Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Follow-up Questionnaire for Asymptomatic Passengers and Crew, MERS CoV Aircraft Contact Investigation
Identifying and Residency Information (complete from 1st questionnaire)
Passenger’s name:____________________________________________________
Home Phone: _________________________ Mobile Phone: __________________
E-mail address: _________________________________
Flight Information: Date: ____/____/14 Destination:_____________________
Attempt(s) to reach passenger
Date |
Time |
Outcome (circle one) |
Message left/e-mail sent |
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Interview completed / not completed |
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Interview completed / not completed |
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Interview completed / not completed |
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Interview completed / not completed |
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Interview completed / not completed |
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Name of person answering the questions (if not traveler): _________________________
Relationship of person answering questions (if not traveler):_______________________
Name of Interviewer: ________________________ Date of interview: (____/____/14)
Agency/Affiliation of Interviewer: ______________________________________
Follow-up for asymptomatic contacts [should be 14 days since the flight and will likely be less than 14 days from the date initially interviewed]
Script:
Thank you for agreeing to this follow-up call from (circle one): CDC/Health Department.
We are calling you to find out if you have become sick since our last conversation and if you saw a doctor.
Are you willing to answer a few questions? YES NO
If NO, thank the person for their time.
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You flew on ___/___/14. Fourteen days after this time period is [today’s date or state other date].This 14-day period is the monitoring period.
A. Illness History
1. Have you been ill since we last spoke with you? Yes No
IF YES, go to question #2. IF NO, thank the person for their time.
2. Have you had any of the following symptoms?
Specify date of onset in mm/dd/yy format for each Yes answer.
Fever (measured temp of > 100.40 F (380 C) Yes (_____°) Temp if known No Don’t Know
Coughing Yes No Don’t Know
Difficulty breathing or shortness of breath Yes No Don’t Know
Wheezing Yes No Don’t Know
Pain with coughing or breathing Yes No Don’t Know
Other symptom(s): Yes List___________________ No Don’t Know
If NO to 2. a-e, END.
3. What date did you first become ill with these symptoms? Date____/____/14
4. Are you still sick? Yes No
4a. If NO, when did you feel better? Date__/__/14
5. Did you see a doctor for this illness? Yes No
If YES,
What date were you seen? Date__/__/14
Did you receive any treatment for the illness? Yes No
If YES, specify: _____________________________________
Were you tested by a medical provider for the illness (including, but not limited to, providing a blood sample or nasal or throat swab) since the day of your flight [insert date of flight]? Yes No
If YES – Specify test or what kind of specimen was tested for you (e.g., blood, nasal swab, throat swab): _______
Date (mm/dd/yy) ____/____/14
Facility where tested_____________________
Were you admitted to the hospital (kept overnight, not just in emergency room)? Yes No If yes, which hospital? ________________
6. Do you have any medical conditions that you are treated for regularly?
Yes (Specify: ______________) No Don’t Know
7. For women: Are you currently pregnant? Yes No Don’t Know
B. GEOGRAPHIC EXPOSURES
8. Have you visited the Middle East since [insert date that is 14 days before the flight date]*?
Yes No If NO, skip to Question 27.
If YES : Dates of visit (mm/dd/yy) ___/____/14 to ___/_____/14
List country(ies): ___________________________
(Omit for crew) What was the purpose of your trip? (check all that apply)
Visit family/friends Personal travel Business Study Other; specify: _____
9. While you were in the Middle East, did you:
Have any close contact with someone who was sick with the MERS coronavirus? Yes No
Have any close contact with someone who was sick with a serious respiratory infection, such as pneumonia? Yes No
b. Visit a health care facility? Yes No
c. (Omit for crew) Work in a health care facility? Yes No
Household Contacts
10. Has anyone in your household or someone else you have had close contact with had fever, cough, difficulty breathing (or symptoms similar to what you described)?
Yes *** No Don’t Know
Name: ____________________________________
Relationship: __________________________________
Symptoms: _________________________________________
Date of onset (mm/dd/yy): ____/____/____
Address: ____________________________________________
Phone #: ________________________
Name: ____________________________________
Relationship: __________________________________
Symptoms: _________________________________________
Date of onset (mm/dd/yy): ____/____/____
Address: ____________________________________________
Phone #: ________________________
*** Note this person’s name and contact information on the form for follow-up by local health department.
IF FEVER PLUS ANY RESPIRATORY SYMPTOMS (2 b-e).
If ill person has not received health care, read symptomatic contact script.
Send completed questionnaire to the health department.
CONSULT MEDICAL OFFICER IF FEVER ALONE OR WITH ONLY “OTHER” SYMPTOMS, OR RESPIRATORY SYMPTOMS WITHOUT FEVER.
THE END
Script: Thank you for taking the time to answer these questions.
Do you have any questions for me?
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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Emergency Epidemic Investigations |
Author | lmp2 |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |