Optional Measles, Mumps, or Rubella Maritime Contact Investigation Outcome Reporting Form

Optional Measles, Mumps, or Rubella Maritime Contact Investigation Outcome Reporting Form

1. Passenger Contact Information
Last name, First name	Cabin #	Sex	DOB (mm/dd/yyyy) 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 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 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 (yrs) received ____; 2. ___/___/___ or age (yrs) received ____;  Unknown Serologic proof of immunity?  No  Yes; Is there written documentation? No Yes Is the contact considered susceptible?  No  Yes
5. measleS/RUBELLA: intervention related to exposure on the Conveyance
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:___/___/____ Was contact quarantined alone?  No  Yes; /cohorted with others?  No  Yes  Yes, how many days? ____  No
6. MEASLES: health since TRAVEL
6a. first interview done < 21 days after TRAVEL NOTE: If your first interview was after the incubation period (>21 days), 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 TRAVEL 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 TRAVEL
6a. first interview done < 25 days after TRAVEL NOTE: If your first interview was after the incubation period (>25 days), 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 TRAVEL 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 TRAVEL
6a. first interview done < 23 days after TRAVEL NOTE: If your first interview was after the incubation period (>23 days), 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 TRAVEL 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 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  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): 1. ________________ From: ____/____ to _____/_____ 2. _________________ From: ____/____ to _____/_____ 3. ________________ 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