Optional General Maritime Contact Investigation Outcome Reporting Form

Optional General 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 (Continue) If contact is a woman of child-bearing age, is she pregnant?  No  Yes; what trimester at the time of travel?  1st  2nd  3rd Is the contact immunocompromised?  No  Yes, specify: ______________________  Unknown Relationship to index case:  Workmate  Cabinmate Tablemate  Shared bathroom facilities  Other, specify_________________________ Date of last exposure to index case: __/__/____ Duration of contact with index case _____  Minutes  Hours  Days Did this person know of anyone else from the conveyance who may have developed this disease as a result of this exposure? No Yes; Who? ________________________________ Unknown Did contact receive a notification letter from the ship?  No  Yes
4. History of THIS disease or vaccine
History of disease:  No  Yes; Approximate date ___/___/____or age (yrs) ___ when had [this disease], Was the diagnosis confirmed by a health care provider? No  Yes  Unknown History of vaccination:  No  Yes; Number of doses of (disease auto-populated)-containing vaccine _____, Unknown Is there written documentation of vaccination? No  Yes Approximate dates or age received: 1. ___/___/___ or age ____; 2. ___/___/___ or age ____; 3. ___/___/___ or age ____; 4. ___/___/___ or age ____; 5. ___/___/___ or age ____    Unknown Serologic proof of immunity? No Yes; Is there written documentation? No Yes Is the contact considered susceptible? No Yes
5. intervention related to exposure on the conveyance
Did contact receive prophylaxis for this exposure?  No  Yes If no, please check why not:  Outside window for prophylaxis  Within window for prophylaxis but declined  Other (specify): _____________ If yes, please check what the contact received and the date (mm/dd/yy) :  Antimicrobial drug, Date received: ___/___/____  Vaccination for this disease; Date received: ___/___/____  Immunoglobulin; Date received: ___/___/____ Was contact quarantined alone?  No  Yes; /cohorted with others?  No  Yes  Yes, how many days? ____  No
6. health since travel: first interview done less than ONE incubation period since travel
NOTE: If your first interview was after the incubation period (># days since travel, please skip to section 7 Interview Date: ___/___/_____ Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Fever ; Date of onset:­­­___/___/____ , Maximum measured temperature ______oC/F  Feverishness (no temperature measured): __/__/____  Cough; Date of onset:­­­___/___/____  Rash; Date of onset:­­­___/___/____  Coryza; Date of onset:­­­___/___/____  Conjunctivitis; Date of onset:­­­___/___/____  Sore throat; Date of onset:­­­___/___/____  Swollen glands; Date of onset:­­­___/___/____  Vomiting; Date of onset:­­­___/___/____  Diarrhea; Date of onset:­­­___/___/____  Jaundice; Date of onset:­­­___/___/____  Headache; Date of onset:­­­___/___/____  Neck stiffness; Date of onset:­­­___/___/____  Unusual bleeding; Date of onset:­­­ ___/___/____  Decreased consciousness; Date of onset:­­­___/___/____  Difficulty breathing/shortness of breath; Date of onset:­­­____/___/____  Recent onset of focal weakness and/or paralysis; Date of onset:­­­___/___/____
7. health since travel: interview done at LEAST one incubation period since travel
Interview Date: ___/___/_____  N/A (did not follow-up with passenger after first interview) Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Fever ; Date of onset:­­­___/___/____ , Maximum measured temperature ______oC/F  Feverishness (no temperature measured): __/__/____  Cough; Date of onset:­­­___/___/____  Rash; Date of onset:­­­___/___/____  Coryza; Date of onset:­­­___/___/____  Conjunctivitis; Date of onset:­­­___/___/____  Sore throat; Date of onset:­­­___/___/____  Swollen glands; Date of onset:­­­___/___/____  Vomiting; Date of onset:­­­___/___/____  Diarrhea; Date of onset:­­­___/___/____  Jaundice; Date of onset:­­­___/___/____  Headache; Date of onset:­­­___/___/____  Neck stiffness; Date of onset:­­­___/___/____  Unusual bleeding; Date of onset:­­­ ___/___/____  Decreased consciousness; Date of onset:­­­___/___/____  Difficulty breathing/shortness of breath; Date of onset:­­­____/___/____  Recent onset of focal weakness and/or paralysis; Date of onset:­­­___/___/____
8. DIAGNOSIS
If contact reported symptoms, was s/he evaluated by a health care provider?  No  Yes; Date(s): ___/___/____;___/___/___ If yes, was the contact diagnosed with [this disease]?  No  Yes; Date:­­­ ___/___/____  Insufficient Information How was diagnosis made?  IgM  Paired IgG  PCR  Culture  Epi-linked  Clinical diagnosis only  Other (specify):___________ Did the infection develop within the incubation period?  No  Yes Has anyone else developed [this disease] as a result of exposure to this person?  No  Yes; Who?__________ 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 [this disease] other than the person on the conveyance?  No  Yes; with whom? _______________ Date of last exposure (mm/dd): ____/____  Unknown Has contact visited other countries during the past month?  No  Unknown  Yes If yes, list the country with the corresponding dates (mm/dd): ________________ From: ____/____ to _____/_____ ________________ From: ____/____ to _____/_____ ________________ From: ____/____ to _____/_____
9. 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