Community Assessment

Form Approved

OMB No. 0920-1011

Exp Date 3/31/17

Potential Rabies Exposure Assessment Form for Household, Co-worker and Patient Contacts

Name of Interviewer (if applicable):____________________________

Interviewer email:____________________________

Interviewer phone:____________________________

Date of interview:___________________________

HD initiating this questionnaire

□ Dept of Health

□ Other ____________________________________

Respondent Information

Name:_________________________________________________________________

Address:________________________ Home Phone:__________________

________________________ Work Phone:__________________ ________________________

Municipality: ___________________

Occupation:_____________________ Employer:_____________________

DOB:_____________ Sex: M F

Age: _______yrs

If a minor, name of parent or guardian:________________________________________

If different than above:

Address:________________________ Home Phone:__________________

________________________ Work Phone:__________________ ________________________

Relationship to patient: (check all that apply)

□ Friend □ Housemate

□ Coworker □ Relative

□ Other, please describe:__________________

1. Did you had any type of contact with the patient since 11/9/15?

 Yes  No

If no, thank you for participating in the survey. No additional follow up is needed.

2. What dates since 11/9/15 did you have contact with the patient?

3. Did you ever share food or drinks with the patient in such a way that fresh saliva from this patient may have come into contact with your mouth since 11/9/15? (e.g., sharing a drink where both of you were drinking out of the same bottle/glass/can at the same time, sharing the same utensil while eating at the same time or sharing a sandwich that the patient was also eating such that your mouth may have been exposed to fresh saliva from the patient)

 Yes  No  Unsure

4. Did you share a cigarette with the patient since 11/9/15?

 Yes  No  Unsure

5. Since 11/9/15, did you share a toothbrush, floss, or other oral hygiene product with the patient?

 Yes  No  Unsure

6. Did you kiss the patient on the mouth since 11/9/15?

 Yes  No  Unsure

7. Did you have direct, barehanded contact with this patient’s saliva since 11/9/15?

 Yes  No  Unsure

If no, go to question #9

8. When you had direct, barehanded contact with the patient’s saliva, did the saliva have contact with any skin that was not intact? (e.g., a fresh, open wound or cut that was not scabbed over)

 Yes  No  Unsure

9. Did you ever have direct, barehanded contact with the patient’s tears?

 Yes  No  Unsure

If no, go to question #11

10. When you had direct, barehanded contact with the patient’s tears, did this fluid have contact with any skin that was not intact? (e.g., a fresh, open wound or cut that was not scabbed over)

 Yes  No  Unsure

11. Were you bitten by this patient at any time since 11/9/15?

 Yes  No  Unsure

If no, go to question #13

12. Did the bite break the skin?

 Yes N o

13. Have you ever been immunized against rabies (before or after a potential exposure)?

□ No □ Yes (specify date/circumstance)

Which vaccine?

Recent titer drawn? Date_________ Results?

A Puerto Rico public health representative will be in touch with you within a few days to discuss whether or not you need rabies postexposure prophylaxis. In the meantime, if you have any questions, please call .

Interviewer:

After completion of assessment, please email to [] or FAX to [].

Public reporting burden of this collection of information is estimated to average 10 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)