The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Outbreak-Specific Questionnaire: AL1804exh-49a (LeFlore High School)

The Alabama Department of Public Health (ADPH), Infectious Diseases & Outbreaks Division, is investigating a gastrointestinal illness among students and/or staff who attend/work at LeFlore High School. We are conducting a survey to help us determine what factors may have played a role in causing illness among these individuals.

You/your child have been selected to participate in this survey either because of your/your child's illness or because you/your child are listed as having attended or worked at the school since April 11, 2018.

The survey should take no more than 20 minutes and your answers will be extremely helpful to us. Please note, your participation is completely voluntary and all information you give will be kept confidential to the extent legally possible. You may refuse to answer any question at any time. Neither your name nor any identifying information will appear on any report.

Thank you!

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Last Name

* must provide value

First Name

* must provide value

Age (in years)

* must provide value

If child, please provide parent or guardian's name

Sex

* must provide value

Student's Grade or Staff Member

* must provide value

Ethnicity

Race

Did you/your child eat breakfast in the school's cafeteria between Wednesday, April 11, and Friday, April 20?

* must provide value

Yes

No

Maybe

Don't Know

Mini Waffles

Sausage Link

Yogurt

Cheese Sticks

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Cereal

Pop-tart

Yogurt

Cheese Sticks

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Pancackes

Chicken Patty

Yogurt

String Cheese

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Chicken Patty

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Breakfast Pizza

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Pancackes (on a stick)

Sausage Link

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Cinnamon Roll

Biscuit

Jelly

Ham Slice

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Biscuit

Jelly

Sausage Patty

Fruit

Fruit Juice

Milk

Did you/your child eat lunch in the school's cafeteria between Wednesday, April 11, and Friday, April 20?

* must provide value

Yes

No

Maybe

Don't Know

Chili Red Beans & Rice

Broccoli

Salad

Roll

Sugar Cookie

Rice Crispy Treat

Other Dessert

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Hamburger

If yes to hamburger, was the meat pink or red inside when eaten?

Hamburger Bun

Cheese

Lettuce

Tomatoes

Pickles

Ketchup

Mayo

Mustard

Fries

Other Potatoes

Carrots

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Fajita Chicken

Sweet Peas

Yams

Roll

Biscuit

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Pizza

Black Beans

Pinto Beans

Corn

Corn Nuggets

Sugar Cookie

Brownie

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Chicken Patty

Hamburger Bun

Fries

Cheese

Lettuce

Tomatoes

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Asian Chicken

Other Chicken Option

Fried Rice

Broccoli

Vegetable Egg Roll

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Taco Meat

If yes to taco meat, was the meat pink or red inside when eaten?

Taco Shell

Lettuce

Tomatoes

Cheese

Green Beans

Salad

Breadstick

Roll

Fruit

Fruit Juice

Milk

Yes

No

Maybe

Don't Know

Chicken Fillet

Hamburger Bun

Mashed Potatoes

Sweet Peas & Carrots

Mixed Veggies

Biscuit

Roll

Fruit

Fruit Juice

Milk

Did you attend prom on Friday, April 13?

* must provide value

If yes to attending prom, did you/your child eat/drink anything while at the prom??

* must provide value

Yes

No

Maybe

Don't Know

Chicken Wings

Grilled Chicken Tortellini

Parmesan Cream Sauce

Bolognese Sauce

Potato Gnocchi

Hamburger Sliders

If yes or maybe to sliders, was the meat pink or red when eaten?

Cookies

Brownies

Lemonade

Water

Did you/your child participate in any after-school activities from Wednesday, April 11, and Friday, April 20?

* must provide value

If yes or maybe to after-school activities, please specify:

Expand

Did you/your child attend/participate in any special gatherings outside of school from Wednesday, April 11, and Friday, April 20?

* must provide value

If yes or maybe to special gatherings, please provide details:

Expand

If yes or maybe to special gatherings, did you eat/drink anything while in attendance?

If yes or maybe to eating/drinking while at special gatherings, please specify:

Expand

If there is anything else you/your child feels ADPH should know about with regards to this outbreak (e.g., saw someone get sick in the cafeteria, gloves weren't being used by kitchen staff, etc.), please provide details:

Expand

Were you/your child ill with abdominal cramps, diarrhea and/or vomiting since April 21?

* must provide value

Yes

No

Date/Time of Illness Onset

M-D-Y H:M

Symptoms

*Diarrhea = 3 or more loose stools in a 24-hour period.

Abdominal Cramps

Blood in Stool

Body Aches

Chills

Diarrhea

Fatigue

Fever

Headache

Muscle Aches

Nausea

Sweats

Vomiting

If yes to diarrhea...

Date/time of onset?

M-D-Y H:M

Maximum number of stools in a 24-hour period

If yes to vomiting...

Date/time of onset?

M-D-Y H:M

Maximum number of vomiting episodes in a 24-hour period

Are you/your child still ill?

Yes

No

If no, what day did you/your child fully recover?

M-D-Y

Did you/your child seek medical care for this illness?

Yes

No

If yes, please indicate the healthcare provider(s) you/your child saw...

Healthcare Provider Type

Doctor's Office/Clinic

Urgent Care

Emergency Room/Hospital

Doctor/Facility Name:

Date of Visit:

M-D-Y

Urgent Care Facility Name:

Date of Visit:

M-D-Y

Emergency Room/Hospital Facility Name:

Date of Visit:

M-D-Y

Was a stool sample collected?

Yes

No

If yes, what day was the sample taken?

M-D-Y

Results of stool testing:

If no, would you/your child be willing to provide a stool sample?

Yes

No

If you indicated that you would be willing to submit a stool sample, one of our District Investigators may be contacting you to arrange that.

Was anyone else in you/your child's household sick with abdominal cramps, diarrhea or vomiting in the week prior to you/your child's illness?

Yes

No

If yes, when was their illness onset?

M-D-Y

Name and relationship of ill household member:

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.