Form 0920-15CN Attachment H_Viral Hemorrhagic Fever Contact Listing For

OMB Approved

0920-XXXX

Expiration Date: XX/XX/XXXX

VIRAL HEMORRHAGIC FEVER CONTACT LISTING FORM

Case Information
Case ID	Surname	Other Names	Head of Household		Village	Sub-County	District	Date of Symptom Onset	Date of Admission to Isolation	Date of Death

**For all information on location, please list information on where the contact will be residing for the next month.

Contact Information

Surname

Other Names

Sex (M/F)

Age (yrs)

Relation to Case

Date of Last Contact with Case

Type of Contact (1,2,3,4)* list all

Head of Household

Village

District

Sub-County

Village Leader

Phone Number

Healthcare Worker (Y/N) If yes, what facility?

*Types of Contact:

1 = Touched the body fluids of the case (blood, vomit, saliva, urine, feces)

2 = Had direct physical contact with the body of the case (alive or dead)

3 = Touched or shared the linens, clothes, or dishes/eating utensils of the case

4 = Slept, ate, or spent time in the same household or room as the case

Contact Sheet Filled by: Name: ___________________________________ Position: ___________________________ Phone: ________________________

Public reporting burden of this collection of information is estimated to average 15 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.