Sacred Heart Turkey Dinner, November 8, 2010

1. Sacred Heart Turkey Dinner Investigation

Kansas Department of Health and Environment along with the Cowley County Health Department are investigating a possible foodborne disease outbreak that could be associated with the Sacred Heart Turkey Dinner that was held on November 8 in Arkansas City.

To determine the cause of illness and to prevent future occurrences, we are collecting information from individuals who became ill as well as from those that did NOT become ill. Your participation is completely voluntary, and any information you provide will be kept strictly confidential.

Question Title

* 1. Last Name:

Question Title

* 2. First Name:

Question Title

* 3. County where you live:

Question Title

* 4. Phone Number:

Question Title

* 5. Age(years):

Question Title

* 6. Sex:

Male

Female

Question Title

* 7. What date did you eat the food from the turkey dinner?

Date

Question Title

* 8. What time did you eat the food from the turkey dinner?

Time

AM/PM

Question Title

* 9. Did you eat the meal at Sacred Heart?

Yes

Question Title

* 10. Did you take food home or have food brought to you from the Sacred Heart Dinner?

Yes

Question Title

* 11. Please answer yes to the items that you ate and no to the ones that you did not eat from the Sacred Heart Turkey Dinner.

	Yes	No
Turkey	Turkey Yes	Turkey No
Mashed Potatoes	Mashed Potatoes Yes	Mashed Potatoes No
Dressing	Dressing Yes	Dressing No
Gravy	Gravy Yes	Gravy No
Green Beans	Green Beans Yes	Green Beans No
Cranberry Sauce	Cranberry Sauce Yes	Cranberry Sauce No
Buttered Bread	Buttered Bread Yes	Buttered Bread No

Question Title

* 12. Did you have any desserts?

Yes