Optional TB Maritime Contact Investigation Outcome Reporting Form

Optional TB Maritime Contact Investigation Outcome Reporting Form

1. PASSENGER Contact Information
Last name, First name	Cabin #	Sex	DOB (mm/dd/yy) OR	Age (yrs)	Country of birth	Country of residence
(Auto-populated)
Was contact a passenger or crew member?  Passenger Crew member, specify occupation______________________________
2. Contact investigation outcome for above-named contact
Is contact still on this ship?  Yes, date due to disembark: __/__/____  No, why not? Returned to country of residence  Transferred to another ship of the same company  Disembarked in another country (specify): ­­­____________, Location (specify address): ______________________ Other; _________________________________________ Additional comments:
3. INTERVIEW INFORMATION
Was contact interviewed?  No, why not? Declined Other (specify) ________ (Stop here)  Yes, date: __/__/___ (Continue) Has contact ever had a previous TST?       If yes, has the result ever been positive?         Yes, Date: ___/___/_____    Result: _____ mm induration or    Unknown        No, Date of most recent negative result: ___/___/_____     Result:_____ mm induration or    Unknown    Unknown  Has contact ever had a previous IGRA?        Yes, has the result ever been positive?   No    Yes, Date: ___/___/____          No, date of most recent negative or indeterminate result: ___/___/____  Unknown Does contact have a history of previous treatment for LTBI or active TB?  No  Yes Has contact ever received BCG vaccine?  No Yes; Approximately what age (yrs)______  Unknown Was this passenger a close contact of the index case other than on the conveyance?  No  Yes, type:  Household  Travel companion  Social  Work  Other _____________________ Is this passenger a close contact with a known case of TB other than the person on the conveyance?  No  Yes; With whom? _______________ Date of last exposure): __/__/__  Unknown Date of last exposure with index case: __/__/____ Did the contact experience any of the following symptoms? No Yes Unknown If yes, check the appropriate symptoms:  Fever; Onset Date: __/__/____ If measured, maximum temperature ______oC/F Persistent cough; Onset Date: __/__/____ With blood Without blood Night sweats, Onset Date: __/__/____ Unexplained weight loss; Onset Date: __/__/____ Severe fatigue; Onset Date: __/__/____ Does the contact have a medical risk factor for TB progression? No Yes, specify: ____________________________________ Unknown
3. TB SCREENING
Was contact screened for TB infection?  Yes (Continue to next question)  No, why not?  Previous positive TST or IGRA, such as the QuantiFERON or T-Spot  History of previous treatment for LTBI or active TB  Declined  Failed appointment  Other (specify): _____________________________ (Stop here)
4. RESULTS OF TB SCREENING AND EVALUATION (Please complete all that apply)
Date of 1st TST placement: __/__/__ Date 1st TST read: __/__/__  Results: Positive   Negative, ____ mm induration Date of 1st IGRA: __/__/__ Results: Positive   Negative   Indeterminate
Date of 2nd TST placement: __/__/__ Date 2nd TST read: __/__/__  Results: Positive   Negative, ____ mm induration Date of 2nd IGRA: __/__/__ Results: Positive   Negative   Indeterminate
Was a chest X-ray done?:  No  Yes Date: __/__/__ Results:  Normal  Abnormal, noncavitary  Abnormal, cavitary
Diagnosis:  No infection  LTBI  TB disease suspected  TB disease confirmed* *If TB disease was confirmed, was the genotype result the same as the index case?  Yes  No
Was treatment prescribed?  N/A  No Yes, for LTBI Yes, for TB disease
Risk factors for prior TB infection (Please complete regardless of TST/IGRA results and check all that apply below):  No known risk factors other than conveyance  Born in a country with high TB prevalence (>20/100,000) (specify country)________________________  Ever lived in a country with high TB prevalence (>20/100,000) Country _____________ Duration: _____  Months  Years Purpose (check all that apply):  Work  Student  Volunteer  Missionary  Other (specify):______ 2. Country _____________ Duration: _____  Months  Years Purpose (check all that apply):  Work  Student  Volunteer  Missionary  Other (specify):______ 3. Country _____________ Duration: _____  Months  Years Purpose (check all that apply):  Work  Student  Volunteer  Missionary  Other (specify):______
5. Comments [free text field]

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

Version: 10/29/10 draft