Novel Influenza A Virus Infection Contact Tracing Form

Form Approved
OMB No. 0920-0004

Novel Influenza A Virus Infection Contact Tracing Form
For Investigation of Contacts Potentially Exposed to Persons with Suspected or Confirmed Novel Influenza A Virus Infection
ID Number of confirmed case:__________________
ID #

Contact’s Name, Sex,
and Date of Birth

Telephone and
Email

Relationship to
Case

Family
First Name:____________ Home Phone:
____-_____-______ Friend
Last Name:____________ Cell Phone:
Co-Worker
Sex:
M F U ____-_____-______
Classmate
DOB(dd/mm/yyyy):
Email:
Health Care Worker
_____/_____/________
________________
Other:____________

1

Case
Status1

Resp.
Illness

Contact Level2 and Dates of Contact

Direct: _____/_____/_______ to _____/_____/_______

Suspect

Resp. illness +/7 days from
case contact:

Probable

Y

Not a
Case

If yes, onset:
___/____/_____

Confirmed

N

U

Disposition
Recovered:

Y N U

Hospitalized: Y N U

Indirect: _____/_____/______ to _____/_____/_______ Date:___/____/_____
Died:
Y N U
Other: _____/_____/_______ to _____/_____/_______
Date:___/____/_____

Describe the nature of contact with case patient:

ID #

Contact’s Name, Sex,
and Date of Birth

Telephone and
Email

Relationship to
Case

Family
First Name:____________ Home Phone:
____-_____-______ Friend
Last Name:____________ Cell Phone:
Co-Worker
Sex:
M F U ____-_____-______
Classmate
DOB(dd/mm/yyyy):
Email:
Health Care Worker
_____/_____/________
________________
Other:____________

2

Case
Status1

Resp.
Illness

Contact Level2 and Dates of Contact

Direct: _____/_____/_______ to _____/_____/_______

Suspect

Resp. illness +/7 days from
case contact:

Probable

Y

Not a
Case

If yes, onset:
___/____/_____

Confirmed

N

U

Disposition
Recovered:

Y N U

Hospitalized: Y N U

Indirect: _____/_____/______ to _____/_____/_______ Date:___/____/_____
Died:
Y N U
Other: _____/_____/_______ to _____/_____/_______
Date:___/____/_____

Describe the nature of contact with case patient:

ID #

Contact’s Name, Sex,
and Date of Birth

Telephone and
Email

Relationship to
Case

Case
Status1

Resp.
Illness

Contact Level2 and Dates of Contact

Disposition

Public reporting burden of this collection of information is estimated to average 30 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 Information Collection Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, 
Georgia 30333; ATTN: PRA (0920‐0004).

3

Family
First Name:____________ Home Phone:
____-_____-______ Friend
Last Name:____________ Cell Phone:
Co-Worker
Sex:
M F U ____-_____-______
Classmate
DOB(dd/mm/yyyy):
Email:
Health Care Worker
_____/_____/________
________________
Other:____________

Suspect

Resp. illness +/7 days from
case contact:

Probable

Y

Not a
Case

If yes, onset:
___/____/_____

Confirmed

N

U

Recovered:
Direct: _____/_____/_______ to _____/_____/_______

Y N U

Hospitalized: Y N U

Indirect: _____/_____/______ to _____/_____/_______ Date:___/____/_____
Died:
Y N U
Other: _____/_____/_______ to _____/_____/_______
Date:___/____/_____

Describe the nature of contact with case patient:

1. Case Status: Follow case definitions at URL.
2. Level of Contact: Direct contact involves touching or providing care for a person. Indirect contact involves speaking to or touching items belonging to patient.
ID #

4

Contact’s Name, Sex,
and Date of Birth

Telephone and
Email

Relationship to
Case

Family
First Name:____________ Home Phone:
____-_____-______ Friend
Last Name:____________ Cell Phone:
Co-Worker
Sex:
M F U ____-_____-______
Classmate
DOB(dd/mm/yyyy):
Email:
Health Care Worker
_____/_____/________
________________
Other:____________

Case
Status1

Resp.
Illness

Contact Level2 and Dates of Contact

Direct: _____/_____/_______ to _____/_____/_______

Suspect

Resp. illness +/7 days from
case contact:

Probable

Y

Not a
Case

If yes, onset:
___/____/_____

Confirmed

N

U

Disposition
Recovered:

Y N U

Hospitalized: Y N U

Indirect: _____/_____/______ to _____/_____/_______ Date:___/____/_____
Died:
Y N U
Other: _____/_____/_______ to _____/_____/_______
Date:___/____/_____

Describe the nature of contact with case patient:

ID #

5

Contact’s Name, Sex,
and Date of Birth

Telephone and
Email

Relationship to
Case

Family
First Name:____________ Home Phone:
____-_____-______ Friend
Last Name:____________ Cell Phone:
Co-Worker
Sex:
M F U ____-_____-______
Classmate
DOB(dd/mm/yyyy):
Email:
Health Care Worker
_____/_____/________
________________
Other:____________

Case
Status1

Resp.
Illness

Contact Level2 and Dates of Contact

Direct: _____/_____/_______ to _____/_____/_______

Suspect

Resp. illness +/7 days from
case contact:

Probable

Y

Not a
Case

If yes, onset:
___/____/_____

Confirmed

N

U

Disposition
Recovered:

Y N U

Hospitalized: Y N U

Indirect: _____/_____/______ to _____/_____/_______ Date:___/____/_____
Died:
Y N U
Other: _____/_____/_______ to _____/_____/_______
Date:___/____/_____

Describe the nature of contact with case patient:

ID #

Contact’s Name, Sex,
and Date of Birth

Telephone and
Email

Relationship to
Case

Case
Status1

Resp.
Illness

Contact Level2 and Dates of Contact

Disposition

6

Family
First Name:____________ Home Phone:
____-_____-______ Friend
Last Name:____________ Cell Phone:
Co-Worker
Sex:
M F U ____-_____-______
Classmate
DOB(dd/mm/yyyy):
Email:
Health Care Worker
_____/_____/________
________________
Other:____________

Suspect

Resp. illness +/7 days from
case contact:

Probable

Y

Not a
Case

If yes, onset:
___/____/_____

Confirmed

N

U

Recovered:
Direct: _____/_____/_______ to _____/_____/_______

Y N U

Hospitalized: Y N U

Indirect: _____/_____/______ to _____/_____/_______ Date:___/____/_____
Died:
Y N U
Other: _____/_____/_______ to _____/_____/_______
Date:___/____/_____

Describe the nature of contact with case patient:

1. Case Status: Follow case definitions at URL.
2. Level of Contact: Direct contact involves touching or providing care for a person. Indirect contact involves speaking to or touching items belonging to patient.