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

OMB Approved
0920-XXXX
Expiration Date: xx/xx/xxxx

FIEVRE HEMORRAGIQUE VIRALE – FORMULAIRE LISTANT LES CONTACTS
Informations sur le malade
Numéro
d’identification
du malade

Nom de
Famille

Autres Noms

Chef de Famille

Village

SousPréfecture

Préfecture

Date de Début
de la Maladie

Date
d’admission à
l’isolement

Date du
Décès

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

Contact Information
Nom

Autres
noms

Sexe Age
(H/F) (an)

Lien du
contact
au cas

Date du
dernier
contact
avec le
malade

Types de
Contact
(1,2,3,4)*
indiquez
tout

Chef de
famille

Village

Préfecture

SousPréfecture

Chef de
Village

Numéro de
telephone

Personnel de
Santé (O/N)
Si oui, quel
centre médicale?

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.

OMB Approved
0920-XXXX
Expiration Date: xx/xx/xxxx
*Types de Contacts (notez toutes les possibilités):
1 – A touché des sécrétions/excrétions du malade (sang, vomissures, salive, urine, selles)
2 – A touché directement le corps du malade (vivant ou décédé)
3 – A touché ou partagé linges, habits, plats/assiettes, instruments avec le malade
4 – A dormi ou mangé avec, ou séjourné dans la même maison ou pièce que le malade

Feuille de contacts remplie par: Nom: ___________________________ Position: ___________________________ Téléphone: _________________________

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.