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Date questionnaire completed (dd/mm/yyyy)

Questionnaire completed by ...... (name, profession, department, hospital, address, telephone, fax)

Person interviewed (delete as appropriate): Patient themselves, Family Member, Friend/associate, Hospital Staff

A) Patient identification

Date of legionellosis symptoms onset (dd/mm/yyyy)

Period of questioning (ideally 14 days before onset date of symptoms) from dd/mm/yyy/ to dd/mm/yyyy

B) Confirmation of diagnosis

Case of: Legionnaires' disease □ , Pontiac fever □ or asymptomatic Legionella infection □

Other clinical features: Chest pains □, Confusion □, Cough □, Diarrhoea □, Lethargy □, Shortness of breath□, other (please state ….)

Microbiological detail:

Clinical Risk factors: cancer □ (please state which type................................), corticosteroids □, other immunosuppressants □, smoking □, diabetes □, chronic pulmonary disease (chronic bronchitis, emphysema….) □, cardiovascular disease □, renal failure □, dialysis □, transplant □, other (please state ....................)

C) Exposures

Do you have an idea of where you may have contracted Legionellosis? yes □ no □ don't know □

If yes, please state where, when and how

1) Overnight stays outside of the house

In the 14 days BEFORE the first day of your illness, did you spend a night away from the residential address given above? yes □ no □ don't know □

If yes, was this spent at a:

Hospital yes □ no □ don't know □

Other health care institution yes □ no □ don't know □

Hotel yes □ no □ don't know □

Campsite yes □ no □ don't know □

Apartment or cottage yes □ no □ don't know □

Ship yes □ no □ don't know □

Private accommodation yes □ no □ don't know □

Second home yes □ no □ don't know □

Other yes □ no □ don't know □

If yes, please give details:

* If temporary accommodation is a hospital or healthcare institution then check they have not been transferred from another similar institution in the past 14 days and ensure this sites details are captured too.

** possible sources of contamination include: any system that might generate aerosols, for example but not limited to: water systems (showers), air cooling systems and cooling towers, whirlpool/spa/hot tubs/thermal baths, aerosol respiratory equipment, thermal waters, decorative fountains, biological treatment plants and cooling towers)

2) Other visits to Hospital settings

In section 1 you told me about any overnight stays in hospital or other health care institution and where and when these occurred. Could you now tell me of any day trips in the fourteen days BEFORE the first day of your illness, as patient or visitor in a hospital or similar institution?

Date of visit (dd/mm/yyyy)

Type of ward in which you were visitor/patient:

Name of institution

Room no.

Address:

Postal code (if relevant):

Did you visit other hospitals in the 14 day period not already stated above or in section 1? If so please give details?

If yes, please give details:

Name of hospital before transfer

Date of stay from (dd/mm/yyyy) to (dd/mm/yyyy)

When was your last visit to a hospital? (dd/mm/yyyy)

3) Possible sources at work or during regular activity

Occupation (or activity if retired):

Name and address of place of work (or place of regular activity):

During the 14 days before your first day of illness , have you taken one or more showers at your place of work? yes □ no □ don't know □

Do you work with pressurised water (water gun, cutting fluid)? yes □ no □ don't know □

If yes, please state:

At work, are you in contact with an air cooling system (air conditioning system, cooling tower)? yes □ no □ don't know □

If yes, please state:

If so is your air conditioning associated with a cooling tower? yes □ no □ don't know □

Are there temporary remedial works (i.e. road etc) near to your work? yes □ no □ don't know □

At approximately what distance from your place of work?

How do you make the journey between home and work?

On foot □, by car □, public transport □, other (example car plus train), don't know □

Can you share details about your normal route to work from place of residence? (Roads normally used, extraordinary deviations from typical route in 14 days prior to onset of symptoms)

Travelling to work, do you pass (f yes please provide specific geographical detail about areas and/or roads):

• through urban areas? yes □ no □ don't know □
• industrial areas? yes □ no □ don't know □
• biological treatment plants? yes □ no □ don't know □
• temporary works (such as road maintenance etc)? yes □ no □ don't know □

If yes, what type (construction, excavation)?

4) Leisure activities

During the 14 days before your first day of illness, have you done any gardening? yes □ no □ don't know □

If yes, what type?

• Watering with hose pipe: yes □ no □ don't know □
• Handling soil or compost: yes □ no □ don't know □
• Have you used a water spray for treating plants (inside or outside)? yes □ no □ don't know □

During the 14 days before your first day of illness, have you washed your car yes □ no □ don't know□

If yes, was this at home or at a car-wash? If car-wash, please state place and date:

During the 14 days before your first day of illness, have you been in contact with water systems such as:

During the 14 days, have you visited

5) Person's residence

Do you live in a: house □, block of flats □, Other □ please state:

If you live in a block of flats, is the hot water production of your home: individual □, collective □, not known □

Is the source of your domestic water: municipal □, individual (e.g. well) □, mixed □, not known □

If individual, is it from: a well □ a channel? □ don't know □

In your bathroom, is the hot water from:

- Storage tank yes □ no □ don't know □

- Instant production (boiler, immersion) yes □ no □ don't know □

- Other yes □ no □ if yes, please state:

Do you have air-conditioning at home yes □ no □ don't know □

If yes, was it used for at least one day during this period? yes □ no □ don't know □

Have you used a nebuliser at home? yes □ no □ don't know □

During the period, have you had any cuts to your water supply to your house? yes □, no □, not known □

Have there been any works/construction/excavation near to your house (i.e. same street)?

If yes, which type (construction/excavation)?

And at what distance from your house (or give road name)?

Is your house near an industrial unit which produces fumes? yes □, no □, not known □

If yes, which factory and what does it produce?: Town:

6) Summary table of cases activities in the 14 days before onset of symptoms. Please complete as accurately as possible

D) Epidemiological links to other cases

Do you know people near to you who have recently been hospitalised with pneumonia? yes □, no □, not known □

If yes, please state which hospital

(Interviewer/outbreak control team to complete following parts, if necessary)

Have any other legionellosis cases visited the same places or areas within a period of 2 years? yes □ no □

If yes, give case numbers: date of symptom onset: (dd/mm/yyyy)

Other notes/comments: