Contact Follow Up

The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

8CByHk5stwURjRWxGecxEXsB5F9W8vT7nSxxmLmMFnpwAPSPmHPb2GMMLIDSDhV

The Alabama Department of Public Health is investigating exposures to raw, or unpasteurized, milk that may have caused illness. Please answer the following questions to the best of your ability.

Thank you!

Date of Report:

M-D-Y

Reportable Disease/Health Condition:

* must provide value

Investigator Type Code:

First Name:

* must provide value

Last Name:

* must provide value

Phone Number:

* must provide value

Age Group:

* must provide value

If respondent's <18 years old, provide parent/proxy's name:

* must provide value

Race

* must provide value

If other, please specify:

Ethnicity

* must provide value

Gender

* must provide value

State of Residence:

* must provide value

County of Residence:

* must provide value

Have you consumed raw, or unpasteurized, milk in the last six months?

* must provide value

Thank you for your time. We have no further questions.

* must provide value

Under which label was the raw milk packaged?

* must provide value

Miller's Biodiversity Farm

Other

Unknown

If other, please specify:

Which symptoms are you experiencing?

* must provide value

Fever

Sweats

Fatigue

Loss of appetite

Headache

Muscle pain

Joint pain

Back pain

Other

None

If other, please specify:

Have you visited a physician?

Physician Name:

Physician Phone Number:

Date of Illness Onset:

M-D-Y

Take a moment to view the flyer with more information:

Attachment:Brucella Flyer.docx

Take the attached flyer when you visit a physician:

Attachment:Brucella Flyer_DRAFT.docx

Comments:

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.