify) |
Medical & Vaccination History
| Field | Response |
|---|---|
| Vaccinated? | |
| Type of Vaccines | |
| Date of Last Vaccination | |
| Medical Conditions Noted | |
| Previous Illness Episodes |
Additional Notes
| Notes | |
|---|---|