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  1. Surveys
  2. 2015
  3. March
  4. I
  5. INDONESIAN NIGHT
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Exit Survey
 
 
Hello!  This survey is being conducted by the  Athens City County Health Department  because of a concern of reported illness following the Indonesian Night Dinner on February 27, 2015. We are working to identify the source of this illness, so we can prevent additional illness. We understand that you are one of the people who attended this event.  We would like to ask you some questions about the event and foods that you ate at Indonesian Night whether you became ill or not. Your survey responses will be strictly confidential and data from this survey will be reported only in the aggregate.  If you have questions about the survey or the investigation, you may contact Tonya McGuire at 740-441-2964 or by emailing [email protected].

Thank you very much for your time and help! Please start with the survey now by clicking on the Continue button below.
 
 
 
* Name:
   
 
 
 
* Did you attend the Indonesian Night Dinner on February 27, 2015?
 
Yes
 
No
 
 
 
* If necessary, may we contact you again?
 
Yes
 
No
 
 
 
Your phone number:
   
 
 
 
Your e-mail address:
   
 
 
 
* What is your date of birth?
MonthDayYear
  
 
 
 
* Your gender:
 
Male
 
Female
 
 
 
Race/Ethnicity:
 
Hispanic or Latino
 
American Indian or Alaska Native
 
Asian
 
African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
Other
 
 
 
* Your age?
 
<1 year
 
1 to 4 years
 
5 to 9 years
 
10-19 years
 
20-49 years
 
50-74 years
 
>= 75 years
 
 
 
* Which buffet serving table did you eat from the first time you prepared your plate?
TABLE 1
TABLE 2
 
 
 
* What time did you first eat from the buffet table?
Hrs.Mins.AM/PM
  
 
 
 
* Please mark the foods you ate from your first trip to the buffet table?  (Mark all that apply.)
 
Onde-onde (round pastry/dumpling)
 
Lumpia (springroll)
 
Nasi putih (steamed rice)
 
Sate Ayam (grilled chicken)
 
Peanut Sauce served with Sate Ayam
 
Rendang (spicy beef dish)
 
Balado Telur (tofu in chili sauce)
 
Kari Sayur (curried mixed vegetables)
 
Es Cendol (shaved ice dessert/drink)
 
Keupuk Bawang (colorful crackers/chips)
 
Sambal (vinegar sauce)
 
Teh Kotak dan Juice (juice box)
 
Bottled Water

 
 
 
* Did you have multiple servings? (Seconds, go back for more)
 
Yes
 
No
 
 
 
What time did you last eat from the buffet?
Hrs.Mins.AM/PM
  
 
 
 
Which buffet table did you eat from when you went back for more?  
 
I went back for food but always ate from the same buffet table.
 
I went back for food and ate food from both buffet tables.
 
 
 
What foods/beverages did you have when you returned to the buffet?  (Mark all that apply.)
 
Onde-onde (round pastry/dumpling)
 
Lumpia (springroll)
 
Nasi Putih (steamed rice)
 
Sata Ayam (grilled chicken)
 
Peanut Sauce served with Sate Ayam
 
Rendang (spicy beef dish)
 
Balado Telur (tofu in chili sauce)
 
Kari Sayur (curried mixed vegetables)
 
Es Cendol (shaved ice dessert/drink)
 
Keupuk Bawang (colorful crackers/chips)
 
Sambal (vinegar sauce)
 
Teh Kotak dan Juice (juice box)
 
Bottled Water
 
 
 
* Did you become ill with any gastrointestinal symptoms after attending Indonesian Night?
 
Yes
 
No
 
 
 
IF you experience vomiting or diarrhea, which did you have FIRST?
 
I vomited first.
 
I had diarrhea first.
 
I did not vomit or have diarrhea.
 
 
 
What date and time did you first experience vomiting or diarrhea (best guess)?
MonthDayYearHrs.Mins.AM/PM
    
 
 
 
Date of last time experiencing vomiting or diarrhea?
MonthDayYearHrs.Mins.AM/PM
    
 
 
 
Please mark ALL symptoms you had in association with this illness?
 
Nausea
 
Vomiting
 
Diarrhea
 
Bloody diarrhea
 
Abdominal cramps
 
Fever
 
Chills
 
Headache
 
Body aches
 
Fatigue
 
Other
 

 
 
 
What date and time did you first experience ANY of these symptoms?
MonthDayYearHrs.Mins.AM/PM
    
 
 
 
What date and time did you last experience ANY of these symptoms?
MonthDayYearHrs.Mins.AM/PM
    
 
 
 
Did you seek healthcare?
 
Yes
 
No
 
 
 
If you sought healthcare, where did you go?
   
 
 
 
Did any of your close contacts or other household members become ill with similar symptoms after you were ill?
 
Yes
 
No