Print Form
FoodNet - Foodborne Diseases Active Surveillance Network
Please fill out the laboratory information below. For each positive culture identified, fill out the sections on
isolation site and age category that follow on subsequent pages. Please save the file electronically (if
possible) and email to [email protected] or print and fax it to 651-201-5082, attention Josh
Rounds.
Laboratory Information
FoodNet state requesting surveillance review
Please indicate the month and year that surveillance records were reviewed:
Surveillance review start date (MM-YYYY)
Surveillance review end date (MM-YYYY)
From the surveillance records, did your lab isolate Cronobacter sakazakii ?
If yes, how many positive Cronobacter sakazakii cultures?
If one or more positive specimen(s), please go to page 2
Page 1 of 6
FoodNet - Foodborne Diseases Active Surveillance Network
Positive Cronobacter sakazakii culture number 1
Specimen Collection Information
Month and year of specimen collection (MM-YYYY)
Unique ID #1 7071542c29b642549a774307319c0b80
Isolation Site(s) - Please check all that apply
Central nervous system
Blood
Stool / rectal swab
Brain abscess / tissue
Sputum, pharyngeal swab, or tracheal aspirate
Cerebrospinal fluid
Urine (collection method)
Conjuctiva
Vagina
Urine (catheter)
Wound
Urine (transabdominal aspiration)
Other
Urine (urine bag)
Urine (clean catch)
Other specify
Urine (collection method not specified)
Age Category
If case-patient's age is less than or equal to 2 months, then record the age in days at specimen collection
Days
If case-patient's age is greater than 2 months but less than 1 year, then record the age in months at specimen collection
Months
If case-patient's age is greater than or equal to 1 year, then record the age in years at specimen collection
Years
Comments
Page 2 of 6
FoodNet - Foodborne Diseases Active Surveillance Network
Positive Cronobacter sakazakii culture number 2
Specimen Collection Information
Month and year of specimen collection (MM-YYYY)
Unique ID #2 2e5e0f176ad9494196b63b3f12181ea0
Isolation Site(s) - Please check all that apply
Central nervous system
Blood
Stool / rectal swab
Brain abscess / tissue
Sputum, pharyngeal swab, or tracheal aspirate
Cerebrospinal fluid
Urine (collection method)
Conjuctiva
Vagina
Urine (catheter)
Wound
Urine (transabdominal aspiration)
Other
Urine (urine bag)
Urine (clean catch)
Other specify
Urine (collection method not specified)
Age Category
If case-patient's age is less than or equal to 2 months, then record the age in days at specimen collection
Days
If case-patient's age is greater than 2 months but less than 1 year, then record the age in months at specimen collection
Months
If case-patient's age is greater than or equal to 1 year, then record the age in years at specimen collection
Years
Comments
Page 3 of 6
FoodNet - Foodborne Diseases Active Surveillance Network
Positive Cronobacter sakazakii culture number 3
Specimen Collection Information
Month and year of specimen collection (MM-YYYY)
Unique ID #3 4bfe48b706434ee69bd8206170db149d
Isolation Site(s) - Please check all that apply
Central nervous system
Blood
Stool / rectal swab
Brain abscess / tissue
Sputum, pharyngeal swab, or tracheal aspirate
Cerebrospinal fluid
Urine (collection method)
Conjuctiva
Vagina
Urine (catheter)
Wound
Urine (transabdominal aspiration)
Other
Urine (urine bag)
Urine (clean catch)
Other specify
Urine (collection method not specified)
Age Category
If case-patient's age is less than or equal to 2 months, then record the age in days at specimen collection
Days
If case-patient's age is greater than 2 months but less than 1 year, then record the age in months at specimen collection
Months
If case-patient's age is greater than or equal to 1 year, then record the age in years at specimen collection
Years
Comments
Page 4 of 6
FoodNet - Foodborne Diseases Active Surveillance Network
Positive Cronobacter sakazakii culture number 4
Specimen Collection Information
Month and year of specimen collection (MM-YYYY)
Unique ID #4 00dc7739546844748433613f516f5654
Isolation Site(s) - Please check all that apply
Central nervous system
Blood
Stool / rectal swab
Brain abscess / tissue
Sputum, pharyngeal swab, or tracheal aspirate
Cerebrospinal fluid
Urine (collection method)
Conjuctiva
Vagina
Urine (catheter)
Wound
Urine (transabdominal aspiration)
Other
Urine (urine bag)
Urine (clean catch)
Other specify
Urine (collection method not specified)
Age Category
If case-patient's age is less than or equal to 2 months, then record the age in days at specimen collection
Days
If case-patient's age is greater than 2 months but less than 1 year, then record the age in months at specimen collection
Months
If case-patient's age is greater than or equal to 1 year, then record the age in years at specimen collection
Years
Comments
Page 5 of 6
FoodNet - Foodborne Diseases Active Surveillance Network
Positive Cronobacter sakazakii culture number 5
Specimen Collection Information
Month and year of specimen collection (MM-YYYY)
Unique ID #5 4c6b31e524984a87a85603042dd6373c
Isolation Site(s) - Please check all that apply
Central nervous system
Blood
Stool / rectal swab
Brain abscess / tissue
Sputum, pharyngeal swab, or tracheal aspirate
Cerebrospinal fluid
Urine (collection method)
Conjuctiva
Vagina
Urine (catheter)
Wound
Urine (transabdominal aspiration)
Other
Urine (urine bag)
Urine (clean catch)
Other specify
Urine (collection method not specified)
Age Category
If case-patient's age is less than or equal to 2 months, then record the age in days at specimen collection
Days
If case-patient's age is greater than 2 months but less than 1 year, then record the age in months at specimen collection
Months
If case-patient's age is greater than or equal to 1 year, then record the age in years at specimen collection
Years
Comments
Page 6 of 6