0920-1011 Appendix 2- Contact Tracing Form

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Appendix 2:

CONTACT TRACING 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)

*8,1($ 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: ________________________