VHF Contact Tracing Follow-Up Form - English

Form Approved

OMB No. 0920-XXXX

Expiration Date xx/xx/xxxx

[Name of Country] Viral Hemorrhagic Fever Contact Tracing Follow-Up Form

Write ✓ if seen and healthy Write ✗ if seen and sick. If sick, write symptoms under Notes. Write – if not seen.

Team: Team Leader:

Village:       Sub-County:       District:

Surname	Other Names	Sex	Age	Date of last contact	Source case	Head of household	Phone	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21
Notes:

Public reporting burden of this collection of information is estimated to average 63 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.