Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form

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Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form

For Investigation of Contacts Potentially Exposed to Persons with Suspected or Confirmed Pandemic or Novel Influenza A Virus Infection
Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form – For Investigation of Contacts Potentially Exposed to Persons with Suspected or Confirmed Pandemic or Novel Influenza A Virus Infection 

State/Local case ID#		_______________		Date of case-patient Illness onset 		__________________
CDC case ID #		_______________		Date of case-patient Illness notification	__________________
Contact Group ID#		_______________

**NOTE: A contact of a case-patient is anyone who came within 1 meter or 3 feet of the case-patient, by for example, taking care of, speaking to, directly touching, or handling case-patient items**

Close Contacts—Family, friends, and other persons who live with or take care of the case-patient 

Last Name

First Name

DOB

Age

Gender

Relationship
with case*

Telephone

Email

Address

Date of Last Contact with Case

Under 
Follow-up




 M      F










 M      F










 M      F










 M      F










 M      F










 M      F










 M      F






 * Family member(specify), friend, other(specify)

Medical Contacts—Doctors, nurses, or others healthcare workers

Last Name

First Name

DOB

Age

Gender

Relationship
with case**

Telephone

Email

Address

Date of Last Contact with Case

Under 
Follow-up




 M      F










 M      F










 M      F










 M      F










 M      F










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 ** Specify type of type of healthcare worker


Work or School Contacts—Co-workers, classmate,  employers, teachers, or other members of workplace or school

Last Name

First Name

DOB

Age

Gender

Relationship
with Case***

Telephone

Email

Address

Date of Last Contact with Case

Under 
Follow-up




 M      F










 M      F










 M      F










 M      F










 M      F










 M      F






 ** specify co-worker, employee, employer, etc