GI Illness Survey

The San Bernardino County Department of Public Health is investigating multiple gastrointestinal illness reports that occurred between 8/15/19 to 8/27/19 among students and staff members at Adelanto School District. If you are a parent or guardian of a student or a staff member that became ill during this time frame, please complete the following survey. Please note that all of the information collected is confidential and will be used to better understand the causes of the ongoing illnesses. If you have any questions or concerns, please contact Ruchi Pancholy, Epidemiologist via email at: Ruchi.Pancholy@dph.sbcounty.gov or via phone at: (909) 677-6132.

Para completar esta encuesta en español, por favor utilice el siguiente enlace: https://www.surveymonkey.com/r/enfermedad_GI
 

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* 1. Please provide your contact information

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* 2. What is your child's full name?

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* 3. Please complete the following information regarding your child (If you are a ill staff member, please leave this section blank).

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* 4. If you are an ill staff member, please complete the following information (if you are a parent of an ill child, please leave this section blank).

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* 5. Since Thursday, 8/15/19, did you or your child become ill with gastrointestinal symptoms (e.g., vomiting, diarrhea, abdominal pain, etc.)?

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* 6. When did you or your child first begin to experience symptoms? Please enter a date and time.

Date
Time

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* 7. Are you or your child still ill with GI symptoms?

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* 8. When did you or your child's symptoms end? Please enter a date and time.

Date
Time

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* 9. Did you or your child experience any of the following symptoms? (Please check all that apply)

  Yes No Don't recall
Vomiting
Diarrhea (defined as > 3 loose stools in a 24 Hour Period
Blood Diarrhea
Abdominal Cramps
Nausea
Constipation
Headache
Fever
Chills
Body aches/myalgia
Fatigue

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* 10. If you or your child experienced a fever, please enter the highest recorded temperature.

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* 11. If you or your child experienced diarrhea, please enter the number of loose stools he/she experienced in a 24 hour period.

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* 12. Did you or your child seek medical attention for his/her illness?

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* 13. Were you or your child hospitalized for the GI illness?

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* 14. If you or your child sought medical attention, was laboratory testing performed to determine the etiologic agent associated with the illness?

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* 15. If you or your child did not seek medical attention or no testing was performed, would you or your child be willing to submit a stool specimen upon request? (Please note that the San Bernardino County Department of Public Health will coordinate efforts to collect and perform testing stool testing on behalf of you or your child).

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* 16. If you know of anyone else that became ill with GI symptoms during this time period, please provide us with a name, email, and phone number so we are able to send them this survey. (Please note that we will not inform them that you provided us with this information).

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* 17. May we contact you via phone to clarify any responses you provided or follow-up with you regarding coordinating testing for your child?

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This completes the survey, please hit the (Submit Responses) button below . Thank-you for taking the time to answer all of our questions. Your responses are very helpful in preventing further illnesses and taking appropriate actions necessary to control the ongoing outbreak.
 

This completes the survey, please hit the (Submit Responses) button below . Thank-you for taking the time to answer all of our questions. Your responses are very helpful in preventing further illnesses and taking appropriate actions necessary to control the ongoing outbreak. <br> <br><br>

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