Optional Measles, Mumps or Rubella Air/Land Contact Investigation Outcome Reporting Form

Optional Measles, Mumps, or Rubella Air/Land Contact Investigation Outcome Reporting Form

1. Passenger Contact Information
Last name, First name	Assigned seat	Actual/verified seat #	Sex				DOB (mm/dd/yyyy) OR	Age (yrs)	Country of birth	Country of residence
(Auto-populated)	(Auto-pop)									(Auto-pop, if available)
2. Contact investigation outcome for above named PASSENGER contact
Were you able to contact this passenger?  Yes  No
If yes, date passenger was contacted: ___/___/____ How did you reach the passenger? (please check all that apply)  Telephone  Sent letter or visited in person  E-mail  Emergency Contact  Other (please specify): _________________ (Continue)				If no, why could you not contact the passenger? (please check all that apply)  Incorrect locating info  No longer at temporary address  No response  Returned to country of residence  Other (please specify): _____________________________ (Stop here)
Additional Comments:
3. INTERVIEW INFORMATION
Was contact interviewed?  No, why not?  Declined  Lives in different jurisdiction (specify) _______  Other (specify) ________ (Stop here)  Yes (Continue) If contact is a woman of child-bearing age, is she pregnant?  No  Yes; what trimester at time of the flight?  1st  2nd  3rd
4. History OF disease or VACCINE
History of disease:  No  Yes; Approximate date ___/___/____or age (yrs) ___ when had [this disease]  Unknown History of vaccination:  No  Yes; Number of doses of (disease auto-populated)-containing vaccine ____;  Unknown Approximate dates received: 1. ___/___/___ or age (yrs) received ____; 2. ___/___/___ or age (yrs) received ____;  Unknown
5. measleS/RUBELLA: intervention related to exposure on the flight
Did contact receive prophylaxis for this exposure to (disease auto-populated)?  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 she or he received and the date :  MMR or other (disease auto-populated)-containing vaccine; Date received: ___/___/____  Immunoglobulin; Date received:___/___/____
6. MEASLES: health since flight
6a. first interview done < 21 days after flight NOTE: If your first interview was after the incubation period (>21 days since the flight), please go to 6b Interview Date: ___/___/_____ Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Rash: Date of onset:­­­___/___/____  Fever : Date of onset:­­­___/___/____ , Max measured temperature ______oC/F  Feverishness (no temp measured): Date of onset:__/__/____  Cough: Date of onset:­­­___/___/____  Coryza: Date of onset:­­­___/___/____  Conjunctivitis: Date of onset:­­­___/___/____						6b. interview done > 21 days after flight Interview Date: ___/___/_____  N/A (did not follow-up with contact after first interview) Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Rash: Date of onset:­­­___/___/____  Fever ; Date of onset:­­­___/___/____ , Max measured temperature ______oC/F  Feverishness (no temp measured): __/__/____ Cough: Date of onset:­­­___/___/____ Coryza: Date of onset:­­­___/___/____  Conjunctivitis: Date of onset:­­­___/___/____
6. MUMPS: health since flight
6a. first interview done < 25 days after flight NOTE: If your first interview was after the incubation period (>25 days since the flight), please skip to section 6b Interview Date: ___/___/_____ Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Fever ; Date of onset:­­­___/___/____ , Max measured temperature ______oC/F  Feverishness (no temp measured): Date of onset:__/__/____  Parotitis: Date of onset: ­­­___/___/____  Upper respiratory symptoms: Date of onset:­­­___/___/____ Please describe symptoms_________________________  Other: Date of onset __/__/____ Please describe: __________________________________					6b. interview done > 25 days after flight Interview Date: ___/___/_____  N/A (did not follow-up with contact after first interview) Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Fever ; Date of onset:­­­___/___/____ , Max measured temperature ______oC/F  Feverishness (no temp measured): Date of onset:__/__/____  Parotitis: Date of onset:­­­___/___/____  Upper respiratory symptoms: Date of onset:­­­___/___/____ Please describe symptoms_________________________  Other: Date of onset __/__/____ Please describe: _________________________________
6. RUBELLA: health since flight
6a. first interview done < 23 days after FLIGHT NOTE: If your first interview was after the incubation period (>23 days since the flight), please skip to section 6b Interview Date: ___/___/_____ Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply:  Fever ; Date of onset:­­­___/___/____ , Max measured temperature ______oC/F  Feverishness (no temp measured): __/__/____  Rash: Date of onset:­­­___/___/___  Coryza: Date of onset:­­­___/___/____  Conjunctivitis: Date of onset:­­­___/___/___  Arthralgia/arthritis: Date of onset: ___/___/___  Lymphadenopathy: Date of onset:­­­___/___/___					6b. interview done > 23 days after FLIGHT Interview Date: ___/___/_____  N/A (did not follow-up with contact after first interview) Did contact report any signs or symptoms?  No (Stop here)  Yes; please check all that apply::  Fever ; Date of onset:­­­___/___/____ , Max measured temperature ______oC/F  Feverishness (no temp measured): __/__/____  Rash: Date of onset:­­­___/___/___  Coryza: Date of onset:­­­___/___/____  Conjunctivitis: Date of onset:­­­___/___/___  Arthralgia/arthritis: Date of onset: ___/___/___  Lymphadenopathy: Date of onset:­­­___/___/___
7. DIAGNOSIS (applicable for measles, mumps, AND rubella)
If contact reported symptoms, was s/he evaluated by a health care provider?  No  Yes; Date(s): ___/___/____;___/___/___ If yes, was 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 flight?  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 flight?  No  Unknown  Yes; With whom? _______________ Date of last exposure (mm/dd): ____/____ Has contact visited other countries during the past month?  No  Yes  Unknown If yes, list the country with the corresponding dates (mm/dd): ________________ From: ____/____ to _____/_____ ________________ From: ____/____ to _____/_____ ________________ From: ____/____ to _____/_____
8. 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