First name Surname Date of birth Sex Relationship Address Diarrhoea? Onset date Occupation Risk group to you (dd/mm/yyyy) (if different to you) (dd/mm/yyyy) (Official Use) Female Yes A B Male No C Other D None Female Yes A B Male No C Other D None Female Yes A B Male No C Other D None Female Yes A B Male No C Other D None you for completing this questionnaire. If you completed this form on a computer, please return the completed form by to the address provided. If you received a version of this questionnaire, please return the completed questionnaire by post using the pre-addressed envelope provided. For further information on shigellosis and how you can prevent infection, please see:
First name Surname Date of birth (dd/mm/yyyy) Sex Relationship to you Address (if different to you) Diarrhoea? Onset date (dd/mm/yyyy) Occupation Risk group (Official Use) Female Male Other Yes No A B C D None Female Male Other Yes No A B C D None Female Male Other Yes No A B C D None Female Male Other Yes No A B C D None you for completing this questionnaire. If you completed this form on a computer, please return the completed form by to the address provided. If you received a version of this questionnaire, please return the completed questionnaire by post using the pre-addressed envelope provided. For further information on shigellosis and how you can prevent infection, please see:
Shigellosis_interim_enhanced_surveillance_questionnaire.docx