HomeMy WebLinkAboutData Sharing cf 615 Sheridan Street
Port Townsend, WA 98368
c9e!enson www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Healt
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, Public Health Director
Denise Banker, Community Health Director
DATE:
SUBJECT: Agenda item — Data Sharing Agreement with Washington State Department of
Health (DOH) for sharing of information concerning Foodborne Illness; May 16,
2024 — May 15, 2029
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH) requests Board approval of a Data Sharing Agreement between DOH
and JCPH for sharing of information concerning Foodborne Illness; May 16, 2024 — May 15, 2029
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S:
Approximately 40 to 60 (or more) foodborne illness outbreaks occur each year in Washington, affecting
hundreds of communities and creating a large economic burden. The purpose of this agreement is to provide
access to the Foodborne Illness Notification System (FINS) which provides a secure database of self-reported
foodborne illness. DOH provides the FINS system to coordinate the appropriate authority receiving
notification of a potential foodborne illness or food safety concern so they may respond and mitigate any risk
to the public health in accordance with RCW 70.05.070(3).
FISCAL IMPACT/COST BENEFIT ANALYSIS:
There is no financial component to this agreement.
RECOMMENDATION:
JCPH management requests approval of a Data Sharing Agreement with DOH for sharing of information
concerning Foodborne Illness; May 16, 2024 — May 15, 2029
REVIEWED BY:
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Mark McCauley, Administrator Date
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Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 (f) 360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
A D-24-022
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: WA DOH Contract No: AD-24-022
Contract For: Data sharing: Foodborne Illness Term: 05/16/2024 - 5/15/2029
COUNTY DEPARTMENT: Public Health
Contact Person: Denise Banker
Contact Phone: x 438
Contact email: dbanker@co.jefferson.wa.us
AMOUNT: -0- PROCESS: Exempt from Bid Process
Revenue: Cooperative Purchase
Expenditure: Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s)of Matching Funds Vendor List Bid
Fund# _ RFP or RFQ
Munis Org/Obj Other:
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIES COMCE W .55.080 AND CHAPTER 42.23 RCW.
CERTIFIED: : N/A: ■ May 17,2024
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN DEBARRED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY. /�'
CERTIFIED: N/A: 62 ?), May 17,2024
Signature Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 5/21/2024.
State agreement: cannot change.
STEP 4: PROSECUTING ATTORNEY REVIEW(will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 5/22/2024.
State contract cannot change. PAO will sign via Docusign
STEP 5: DEPARTMENT MAKES. REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL
1
DATA SHARING AGREEMENT
FOR
CONFIDENTIAL INFORMATION OR LIMITED DATASET(S)
BETWEEN
STATE OF WASHINGTON
DEPARTMENT OF HEALTH
AND
LOCAL HEALTH JURISDICTIONS
Jefferson County Public Health
This Agreement documents the conditions under which the Washington State Department of
Health(DOH)shares confidential information or limited Dataset(s)with other entities.This agree-
ment is between Washington Department of Health and all Local Health Jurisdictions.
CONTACT INFORMATION FOR ENTITIES RECEIVING AND PROVIDING INFORMATION
INFORMATION RECIPIENT INFORMATION PROVIDER
Organization Name Jefferson County Public Health Washington State Department of
Health (DOH)
Business Contact Name Alyssa Pilot
Noel Hatley
Laura Newman
Title Public Health Advisor
Epidemiologist 2 (non-medical)
Deputy Director of Communicable Dis-
ease
Address 111 Israel Rd SE, Tumwater, WA
98501
Telephone# 360.764.0893
360.485.5654
360.878.1473
Email Address Alyssa.pilot@doh.wa.gov
Noel.hatley@doh.wa.gov
Laura.Newman@doh.wa.gov
IT Security Contact John Weeks
Title IT Security Manager
Address 111 Israel Rd SE, Tumwater, WA 98501
DOH Contract GVL29655-0 Page 1 of 41
Jefferson: AD-24-022
Telephone# 800.525.0127
Email Address john.weeks@doh.wa.gov
Privacy Contact Name Michael Paul
Title Chief Privacy Officer
Address 111 Israel Rd SE,Tumwater, WA 98501
Telephone# 564.669.9692
Email Address Michael.paul@doh.wa.gov
DEFINITIONS
Aggregate Data is data that has been gathered, processed, and expressed in a summary or report
form for reporting purposes such as making comparisons, predicting trends or other statistical
analyses. Aggregate data is collected from multiple sources and/or measures, variables, or indi-
vidual human subjects. Since aggregate data is the consolidation of data from multiple sources,
it is typically not able to be traced back to a specific human subject.
Anonymous Data is unidentified (i.e., personally identifiable information was not collected, or if
collected, identifiers were not retained and cannot be retrieved) data that cannot be linked di-
rectly or indirectly by anyone to their source(s).
Authorized user means a recipient's employees, agents, assigns, representatives, independent
contractors, or other persons or entities authorized by the data recipient to access, use, or dis-
close information through this agreement.
Authorized user agreement means the confidentiality agreement a recipient requires each of its
Authorized Users to sign prior to gaining access to Public Health Information.
Breach of confidentiality means unauthorized access, use or disclosure of information received
under this agreement. Disclosure may be oral or written, in any form or medium.
Breach of security means an action (either intentional or unintentional) that bypasses security
controls or violates security policies, practices, or procedures.
Coded Data is when direct personal identifiers have been removed from the data and replaced
with words, letters, figures, symbols, or a combination of these (not derived from or related to
the personal information) for purposes of protecting the identity of the source(s). The original
identifiers are retained in such a way that they can be traced back to the source(s) by someone
with the code. A code is sometimes also referred to as a "key," "link," or "map."
DOH Contract GVL29655-0 Page 2 of 41
Confidential information means information that is protected from public disclosure by
law. There are many state and federal laws that make different kinds of information confidential.
In Washington State, the two most common are the Public Records Act RCW 42.56, and the
Healthcare Information Act, RCW 70.02.
Data storage means electronic media with information recorded on it, such as CDs/DVDs, com-
puters, and similar devices.
Data transmission means the process of transferring information across a network from a sender
(or source)to one or more destinations.
De-Identified Data is when all direct personal identifiers are permanently removed from the
data, no code or key exists to link the data to their original source(s), and the remaining infor-
mation cannot reasonably be used by anyone to identify the source(s).
Direct identifier Direct identifiers in research data or records include names; postal address in-
formation (other than town or city,state and zip code);telephone numbers,fax numbers, e-mail
addresses; social security numbers; medical record numbers; health plan beneficiary numbers;
account numbers; certificate/license numbers; vehicle identifiers and serial numbers, including
license plate numbers; device identifiers and serial numbers; web universal resource locators
URLs); Internet protocol (IP) address numbers; biometric identifiers, including finger and voice
prints; and full face photographic images and any comparable images.
Disclosure means to permit access to or release,transfer,or other communication of confidential
information by any means including oral, written, or electronic means, to any party except the
party identified or the party that provided or created the record.
Encryption means the use of algorithms to encode data making it impossible to read without a
specific piece of information, which is commonly referred to as a "key". Depending on the type
of information shared, encryption may be required during data transmissions, and/or data stor-
age.
Health care information means any information, whether oral or recorded in any form or me-
dium,that identifies or can readily be associated with the identity of a patient and directly relates
to the patient's health care...." RCW 70.02.010(7)
Health information is any information that pertains to health behaviors, human exposure to en-
vironmental contaminants, health status, and health care. Health information includes health
care information as defined by RCW 70.02.010 and health related data as defined in RCW
43.70.050.
Health Information Exchange (HIE) means the statewide hub that provides technical services to
support the secure exchange of health information between HIE participants.
DOH Contract GVL29655-0
Page 3 of 41
Human research review is the process used by institutions that conduct human subject research
to ensure that:
• the rights and welfare of human subjects are adequately protected;
• the risks to human subjects are minimized, are not unreasonable,and are outweighed by
the potential benefits to them or by the knowledge gained; and
• the proposed study design and methods are adequate and appropriate in light of the
stated research objectives.
Research that involves human subjects or their identifiable personal records should be reviewed
and approved by an institutional review board (IRB) per requirements in federal and state laws
and regulations and state agency policies.
Human subjects research/human subject means a living individual about whom an investigator
(whether professional or student) conducting research obtains (1) data through intervention or
interaction with the individual, or (2) identifiable private information.
Identifiable data or records contains information that reveals or can likely associate the identity
of the person or persons to whom the data or records pertain. Research data or records with
direct identifiers removed, but which retain indirect identifiers, are still considered identifiable.
Indirect identifiers are indirect identifiers in research data or records that include all geographic
identifiers smaller than a state , including street address, city, county, precinct, Zip code, and
their equivalent postal codes,except for the initial three digits of a ZIP code;all elements of dates
( except year ) for dates directly related to an individual, including birth date, admission date,
discharge date, date of death; and all ages over 89 and all elements of dates ( including year)
indicative of such age, except that such age and elements may be aggregated into a single cate-
gory of age 90 or older.
Limited dataset means a data file that includes potentially identifiable information. A limited
dataset does not contain direct identifiers.
Normal business hours are state business hours Monday through Friday from 8:00 a.m. to 5:00
p.m. except state holidays.
Public Health Authority is an agency or authority of the United States government, a State, a
territory,a political subdivision of a State or territory,or Indian tribe that is responsible for public
health matters as part of its official mandate, as well as a person or entity acting under a grant of
authority from, or under a contract with, a public health agency. See 45 CFR 164.501.
Public Health Surveillance Activities are limited to activities conducted, supported, requested,
ordered, required, or authorized by a "public health authority" and:
• Are necessary to allow a public health authority to identify, monitor, assess,or investigate
potential public health signals,onsets of disease outbreaks, or conditions of public health
DOH Contract GVL29655-0 Page 4 of 41
importance, including trends,signals, risk factors, patterns of diseases, or increases in in-
juries from consumer products.
• Provide timely situational awareness and priority setting during the course of an event or
crisis that threatens public health.
Potentially identifiable information means information that includes indirect identifiers which
may permit linking an individual to that person's health care information. Examples of potentially
identifiable information include:
• birth dates;
• admission,treatment, or diagnosis dates;
• healthcare facility codes;
• other data elements that may identify an individual.These vary depending on factors such
as the geographical location and the rarity of a person's health condition, age, or other
characteristic.
Research refers to a systematic investigation, including research development,testing, and eval-
uation, designed to develop or contribute to generalizable knowledge.
Restricted confidential information means confidential information where especially strict han-
dling requirements are dictated by statutes, rules, regulations, or contractual agreements. Vio-
lations may result in enhanced legal sanctions.
State holidays State legal holidays, as provided in RCW 1.16.050.
GENERAL TERMS AND CONDITIONS
1. USE OF INFORMATION
The Information Recipient agrees to strictly limit use of information obtained or created under
this Agreement to the purposes stated in Exhibit I (and all other Exhibits subsequently attached
to this Agreement). For example, unless the Agreement specifies to the contrary the Information
Recipient agrees not to:
• Link information received under this Agreement with any other information.
• Use information received under this Agreement to identify or contact individuals.
The Information Recipient shall construe this clause to provide the maximum protection of the
information that the law allows.
II. SAFEGUARDING INFORMATION
A. CONFIDENTIALITY
Information Recipient agrees to:
DOH Contract GVL29655-0 Page 5 of 41
• Follow DOH small numbers guidelines as well as dataset specific small numbers re-
quirements unless otherwise stated when publishing, presenting or otherwise
sharing data. (Appendix D)
• Limit access and use of the information:
• To the minimum amount of information.
• To the fewest people.
• For the least amount of time required to do the work.
• Ensure that all people with access to the information understand their responsibil-
ities regarding it.
• Ensure that every person (e.g., employee or agent) with access to the information
signs and dates the "Use and Disclosure of Confidential Information Form" (Appen-
dix A) before accessing the information.
• Retain a copy of the signed and dated form as long as required in Data Dis-
position Section.
The Information Recipient acknowledges the obligations in this section survive completion, can-
cellation, expiration or termination of this Agreement.
B. SECURITY
The Information Recipient assures that its security practices and safeguards meet Wash-
ington State Office of the Chief Information Officer (OCIO) security standard 141.10
curing information Technology Assets.
For the purposes of this Agreement, compliance with the HIPAA Security Standard and all
subsequent updates meets OCIO standard 141.10 "Securing Information Technology As-
sets."
The Information Recipient agrees to adhere to the Data Security Requirements in Appen-
dix B. The Information Recipient further assures that it has taken steps necessary to pre-
vent unauthorized access, use, or modification of the information in any form.
Note: The DOH Chief Information Security Officer must approve any changes to this sec-
tion prior to Agreement execution. IT Security Officer will send approval/denial directly
to DOH Contracts Office and DOH Business Contact.
DOH Contract GVL29655-0 Page 6 of 41
C. BREACH NOTIFICATION
The Information Recipient shall notify the DOH Chief Information Security Officer
rity(&don.wa.go.)within one(1) business days of any suspected or actual breach of secu-
rity or confidentiality of information covered by the Agreement.
III. RE-DISCLOSURE OF INFORMATION
Information Recipient agrees to not disclose in any manner all or part of the information identified
in this Agreement except as the law requires, this Agreement permits, or with specific prior writ-
ten permission by the Secretary of the Department of Health.
If the Information Recipient must comply with state or federal public record disclosure laws, and
receives a records request where all or part of the information subject to this Agreement is re-
sponsive to the request: the Information Recipient will notify the DOH Privacy Officer of the re-
quest ten (10) business days prior to disclosing to the requestor.The notice must:
• Be in writing;
• Include a copy of the request or some other writing that shows the:
• Date the Information Recipient received the request; and
• The DOH records that the Information Recipient believes are responsive to the
request and the identity of the requestor, if known.
IV. ATTRIBUTION REGARDING INFORMATION
Information Recipient agrees to cite "Washington State Department of Health" or other citation
as specified, as the source of the information subject of this Agreement in all text, tables and
references in reports, presentations, and scientific papers.
Information Recipient agrees to cite its organizational name as the source of interpretations,cal-
culations, or manipulations of the information subject of this Agreement.
V. OTHER PROVISIONS
With the exception of agreements with British Columbia for sharing health information, all data
must be stored within the United States.
VI. AGREEMENT ALTERATIONS AND AMENDMENTS
This Agreement may be amended by mutual agreement of the parties. Such amendments shall
not be binding unless they are in writing and signed by personnel authorized to bind each of the
parties
DOH Contract GVL29655-0 Page 7 of 41
VII. CAUSE FOR IMMEDIATE TERMINATION
The Information Recipient acknowledges that unauthorized use or disclosure of the data/infor-
mation or any other violation of sections II or III, and appendices A or B, may result in the imme-
diate termination of this Agreement.
VIII. CONFLICT OF INTEREST
The DOH may, by written notice to the Information Recipient:
Terminate the right of the Information Recipient to proceed under this Agreement if it is found,
after due notice and examination by the Contracting Office that gratuities in the form of enter-
tainment,gifts or otherwise were offered or given by the Information Recipient, or an agency or
representative of the Information Recipient,to any officer or employee of the DOH, with a view
towards securing this Agreement or securing favorable treatment with respect to the awarding
or amending or the making of any determination with respect to this Agreement.
In the event this Agreement is terminated as provided in (a) above, the DOH shall be entitled to
pursue the same remedies against the Information Recipient as it could pursue in the event of a
breach of the Agreement by the Information Recipient. The rights and remedies of the DOH pro-
vided for in this section are in addition to any other rights and remedies provided by law. Any
determination made by the Contracting Office under this clause shall be an issue and may be
reviewed as provided in the "disputes" clause of this Agreement.
IX. DISPUTES
Except as otherwise provided in this Agreement,when a genuine dispute arises between the DOH
and the Information Recipient and it cannot be resolved, either party may submit a request for a
dispute resolution to the Contracts and Procurement Unit. The parties agree that this resolution
process shall precede any action in a judicial and quasi-judicial tribunal. A party's request for a
dispute resolution must:
• Be in writing and state the disputed issues, and
• State the relative positions of the parties, and
• State the information recipient's name, address, and his/her department agree-
ment number, and
• Be mailed to the DOH contracts and procurement unit, P. O. Box 47905, Olympia,
WA 98504-7905 within thirty (30) calendar days after the party could reasonably
be expected to have knowledge of the issue which he/she now disputes.
This dispute resolution process constitutes the sole administrative remedy available under this
Agreement.
DOH Contract GVL29655-0 Page 8 of 41
X. EXPOSURE TO DOH BUSINESS INFORMATION NOT OTHERWISE PROTECTED BY LAW
AND UNRELATED TO CONTRACT WORK
During the course of this contract,the information recipient may inadvertently become aware of
information unrelated to this agreement. Information recipient will treat such information re-
spectfully, recognizing DOH relies on public trust to conduct its work. This information may be
handwritten,typed, electronic, or verbal,and come from a variety of sources.
Xl. GOVERNANCE
This Agreement is entered into pursuant to and under the authority granted by the laws of the
state of Washington and any applicable federal laws. The provisions of this Agreement shall be
construed to conform to those laws.
In the event of an inconsistency in the terms of this Agreement, or between its terms and any
applicable statute or rule,the inconsistency shall be resolved by giving precedence in the follow-
ing order:
• Applicable Washington state and federal statutes and rules;
Any other provisions of the Agreement, including materials incorporated by reference.
XII. HOLD HARMLESS
Each party to this Agreement shall be solely responsible for the acts and omissions of its own
officers, employees, and agents in the performance of this Agreement. Neither party to this
Agreement will be responsible for the acts and omissions of entities or individuals not party to
this Agreement. DOH and the Information Recipient shall cooperate in the defense of tort law-
suits, when possible.
XIII. LIMITATION OF AUTHORITY
Only the Authorized Signatory for DOH shall have the express, implied, or apparent authority to
alter, amend, modify, or waive any clause or condition of this Agreement on behalf of the
DOH. No alteration, modification, or waiver of any clause or condition of this Agreement is ef-
fective or binding unless made in writing and signed by the Authorized Signatory for DOH.
XIV. RIGHT OF INSPECTION
The Information Recipient shall provide the DOH and other authorized entities the right of access
to its facilities at all reasonable times, in order to monitor and evaluate performance,compliance,
and/or quality assurance under this Agreement on behalf of the DOH.
DOH Contract GVL29655-0 Page 9 of 41
XV. SEVERABILITY
If any term or condition of this Agreement is held invalid, such invalidity shall not affect the va-
lidity of the other terms or conditions of this Agreement, provided, however, that the remaining
terms and conditions can still fairly be given effect.
XVI. SURVIVORSHIP
The terms and conditions contained in this Agreement which by their sense and context, are
intended to survive the completion, cancellation, termination, or expiration of the Agreement
shall survive.
XVII. TERMINATION
Either party may terminate this Agreement upon 30 days prior written notification to the other
party. If this Agreement is so terminated, the parties shall be liable only for performance ren-
dered or costs incurred in accordance with the terms of this Agreement prior to the effective
date of termination.
XVIII. WAIVER OF DEFAULT
This Agreement,or any term or condition, may be modified only by a written amendment signed
by the Information Provider and the Information Recipient. Either party may propose an amend-
ment.
Failure or delay on the part of either party to exercise any right, power, privilege, or remedy
provided under this Agreement shall not constitute a waiver.No provision of this Agreement may
be waived by either party except in writing signed by the Information Provider or the Information
Recipient.
XIX. ALL WRITINGS CONTAINED HEREIN
This Agreement and attached Exhibit(s)contains all the terms and conditions agreed upon by the
parties. No other understandings, oral or otherwise, regarding the subject matter of this Agree-
ment and attached Exhibit(s)shall be deemed to exist or to bind any of the parties hereto.
XX. PERIOD OF PERFORMANCE
This Agreement shall be effective from date the agreement is signed by both parties until 5 years
later.
DOH Contract GVL29655-0 Page 10 of 41
Special Terms And Conditions
I. Linking of Data
Data utilized in this Agreement shall be linked only to the records outlined in this Agree-
ment.
IN WITNESS WHEREOF,the parties have executed this Agreement as of the date of last signa-
ture below.
INFORMATION PROVIDER INFORMATION RECIPIENT
State of Washington Department of Health Jefferson County Public Health
�ucsrm �K�u�otnvscon
Signature Signature
Leslie Becker Kate Dean
Print Name Print Name
May 16, 2024 May 15, 2024
Date Date
APPROVED AS TO FORM ONLY:
May 22, 2024
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
DOH Contract GVL29655-0 Page 11 of 41
EXHIBIT I
PURPOSE AND JUSTIFICATION FOR SHARING THE DATA Provide a detailed description of the
purpose and justification for sharing the data, including specifics on how the data will be used.
The Foodborne Illness Notification System (FINS) allows restaurants and members of the public
to report suspected incidents of foodborne disease within the state of Washington. RCW
43.07.020(3) requires the Washington State Department of Health (DOH)to "provide leadership
and coordination in identifying and resolving threats to the public health." DOH provides the
FINS system to coordinate the appropriate authority receiving notification of a potential food-
borne illness or food safety concern so they may respond and mitigate any risk to the public
health in accordance with RCW 70.05.070(3).
In recognition that foodborne illnesses are often the result of supply chain contamination or
linked to a chain of restaurants that span many jurisdictions, DOH is providing state-wide read
access to the FINS system as necessary for the improved detection and prevention of disease.
Access to information outside the Information Recipient's jurisdiction does not convey responsi-
bility for or ownership of such information.
FINS is a "secure electronic disease surveillance system" as defined in WAC 246-101-010(45). In
accordance with WAC 246-101-615(2), DOH will use FINS to notify the investigating jurisdiction
within 1 day of any notifiable condition reported directly to it.To follow up with the complain-
ant, a REDCap account is required to obtain any personal identifiable information.
Collecting data in a centralized location will allow a better understanding of the true burden of
foodborne illness in Washington State and provide a centralized location for the public to report
an illness or food safety concern.
The Information Recipient is authorized under this agreement to use the data for the following
purposes:
A. To use the data for public health surveillance to prevent and control illness,including con-
tacting individuals and firms as part of an investigation process,
B. To forward or share complete details of specific complaints to other regulatory partners
for purposes of public health.
C. To link the data to various sources,
D. To conduct statistical analysis and create visualizations of the same data, and
E. To share and publish aggregate, de-identified data for purposes including population
health analysis, public health surveillance activities, quality improvement, utilization
measures, and to inform interventions.
The Information Recipient agrees not to use the data for the following purposes:
A. Use the data for any commercial purposes, including selling, commercial screening, or
transferring data to a third party for commercial purposes;
B. Transfer the raw data to anyone, except for those authorized above, who is not listed
under the Information Recipient's (on the signature page of this Agreement) direct su-
pervision unless advanced,written approval is given by the Information Provider.
C. Human Subjects Research without WSIRB approval and without a Data Sharing Agree-
ment(DSA).
DOH Contract GVL29655-0 Page 12 of 41
EXHIBIT I
Is the purpose of this agreement for human subjects research that requires Washington State
Institutional Review Board (WSIRB)approval?
Yes No
If yes, has a WSIRB review and approval been received? If yes,please provide copy of approval. If
No, attach exception letter.
Yes No
1. PERIOD OF PERFORMANCE
This Exhibit shall have the same period of performance as the Agreement unless otherwise noted
below:
At a continuous frequency from date the agreement is signed by both parties to 5 years later.
2. DESCRIPTION OF DATA
Information Provider will make available the following information under this Agreement:
Database Name(s): REDCap
Data Elements being provided: Answers to survey questions from the public within the LHJ's
jurisdictional area and statewide from the time the agreement is signed until the date the agree-
ment expires(see elements in Appendix F).
The Information Provider will provide separately a complete data dictionary to the Information
Recipient with information on the following data elements from the REDCap Survey in Appendix
E.
The information described in this section is:
❑ Category 1—Public Information
• Public information is information that can be or currently is released to the public.
It does not need protection from unauthorized disclosure, but does need integrity and
availability protection controls.
❑ Category 2—Sensitive Information
• Sensitive information may not be specifically protected from disclosure by law and
is for official use only. Sensitive information is generally not released to the public
unless specifically requested.
Category 3—Confidential Information
• Confidential information is information that is specifically protected from disclo-
sure by law. It may include but is not limited to: a. Personal Information about
Pa a 13 of 41
DOH Contract GV129655-0 B
EXHIBIT I
individuals, regardless of how that information is obtained; b. Information concerning
employee personnel records; c. Information regarding IT infrastructure and security
of computer and telecommunications systems.
❑ Category 4—Confidential Information Requiring Special Handling
• Confidential information requiring special handling is information that is specifi-
cally protected from disclosure by law and for which:
A. Especially strict handling requirements are dictated, such as by statutes,
regulations, or agreements;
B. Serious consequences could arise from unauthorized disclosure, such as
threats to health and safety, or legal sanctions.
Any reference to data/information in this Agreement shall be the data/information as described
in this Exhibit.
3. STATUTORY AUTHORITY TO SHARE INFORMATION
DOH statutory authority to obtain and disclose the confidential information or limited Dataset(s)
identified in this Exhibit to the Information Recipient:
• RCW 43.07.020(3) requires the Washington State Department of Health (DOH) to "provide
leadership and coordination in identifying and resolving threats to the public health". DOH
provides the FINS system to coordinate the appropriate authority receiving notification of a
potential foodborne illness or food safety concern so they may respond and mitigate any risk
to the public health in accordance with RCW 70.05.070(3). FINS is a"secure electronic disease
surveillance system" as defined in WAC 246-101-010(45). In accordance with WAC 246-101-
615(2), DOH will use FINS to notify the investigating jurisdiction within 1 day of any notifiable
condition reported directly to it.
4. ACCESS TO INFORMATION
METHOD OF ACCESS/TRANSFER
DOH Web Application(indicate application name):Access to REDCap project for complaints
within their specific jurisdiction and statewide.
**NOTE: DOH Chief Information Security Officer must approve prior to Agreement execution.
DOH Chief Information Security Officer will send approval/denial directly to DOH Contracts
Office and DOH Business Contact.
FREQUENCY OF ACCESS/TRANSFER
DOH shall provide access to REDCap at system launch and at a continuous frequency within
the period of performance stated in Section 2.
DOH Contract GVL29655-0 Page 14 of 41
EXHIBIT I
5. REIMBURSEMENT TO DOH
Payment for services to create and provide the information is based on the actual expenses
DOH incurs, including charges for research assistance when applicable.
Billing Procedure
• Information Recipient agrees to pay DOH by check or account transfer within 30 calendar
days of receiving the DOH invoice.
• Upon expiration of the Agreement, any payment not already made shall be submitted
within 30 days after the expiration date or the end of the fiscal year, which is earlier.
Charges for the services to create and provide the information are:
$0 (No charge)
6. DATA DISPOSITION
Unless otherwise directed in writing by the DOH Business Contact, at the end of this Agree-
ment, or at the discretion and direction of DOH,the Information Recipient shall:
In accordance with records retention requirements,retain the data for the purposes stated
herein for a period of time not to exceed 6 years after which Information Recipient shall
destroy the data(as described below) and submit the attached Certification of Data Dispo-
sition (Appendix C) to the DOH Business Contact. Information Recipient shall export the
data and be responsible for following any applicable laws or policies to retain it.
7. RIGHTS IN INFORMATION
Information Recipient agrees to provide, if requested, copies of any research papers or re-
ports prepared as a result of access to DOH information under this Agreement for DOH review
prior to publishing or distributing.
In no event shall the Information Provider be liable for any damages, including,without limi-
tation, damages resulting from lost information or lost profits or revenue,the costs of recov-
ering such Information,the costs of substitute information,claims by third parties or for other
similar costs, or any special, incidental, or consequential damages, arising out of the use of
the information.The accuracy or reliability of the Information is not guaranteed or warranted
in any way and the information Provider's disclaim liability of any kind whatsoever, including,
without limitation, liability for quality, performance, merchantability,and fitness for a partic-
ular purpose arising out of the use, or inability to use the information.
DOH Contract GVL29655-0 Page 15 of 41
EXHIBIT I
8. ALL WRITINGS CONTAINED HEREIN
This Agreement and attached Exhibit(s) contains all the terms and conditions agreed upon by
the parties. No other understandings, oral or otherwise, regarding the subject matter of this
Agreement and attached Exhibit(s) shall be deemed to exist or to bind any of the parties
hereto.
IN WITNESS WHEREOF, the parties have executed this Exhibit as of the date of last signature
below.
INFORMATION PROVIDER INFORMATION RECIPIENT
State of Washington Department of Health Jefferson County Public Health
chi-
Signature Signature
Leslie Becker Kate Dean
Print Name Print Name
May 16, 2024 May 15, 2024
Date Date
DOH Contract GVL29655-0 Page 16 of 41
APPENDIX A
USE AND DISCLOSURE OF CONFIDENTIAL INFORMATION
People with access to confidential information are responsible for understanding and following
the laws, policies, procedures, and practices governing it. Below are key elements:
A. CONFIDENTIAL INFORMATION
Confidential information is information federal and state law protects from public disclosure.
Examples of confidential information are social security numbers,and healthcare information
that is identifiable to a specific person under RCW 70.02. The general public disclosure law
identifying exemptions is RCW 42.56.
B. ACCESS AND USE OF CONFIDENTIAL INFORMATION
1. Access to confidential information must be limited to people whose work specifically
requires that access to the information.
2. Use of confidential information is limited to purposes specified elsewhere in this Agree-
ment.
C. DISCLOSURE OF CONFIDENTIAL INFORMATION
1. An Information Recipient may disclose an individual's confidential information received
or created under this Agreement to that individual or that individual's personal repre-
sentative consistent with law.
2. An Information Recipient may disclose an individual's confidential information, received,
or created under this Agreement only as permitted under the Re-Disclosure of infor-
mation section of the Agreement, and as state and federal laws allow.
D. CONSEQUENCES OF UNAUTHORIZED USE OR DISCLOSURE
An Information Recipient's unauthorized use or disclosure of confidential information is the
basis for the Information Provider immediately terminating the Agreement.The Information
Recipient may also be subject to administrative,civil,and criminal penalties identified in law.
DOH Contract GVL29655-0 Page 17 of 41
APPENDIX B
DATA SECURITY REQUIREMENTS
Protection of Data
The storage of Category 3 and 4 information outside of the State Governmental Network requires
organizations to ensure that encryption is selected and applied using industry standard algo-
rithms validated by the NIST Cryptographic Algorithm Validation Program. Encryption must be
applied in such a way that it renders data unusable to anyone but authorized personnel, and the
confidential process, encryption key or other means to decipher the information is protected
from unauthorized access. All manipulations or transmissions of data within the organization's
network must be done securely.
The Information Recipient agrees to store information received under this Agreement(the data)
within the United States on one or more of the following media, and to protect it as described
below:
A. Passwords
1. Passwords must always be encrypted. When stored outside of the authentication
mechanism, passwords must be in a secured environment that is separate from
the data and protected in the same manner as the data. For example, passwords
stored on mobile devices or portable storage devices must be protected as de-
scribed under section F. Data storage on mobile devices or portable storage me-
dia.
2. Complex Passwords are:
• At least 8 characters in length.
• Contain at least three of the following character classes: uppercase letters,
lowercase letters, numerals, special characters.
• Do not contain the user's name, user ID or any form of their full name.
• Do not consist of a single complete dictionary word but can include a pass-
phrase.
• Do not consist of personal information (e.g., birthdates, pets' names, ad-
dresses, etc.).
• Are unique and not reused across multiple systems and accounts.
• Changed at least every 120 days.
B. Hard Disk Drives/Solid State Drives— Data stored on workstation drives:
1. The data must be encrypted as described under section F. Data storage on mobile
devices or portable storage media. Encryption is not required when Potentially
Identifiable Information is stored temporarily on local workstation Hard Disk
Drives/Solid State Drives. Temporary storage is thirty(30) days or less.
2. Access to the data is restricted to authorized users by requiring logon to the local
workstation using a unique user ID and Complex Password, or other
DOH Contract GVL29655-0 Page 18 of 41
APPENDIX B
DATA SECURITY REQUIREMENTS
authentication mechanisms which provide equal or greater security, such as bio-
metrics or smart cards. Accounts must lock after 5 unsuccessful access attempts
and remain locked for at least 15 minutes, or require administrator reset.
C. Network server and storage area networks(SAN)
1. Access to the data is restricted to authorized users through the use of access con-
trol lists which will grant access only after the authorized user has authenticated
to the network.
2. Authentication must occur using a unique user ID and Complex Password,or other
authentication mechanisms which provide equal or greater security, such as bio-
metrics or smart cards. Accounts must lock after 5 unsuccessful access attempts,
and remain locked for at least 15 minutes, or require administrator reset.
3. The data is located in a secured computer area,which is accessible only by author-
ized personnel with access controlled through use of a key, card key, or compara-
ble mechanism.
4. If the servers or storage area networks are not located in a secured computer area
or if the data is classified as Confidential or Restricted it must be encrypted as
described under F. Data storage on mobile devices or portable storage media.
D. Optical discs(CDs or DVDs)
1. Optical discs containing the data must be encrypted as described under F. Data
storage on mobile devices or portable storage media.
2. When not in use for the purpose of this Agreement, such discs must be locked in
a drawer, cabinet, or other physically secured container to which only authorized
users have the key,combination or mechanism required to access the contents of
the container.
E. Access over the Internet or the State Governmental Network(SGN).
1. When the data is transmitted between DOH and the Information Recipient,access
is controlled by the DOH, who will issue authentication credentials.
2. Information Recipient will notify DOH immediately whenever:
a. An authorized person in possession of such credentials is terminated or other-
wise leaves the employ of the Information Recipient;
b. Whenever a person's duties change such that the person no longer requires
access to perform work for this Contract.
3. The data must not be transferred or accessed over the Internet by the Information
Recipient in any other manner unless specifically authorized within the terms of
the Agreement.
DOH Contract GVL29655-0 Page 19 of 41
APPENDIX B
DATA SECURITY REQUIREMENTS
a. If authorized, the data must be encrypted during transmissions using a key
length of at least 128 bits. Industry standard mechanisms and algorithms,
such as those validated by the National Institute of Standards and Technology
(NIST) are required.
b. Authentication must occur using a unique user ID and Complex Password (of
at least 10 characters). When the data is classified as Confidential or Re-
stricted, authentication requires secure encryption protocols and multi-factor
authentication mechanisms, such as hardware or software tokens, smart
cards, digital certificates, or biometrics.
c. Accounts must lock after 5 unsuccessful access attempts, and remain locked
for at least 15 minutes, or require administrator reset.
F. Data storage on mobile devices or portable storage media
1. Examples of,mobile devices are: smart phones, tablets, laptops, notebook or net-
book computers, and personal media players.
2. Examples of portable storage media are: flash memory devices (e.g. USB flash
drives), and portable hard disks.
3. The data must not be stored by the Information Recipient on mobile devices or
portable storage media unless specifically authorized within the terms of this
Agreement. If so authorized:
a. The devices/media must be encrypted with a key length of at least 128 bits,
using industry standard mechanisms validated by the National Institute of
Standards and Technologies (NIST).
• Encryption keys must be stored in a secured environment that is separate
from the data and protected in the same manner as the data.
b. Access to the devices/media is controlled with a user ID and a Complex Pass-
word (of at least 6 characters), or a stronger authentication method such as
biometrics.
c. The devices/media must be set to automatically wipe or be rendered unusable
after no more than 10 failed access attempts.
d. The devices/media must be locked whenever they are left unattended and set
to lock automatically after an inactivity activity period of 3 minutes or less.
e. The data must not be stored in the Cloud. This includes backups.
f. The devices/media must be physically protected by:
• Storing them in a secured and locked environment when not in use;
• Using check-in/check-out procedures when they are shared; and
• Taking frequent inventories.
4. When passwords and/or encryption keys are stored on mobile devices or portable
storage media they must be encrypted and protected as described in this sec-
tion.
DOH Contract GVL29655-0 Page 20 of 41
APPENDIX B
DATA SECURITY REQUIREMENTS
G. Backup Media
The data may be backed up as part of Information Recipient's normal backup process
provided that the process includes secure storage and transport, and the data is en-
crypted as described under F. Data storage on mobile devices or portable storage me-
dia.
H. Paper documents
Paper records that contain data classified as Confidential or Restricted must be pro-
tected by storing the records in a secure area which is only accessible to authorized
personnel. When not in use, such records are stored in a locked container, such as a
file cabinet, locking drawer, or safe,to which only authorized persons have access.
I. Data Segregation
1. The data must be segregated or otherwise distinguishable from all other data.This
is to ensure that when no longer needed by the Information Recipient,all the data
can be identified for return or destruction. It also aids in determining whether the
data has or may have been compromised in the event of a security breach.
2. When it is not feasible or practical to segregate the data from other data,then all
commingled data is protected as described in this Exhibit.
J. Data Disposition
If data destruction is required by the Agreement, the data must be destroyed using
one or more of the following methods:
Data stored on: Is destroyed by:
Hard Disk Drives/Solid State Drives Using a "wipe" utility which will overwrite the data at least three
(3)times using either random or single character data, or
Degaussing sufficiently to ensure that the data cannot be recon-
structed, or
Physically destroying the disk, or
Delete the data and physically and logically secure data storage
systems that continue to be used for the storage of Confidential or
Restricted information to prevent any future access to stored in-
formation. One or more of the preceding methods is performed
before transfer or surplus of the systems or media containing the
data.
DOH Contract GVL29655-0 Page 21 of 41
APPENDIX B
DATA SECURITY REQUIREMENTS
Paper documents with Confidential or On-site shredding, pulping,or incineration, or
Restricted information Recycling through a contracted firm provided the Contract with
the recycler is certified for the secure destruction of confidential
information.
Optical discs (e.g. CDs or DVDs) Incineration, shredding, or completely defacing the readable sur-
face with a course abrasive.
Magnetic tape Degaussing, incinerating or crosscut shredding.
Removable media (e.g. floppies, USB Using a "wipe" utility which will overwrite the data at least three
flash drives, portable hard disks, Zip, (3)times using either random or single character data.
or similar disks) Physically destroying the disk.
Degaussing magnetic media sufficiently to ensure that the data
cannot be reconstructed.
K. Notification of Compromise or Potential Compromise
The compromise or potential compromise of the data is reported to DOH as required
in Section II.C.
DOH Contract GVL29655-0 Page 22 of 41
APPENDIX C
CERTIFICATION OF DATA DISPOSITION
Date of Disposition
All copies of any Datasets related to agreement DOH# have been deleted from all data
storage systems.These data storage systems continue to be used for the storage of con-
fidential data and are physically and logically secured to prevent any future access to
stored information. Before transfer or surplus,all data will be eradicated from these data
storage systems to effectively prevent any future access to previously stored infor-
mation.
All copies of any Datasets related to agreement DOH# - have been eradicated from all
data storage systems to effectively prevent any future access to the previously stored
information.
All materials and computer media containing any data related to agreement DOH# have
been physically destroyed to prevent any future use of the materials and media.
All paper copies of the information related to agreement DOH # have been destroyed
on-site by cross cut shredding.
All copies of any Datasets related to agreement DOH # that have not been disposed of
in a manner described above, have been returned to DOH.
Other
The data recipient hereby certifies, by signature below, that the data disposition requirements
as provided in agreement DOH # , Section J, Disposition of Information, have been
fulfilled as indicated above.
Signature of data recipient Date
DOH Contract GVL29655-0 Page 23 of 41
APPENDIX D
DOH SMALL NUMBERS GUIDELINES
Aggregate data so that the need for suppression is minimal.Suppress all non-zero
counts which are less than ten.
Suppress rates or proportions derived from those suppressed counts.
Assure that suppressed cells cannot be recalculated through subtraction, by using sec-
ondary suppression as necessary. Survey data from surveys in which 80%or more of
the eligible population is surveyed should be treated as non-survey data.
When a survey includes less than 80%of the eligible population, and the respondents
are unequally weighted, so that cell sample sizes cannot be directly calculated from the
weighted survey estimates,then there is no suppression requirement for the weighted
survey estimates.
When a survey includes less than 80%of the eligible population, but the respondents
are equally weighted,then survey estimates based on fewer than 10 respondents
should be "top-coded" (estimates of less than 5%or greater than 95%should be pre-
sented as 0-5%or 95-100%).
DOH Contract GVL29655-0 Page 24 of 41
APPENDIX E
DATA DICTIONARY
Variable/Field Name Form Name Field Type Field Label
foodborne_com-
record_id plaint text Record ID
foodborne_com-
date_received plaint text Date:
foodborne_com-
reporting plaint radio Please select which best applies to you
foodborne_com-
employee_name plaint text Public Health Worker's Name
foodborne_com-
employee_email plaint text Public Health Worker's Email
foodborne_com-
employee_location plaint dropdown Local Health Jurisdiction/Work Location
foodborne_com-
Ihj_program plaint radio Select the program in which you work
foodborne_com-
program_other plaint text Please specify
foodborne_com-
complaint_received plaint radio How was the complaint received?
foodborne_com-
received_other plaint text Please specify
foodborne_com-
report_type plaint radio What are you reporting?
ABOUT YOU
Please provide your contact information so
staff may follow-up with you about this food-
borne illness report. If reporting for someone
foodborne_com- other than yourself,fill in the information for
section_contact_ill plaint descriptive the sick person.
ABOUT YOU
Please provide us with contact information so
section_con- foodborne_com- we may follow-up with you about your food
tact_not_ill plaint descriptive safety report.
foodborne_com-
anon plaint radio Would you like to remain anonymous?
foodborne_com- Q If you choose not to provide contact infor-
anon_yes_warn plaint descriptive melon,it may slow or stop an investigation.
foodborne_com-
firstname plaint text First Name
foodborne_com-
lastname plaint text Last Name
foodborne_com-
email plaint text Email
foodborne_com-
phone plaint text Phone Number
DOH Contract GVL29655-0 Page 25 of 41
APPENDIX E
DATA DICTIONARY
foodborne_com-
age plaint text +Age in Years
foodborne_com-
gender plaint radio Gender:
foodborne_com-
gender_other plaint text Other Gender:
foodborne_com-
city plaint text City of Residence
foodborne_com-
state plaint dropdown State/Province of Residence
foodborne_com- If you selected 'Other' for the previous ques-
other state plaint text tion, please provide additional detail.
foodborne corn-
zipcode plaint Y text ZIP/Postal Code
foodborne_com- FOOD ESTABLISHMENT INFORMATION
section_fe_info_ill plaint descriptive Let's try to find what made you sick.
FOOD ESTABLISHMENT INFORMATION
sec- foodborne_com- Where did you observe food safety concerns
tion_fe_info_not_ill plaint descriptive or issues?
foodborne_com-
establishment_name plaint text Food Establishment Name
Find the address of the food establishment
you are reporting by clicking the link below.A
new tab will open. Enter the food establish-
ment name and input all address information
foodborne_com- (including zipcode) back into this report form.
maps plaint descriptive hops
establishment_ad- foodborne_com-
dress plaint text Street Address or Cross Street
foodborne_com-
establishment_city plaint text City
foodborne_com-
establishment_zip plaint text Zip Code
foodborne_com-
establishment_Ihj plaint dropdown Food Establishment LHJ
foodborne_com-
establishment_type plaint checkbox What type of food establishment is this?
establish- foodborne_com- If you selected 'Other' for the previous ques-
ment_type_other plaint text tion, please provide additional detail.
Ifoodborne_com-
restaurant_food plaint radio Did you dine in or order takeout?
oodborne_com- If you used a meal delivery service,which ser-
meal_delivery plaint radio vice did you use?
DOH Contract GVL29655-0 Page 26 of 41
111,
APPENDIX E
DATA DICTIONARY
foodborne_com- If you selected 'Other' for the previous ques-
meal_delivery_other plaint text tion, please provide additional detail.
What food items do you suspect caused your
illness?
Please describe foods, beverages, including
garnishes,toppings, and sauces consumed (or
tasted) from the restaurant or event. Please
include any meal substitutions. Consider re-
foodborne_com- viewing online menus and receipts to refresh
food_suspected plaint notes your memory.
When were these food items consumed?
foodborne_com- If the suspected food(s)was consumed at mul-
food_suspected_date plaint text tiple times, please list the earliest date/time.
foodborne_com- When did you observe or witness the food
fs_obs_date plaint text safety concerns you are reporting?
foodborne corn-
time_conversion_2 plaint descriptive Time conversion chart
Please describe any observations or concerns
foodborne_com- with food safety and/or quality at [establish-
Foodsafety_note plaint notes ment_name] (if applicable):
A Please correct food items consumed date,
foodborne_com- the date when you became ill cannot occur be-
error plaint descriptive fore you consumed the food.
ILLNESS DETAILS
foodborne_com- Please give us more information to help un-
section_ill_info plaint descriptive derstand what made you sick.
foodborne_com-
illpersons plaint radio Who are you reporting as ill?
foodborne_com- If you selected 'Other' for the previous ques-
illpersons_other plaint text tion, please provide additional detail.
foodborne_com- Incubation Period of Illness (Hidden on Sur-
incubation_period plaint calc ey)
foodborne_com-
symptom_start_date plaint text When did you start feeling sick?
foodborne_com-
time_conversion plaint descriptive Time conversion chart
foodborne_com- When did symptoms stop? Leave blank if
symptom_stop_date plaint text symptoms are ongoing.
foodborne_com- What symptoms did you or the person who be-
symptom plaint checkbox came ill experience?
foodborne_com- if you selected 'Other' for the previous ques-
symptom_other plaint text tion, please provide additional detail.
DOH Contract GVL29655-0 Page 27 of 41
APPENDIX E
DATA DICTIONARY
foodborne_com- If you or the person who became ill had vom-
max_vomiting plaint text iting, how many times in a 24 hour period?
foodborne_com- If you or the person who became ill had diar-
max_diarrhea plaint text rhea, how many times in a 24 hour period?
If you or the person who became ill had a fe-
foodborne_com- ver,what was the highest temperature meas-
max_fever plaint text ured?
If there are any others you would like to report
foodborne_com- as ill,please list their name(s) and relationship
additional_illpersons plaint notes to you.
Please list any other information you would
foodborne_com- like to share about the illness(es) you are re-
additional_Info plaint notes porting.
MEDICAL INFORMATION
rfoodborne_corn- Please give us more information to help bet-
section_med_info plaint descriptive ter understand what made you sick.
foodborne_com- Did you or the person who became ill see a
provider_seen plaint yesno healthcare provider for this illness?
If you are still ill, please consider seeing a
health care provider.Testing is a crucial part of
foodborne_com- investigating foodborne illness and allows us
hcp_no plaint descriptive to better determine the source of your illness.
foodborne_com-
provider_name plaint notes Healthcare provider/facility name
foodborne_com-
provider_dateseen plaint text Date seen by a provider
foodborne_com- Were any of the following samples collected
provider_sample plaint checkbox and submitted for laboratory testing?
provider_sam- foodborne_com- If you selected 'Other' for the previous ques-
ple_other plaint text tion, please provide additional detail.
foodborne_com- Was a diagnosis given by the provider? If yes,
diagnosis plaint text please list the diagnosis here.
DOH Contract GVL29655-0 Page 28 of 41
APPENDIX E
DATA DICTIONARY
OPTIONAL 3-Day Food History
People often think the last meal they ate
made them sick. Foodborne illness can take
up to 3 days(72 hours)or longer before you
start feeling sick.When thinking about what
might have caused you to become ill, it is
helpful to review the food items you ate over
the last several days.To help us conduct a full
investigation, please complete a recent food
history. Include foods that were prepared or
consumed at home and all foods consumed
outside the home(including restaurants,take
section_op- foodborne_com- out, delivery,community events, parties, pot-
tional_3day plaint descriptive lucks, etc.).
foodborne_com- Would you like to provide a 3 day food his-
opt_3day_yn plaint radio tory?
foodborne_com-
hx_dt_3 plaint text What did you eat on
What did you eat on [hx_dt_3]? Please de-
foodborne_com- scribe (include restaurants, meals at home,
foodhistory3 plaint notes group meals like parties, etc.):
foodborne corn-
hx_dt_2 plaint _ text What did you eat on
What did you eat on [hx_dt_2]? Please de-
foodborne_com- scribe (include restaurants, meals at home,
foodhistory_2 plaint notes group meals like parties,etc.):
foodborne corn-
hx_dt_1 plaint text What did you eat on
What did you eat on [hx_dt_1]? Please de-
foodborne_com- scribe (include restaurants, meals at home,
foodhistory_1 plaint notes group meals like parties,etc.):
foodborne_com-
hx_dt_O plaint text What else did you eat on
What did you eat on [hx_dt_0], the same day
your symptoms started?
NOTE: if you started feeling sick before any
meals on this day, skip this question.
foodborne_com- Please describe (include restaurants, meals at
foodhistory_O plaint notes home,group meals like parties, etc.):
foodborne_com- LH1 of Implicated Establishment (Hidden on
healthdistrict plaint dropdown Survey)
foodborne_com-
section_optional_exp plaint descriptive OTHER POSSIBLE EXPOSURES
DOH Contract GVL29655-0 Page 29 of 41
APPENDIX E
DATA DICTIONARY
foodborne_com- In the 2 weeks before you got sick, did you
travel plaint radio travel outside the state of Washington?
foodborne_com- Which country and/or state did you visit or
travel_location plaint text travel from?
foodborne_com-
travel_return_dt plaint text When did you return to the US or to WA?
In the 2 weeks before you got sick did you go
foodborne_com- swimming in a pool/hot tub or natural body of
swim plaint radio water(e.g. lake, river,sound,ocean,etc.)?
In the 2 weeks before you got sick did you have
any contact with animals (including pets and
foodborne_com- their food,animal feces,farm animals,wild an-
oth_exp_swim_2 plaint radio imals,etc.)?
foodborne_com- How did you hear about FINS (Foodborne III-
fins_advertisement plaint radio ness Notification System)?
foodborne_com- If you selected 'Other' for the previous ques-
advertisement_other plaint text tion, please provide additional detail.
Ihj_responsible Ihj_follow_up dropdown LHJ Responsible for Follow-Up:
reviewer Ihj_follow_up text LHJ Reviewer Name:
follow_up_date Ihj_follow_up text Date of initial follow up:
follow_up_action Ihj_follow_up dropdown Follow up action:
follow_up_other Ihj_follow_up text Please specify:
Is this complaint FBI related? (Hidden on Sur-
fbi_related Ihj_follow_up calc vey)
Was/is this report associated with an out-
outbreak Ihj_follow_up yesno break?* (Hidden on Survey)
If yes,enter the WA DOH outbreak ID number.
outbreak_id Ihj_follow_up text (Hidden on Survey)
follow_up_details Ihj_follow_up notes Additional follow up details:
Ihj_followup Ihj_follow_up notes LHJ Follow Up Details:
DOH Contract GVL29655-0 Page 30 of 41
APPENDIX F
DATA ELEMENTS-REDCAP SURVEY
Page 2
Food Safety and Foodborne Illness Complaint Form
Use this form to report a food borne illness or food safety concern related to a food establishment(restaurant.food
truck,grocery store,market,food bank,catered event)located in Washington State.
Some people may have more serious medical problems if exposed to contaminated food.If the sick person is
experiencing severe symptoms.contact a healthcare provider,especially if the sick person is pregnant elderly,
immunocornpromised,or an infant Severe symptoms include bloody diarrhea,numbness or tingling around the
mouth,visual changes,difficulty breathing,severe nausea and vomiting.or a fever above 102° F.
All fields with an asterisk(*)are required. Please provide as much detail as possible.One form should be completed
for each person who is sick.
When completed.this report will be sent to the appropriate Local Health Department.Only authorized Public Health
Staff may access the submitted information.
Privacy Note:Providing your contact information is essential for Public Health Staff to effectively respond to your
report We will not voluntarily share any information with restaurants or third parties. If we receive a Freedom of
Information Act request,we will redact your personally identifying information before responding. If we are required
to produce records pursuant to a court order or subpoena,you will receive notice.WA State Administrative Code
RCW 42.56
Date:
Please select which best applies to you
o I am a member of the public reporting illness ora food safety concern
I am a Washington Department of Health(WA DOH)or Local Health Jurisdiction(LHJ)employee entering an
illness report or food safety concern for a member of the public
Public Health Worker's Name
(DOH/LHJ employees only)
Public Health Worker's Email
(DOH/LHJ employees only)
03.r19f20242:00pm prajectredcap-orb AEDCaA
vvn\,Utttt act V V LL7UJ,)U rage Ji UI 41
APPENDIX F
DATA ELEMENTS—REDCAP SURVEY
Page 2
Local Health Jurisdiction/Work Location 0 Adams County Integrated Health Care Services
Q Asotln County Public Health
Q Benton•Franklin Health District
Q Chelan-Douglas Health District
Q Clallam County Health and Human Services
Q Clark County Public Health
Q Columbia County Public Health
Q Cowlitz County Health and Human Services
Q Garfield County Health District
Q Grant County Health District
Q Grays Harbor Public Health and Social Services
Q Island County Public Health
Q Jefferson County Public Health
Q Kitsap Public Health District
Q Kittitas County Public Health
Q Klickitat County Public Health
Q Lewis County Public Health and Social Services
Q Lincoln County Health Department
Q Mason County Public Health
Q Northeast Tri County Health District
Q Okanogan County Public Health
Q Pacific County Health and Human Services
Q San Juan County Health and Community Services
Q Seattle and King County Public Health
Q Skagit County Public Health
Q Skamania County Community Health
Q Snohomish County Health Department
Q Spokane Regional Health District
Q Tacoma•Pierce County Health Department
Q Thurston County Public Health and Social Services
Q Wahkiakurn County Public Health and Human Servile
Q Walla Walla County Community Health
Q Whatcom County Health Department
Q Whitman County Public Health
Q Yakima Health District
Q Other State
Q Other LHJ
Q WA DOH
(DOH/LHJ employees only)
Select the program in which you work 0 Environmental Health
Q Epidemiology/Communicable Disease
Q Other
(0OH/IJIJ employees only)
How was the complaint received? 0 Phone call
Q Email
Q In person
Q Other
(DOH/LHJ employees only)
What are you reporting? 0 An illness related to food or a food establishment
O A food safety complaint that did not cause illness
ABOUT YOU
Please provide your contact information so staff may follow•up with you about this foodbome illness report.If
reporting for someone other than yourself,fill in the Information for the sick person.
ABOUT YOU
Please provide us with contact information so we may follow•up with you about your food safety report
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APPENDIX F
DATA ELEMENTS-REDCAP SURVEY
Page 3
Would you like to remain anonymous? 0 Yes
Q No
d If you choose not to provide contact information,tt may slow or stop an investigation.
First Name
Last Name
Email
Phone Number
Age in Years
Gender 0 Male
Q Female
0 Other
City of Residence
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APPENDIX F
DATA ELEMENTS—REDCAP SURVEY
Page 6
State/Province of Residence 0 Alabama 0 Alaska
O Arizona 0 Arkansas
O California 0 Colorado
O Connecticut Q Delaware
O District of Columbia(D.C.)
O Florida 0 Georgia
Q Hawaii Q Idaho Q Illinois
Q Indiana Q Iowa Q Kansas
Q Kentucky 0 Louisiana
O Maine 0 Maryland
Q Massachusetts 0 Michigan
O Minnesota Q Mississippi
O Missouri 0 Montana
Q Nebraska 0 Nevada
Q New Hampshire 0 NewJersey
O New Mexico 0 New York
O North Carolina 0 North Dakota
O Ohio 0 Oklahoma
Q Oregon Q Pennsylvania
Q Rhode Island 0 South Carolina
Q South Dakota Q Tennessee
O Texas 0 Utah 0 Vermont
Q Virginia 0 Washington
O West Virginia Q Wisconsin
Q Wyoming 0 Other
If you selected'Other for the previous question.
please provide additional detail.
ZIP/Postal Code
(Please list 5 digit zip code only)
FOOD ESTABLISHMENT INFORMATION
Let's try to find what made you sick,
FOOD ESTABLISHMENT INFORMATION
Where did you observe food safety concerns or Issues?
Food Establishment Name
(if related to a group event,like a wedding,list
the caterer or name of the event)
Find the address of the food establishment you are reporting by clicking the link below.A new tab will open. Enter
the food establishment name and input all address information(including zipcode)back Into this report form.
https://www,google.comlma ps
Street Address or Cross Street
City
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uuh contract c vLLuo ,-u rage Jv or 41
APPENDIX F
DATA ELEMENTS—REDCAP SURVEY
Page S
Zip Code
Food Establishment LHJ 0 Adams County Integrated Health Care Services
O Asotin County Public Health
O Benton•Franklin Health District
Q Chelan-Douglas Health District
Q Ciallam County Health and Human Services
O Clark County Public Health
O Columbia County Public Health
O Cowlitz County Health and Human Services
O Garfield County Health District
O Grant County Health District
O Grays Harbor Public Health and Social Services
O Island County Public Health
Q Jefferson County Public Health
Q Kitsap Public Health District
�]Kittitas County Public Health
O Klickitat County Public Health
O Lewis County Public Health and Social Services
O Lincoln County Health Department
Q Mason County Public Health
Q Northeast Tri County Health District
Q Okanogan County Public Health
Q Pacific County Health and Human Services
Q San Juan County Health and Community Services
O Seattle and King County Public Health
O Skagit County Public Health
Q Skamania County Community Health
O Snohomish County Health Department
O Spokane Regional Health District
O Tacoma•Pierce County Health Department
O Thurston County Public Health and Social Services
O Wahkiakum County Public Health and Human Service
O Walla Walla County Community Health
Q Whatcom County Health Department
O Whitman County Public Health
Q Yakima Health District
Q WA DOH
What type of food establishment is this? ❑Restaurant
❑Mobile Food Unit lie.Food Truck)
❑Convenience Store
❑Grocery Store
❑Caterer
❑Temporary Food Establishment(TFE)(i.e,vendor at
a fair or festival)
❑Other
(Please select all that apply.)
Did you dine in or order takeout? O Dine in
0 Take out
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APPENDIX F
DATA ELEMENTS—REDCAP SURVEY
Page 6
If you used a meal delivery service,which service did O DoorDash
you use? 0 Uber Eats
Q Grubhub
Q Postmates
Q Blue Apron
Q Hello Fresh
Q Home Chef
o Did not use
Q other
What food items do you suspect caused your illness?
Please describe foods,beverages,including garnishes,
toppings,and sauces consumed(or tasted)from the (This could include meals eaten at home,
restaurant or event Please include any meal restaurants,festivals,catered events,
substitutions. community-based events,etc_.)
Consider reviewing online menus and receipts to
refresh your memory.
When were these food items consumed?
if the suspected food(s)was consumed at multiple (Time based on 24-hour clock.Add 12 if time Is
times,please list the earliest dateitime. after noon.For example:1:00 p.m.is 13:00.)
When did you observe or witness the food safety
concerns you are reporting?
(Time based on 24•hour clock.Add 12 if time is
after noon.For example:1:00 p.m.is 13:00.)
Time conversion chart
AM/Morning PM/Afternoon/Evening
He_P,u1.3r Time 112 ',me hour) kegul,_,r 1 2u-11our)
12:00 AM(midnight) 00:00(or 24:00) 12:00 PM(noon) 12:00
1:00 AM 01:00 1:00 PM 13:00
2:00 AM 02:00 2:00 PM 14:00
3:00 AM 03:00 3:00 PM 15:00
4:00 AM 04:00 4:00 PM 10:00
5;00 AM 05:00 5:00 PM 17:00
6:00 AM 06:00 6:00 PM 18:00
7:00 AM 07:00 7:00 PM 19:00
8:00 AM 08:00 8:00 PM 20:00
9:00 AM 09:00 9:00 PM 21:00
10:00 AM 10:00 10:00 PM 22:00
11:00 AM 11:00 11:00 PM 23:00
12:00 PM(noon) 12;00 12:00 AM(midnight) 24:00(or 00:00)
Please describe any observations or concerns with food
safety andtor quality at f establIshment name)(if
applicable):
(Example:1 saw a food worker make a sandwich using
their bare hands.)
DOH Contract GVL29655-0 Page 36 of 41
•
APPENDIX F
DATA ELEMENTS—REDCAP SURVEY
Page 7
&Please correct food items consumed date,date when you became ill cannot occur before you consumed the food.
ILLNESS DETAILS
Please give us more information to help understand what made you sick.
Who are you reporting as ill? 0 Myself
Q My Spouse)Partner
Q My Child
Q A Relative
Q A Friend
Q Other
(*Only one FINS report per person who is ill)
Incubation Period of Illness(Hidden on Survey)
When did you start feeling sick?
(Time based on 24.hour clock.Add 12 if time is
after noon.For example:1:00 p.m.is 13:00.)
Time conversion chart
AM/Morning PM/Afternoon/Evening
itee*ul,mT rr,.;1^_-hncn tUhtr;ry'1n :.h.rury vuir;r fir •?1 h,,,,ri l it;r;✓ Imc_ i 1_,r1
12:00 AM(midnight) 00:00(or 24:00) 12:00 PM(noon) 12:00
1:00 AM 01:00 1:00 PM 13:00
2:00 AM 02:00 2:00 PM 14:00
3:00 AM 03:00 3:00 PM 1 5:00
4:00 AM 04:00 4:00 PM 16:00
5:00 AM 05:00 5:00 PM 17:00
6:00 AM 06:00 6:00 PM 18:00
7:00 AM 07:00 7:00 PM 19:00
8:00 AM 08:00 8:00 PM 20:00
9:00 AM 09:00 9:00 PM 21:00
10:00 AM 10:00 10:00 PM 22:00
11:00 AM 11:00 11:00 PM 23:00
12:00 PM(noon) 12:00 12:00 AM(midnight) 24:00(or 00:00)
When did symptoms stop?Leave blank if symptoms are
ongoing. ?Time based on 24•hour clock.Add 12 if time is
after noon.For example:1:00 p.m.is 13:00.)
03f19I20241:::[m praiet ap-oR1 f2EDCap, of 41
APPENDIX F
DATA ELEMENTS-REDCAP SURVEY
Pape 8
What symptoms did you or the person who became ill ❑Nausea
experience? ❑Vomiting
❑Diarrhea
❑Bloody Diarrhea
❑Abdominal Cramps
❑fever
❑Body Aches
❑Chills
❑Fatigue
❑Headache
❑Skin Rash
❑Numbness/Tingling around the mouth
❑Other
(Please select Tthat apply.)
If you or the person who became ill had vomiting,how
many times in a 24 hour period?
If you or the person who became ill had diarrhea,how
many times in a 24 hour period? _r
If you or the person who became ill had a fever,what
was the highest temperature measured?
If there are any others you would like to report as
ill,please list their names)and relationship to
you. _
Please list any other information you would like to
share about the illness(es)you are reporting_
MEDICAL INFORMATION
Please give us more information to help better understand what made you sick.
Did you or the person who became ill see a healthcare Q Yes 0 No
provider for this illness?
If you are still ill.please consider seeing a health care provider.Testing Is a crucial part of investigating foodbome
Illness and allows us to better determine the source of your illness.
Healthcareprovider,rfacility name
Date seen by a provider
Were any of the following samples collected and ❑Stool
submitted for laboratory testing? ❑Vomit
❑Other
(Please seleci a1that apply.)
Was a diagnosis given by the provider?If yes.please
list the diagnosis here.
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DOH Contract GVL29655-0 Page 38 of 41
APPENDIX F
DATA ELEMENTS-REDCAP SURVEY
Page 9
OPTIONAL 3-Day Food History People often think the last meal they ate made them sick.Faodborne illness can take
up to 3 days(72 hours)or longer before you start feeling sick.When thinking about what might have caused you CO
become ill,it is helpful to review the food items you ate over the last several days.To help us conduct a full
investigation,please complete a recent food history.Include foods that were prepared or consumed at home and all
foods consumed outside the home(including restaurants,take out,delivery,community events.parties,potlucks.
etc.).
Would you like to provide a 3 day food history? 0 Yes 0 No
What did you eat on
What did you eat on[hx dt 31?
Please describe(include restaurants,meals at home, -
group meals like parties,etc.)-
What did you eat on
What did you eat on[hx dt 21?
Please describe(include restaurants,meals at home,
group meals like parties,etc.):
What did you eat on
What did you eat on[hx dt 11?
Please describe(include restaurants,meals at home.
group meals like parties.etc.):
What else did you eat on
What did you eat on[hx dt 01.the same day your
symptoms started?
NOTE:if you started feeling sick before any meals on
this day.skip this question.
Please describe(include restaurants,meals at home,
group meals like parties,etc.):
03119,20242-00pm nnrs EDCap
DOH Contract GVL29655-0 Page 39 of 41
APPENDIX F
DATA ELEMENTS-REDCAP SURVEY
Page IO
LHJ of Implicated Establishment(Hidden on Survey) 0 Adams County Integrated Health Care
Sers ces Q Asotin County Pubic Health
Q Benton•Frank.in Health Dlstr.ct
Q Chelan-Douglas Health District
O Clallam County Health and Human Services
Q Clark County Public Health
Q Columbia County Public Health
O Cowlitz County Health and Human Services
Q Garfield County Health District
Q Grant County Health District
Q Grays Harbor Public Health and Social
Services 0 Island County Public Health
Q Jefferson County Public Health
Q Krtsap Public Health District
Q IGttltas County Public Health
Q Klickitat County Public Health
Q Lewis County Public Health and Social
Sery ces Q Lincoln County heaitn
Department Q Mason County Pubic Health
Q!Jertneast Tri County Health District
U Okanogan County Public Health
Q Paclfc County Health and human Services
Q San Juan County Health and Comrrunty
Sery ces 0 Seatle and King County Pub'c
Health 0 Skagit County Pubic Heath
Skamania County Commun.,ty Healtn
Q Snohomish County heath Department
Q Spokane Regional heath Dstr:ct
Q Tacoma•Pierce County heath Department
Q Thurston County Pufric Health and Socal
Services Q Wankiakum County Public Heath
and Human Services Q Wal a Wa.la County
Common,ty Hcatn 0 Wnatcom County
Health Department 0 Whitman County
Pubic Heath 0 Yakima Hearth Distrct
0 Other State Q Other LHJ
QWADOH
OTHER POSSIBLE EXPOSURES
In the 2 weeks before you got sick,did you travel 0 Yes 0 No
outside the state of Washington?
Which country and/or state did you visit or travel
from?
When did you return to the US or to WA?
(MMIfib1n U)
In the 2 weeks before you got sick did you go swimming Q Yes Q No
in a pool/hot tub or natural body of water(e.g,lake,
river,sound,ocean,etc.)?
In the 2 weeks before you got sick did you have any 0 Yes 0 No
contact with animals(Including pets and their food,
animal feces,farm animals,wild animals.etc.)?
axle202a 2-00prn proJectreticaRorg IltEDCap`
DOH Contract GVL29655-0 Page 40 of 41
APPENDIX F
DATA ELEMENTS-REDCAP SURVEY
Page 11
How did you hear about FINS(Foodbome Iifness 0 vw::sh,i igtoi ucpa Tat en:of I leai:? {WA DOH}website
Notification System)? 0 r INS riagnetist cker:Ac vert.sement
0 Social media
0 Web-based search(Le.Google)
0 Other _..
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DOH Contract GVL29655-0 Page 41 of 41