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

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities to Conduct Public Health Activities

Attachment H_Viral Hemorrhagic Fever Contact Listing Form_General

Viral Hemorrhagic Fever Contact Listing Form (General)

OMB: 0920-1033

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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.

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