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pdfForm Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Appendix 2
CONTACT LISTING FORM
Public reporting burden of this collection of information is estimated to average 3 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 (0920-1011)
UGANDA VIRAL HEMORRHAGIC FEVER CONTACT LISTING FORM
Case Information
UVRI/MoH
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 Age Relation
(M/F) (yrs) to Case
Date of
Last
Contact
with Case
Type of
Contact
(1,2,3,4)*
list all
Head of
Household
Village
District
SubCounty
LC1
Chairman
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: ________________________
File Type | application/pdf |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
File Modified | 2014-07-18 |
File Created | 2014-07-07 |