VHF Contact Listing Form - English

Form Approved
OMB No. 0920-XXXX
Expiration Date: XX/XX/XXXX

[NAME OF COUNTRY] VIRAL HEMORRHAGIC FEVER CONTACT LISTING FORM
Case Information
Case ID

Surname

Other Names

Head of Household

Village

District

County

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

Zone

County

Village
Leader

Phone Number

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

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.

*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: ________________________