TB Maritime Word

Contact investigation Outcome Reporting Forms

Attachment H - TB Contact Investigation Outcome Reporting Form - Maritime 2

Cruise Ship TB Outcome Reporting - Maritime (Word & Excel)

OMB: 0920-0900

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OMB Control No.  0920-0900

Expiration Date: 09/30/2017


TB Maritime Contact Investigation Outcome Reporting Form

FAX completed form to the CDC at 404.718.2158; For questions, call 404.639.7147


1. Voyage Information on index case

CDC/QARS ID#

Arrival date

Arrival City/Port

Departure City/Port

Crew/Passenger







2. Index case clinical AND lab infoRMATION






3. PASSENGER Contact Information

Last name, First name or other identifier

Assigned cabin

Gender

DOB (mm/dd/yyyy)/Age (yrs)






4. Contact inFORMATION


Were you able to contact this person?

No, why not? Incorrect locating info No longer at temporary address but still in the U.S. No response

Returned to country of residence Didn’t attempt follow-up Other, specify _____________ (Stop here) Yes, date contacted: ___/___/___

Was contact interviewed?

No, why not? Declined Lives in different jurisdiction, specify _________________

Other, specify ________________________________________________ (Stop here)

Yes; actual/verified cabin #:____________ , date of last known exposure to index case: ___/___/___ Unknown


Was this person a crew member? No Yes


Was this person a known close contact of the index case outside of this voyage (e.g. family member)? No Yes


Was this person frequently in close proximity to index case (e.g. cabinmate, work, or social)? No Yes, specify ______________

Country of birth: ______________________________ , Country of residence___________________________

5. INTERVIEW INFORMATION


Risk factors for prior TB infection (check all that apply below):

No known risk factors other than exposure to index case on this ship

Close contact with a known case of TB other than the index case

Ever lived in a country with high TB prevalence*, specify ___________________________________________

Other risk factors (i.e. history of incarceration, homelessness, IV drug use), specify____________________________________


Does person have a history of previous TB? No LTBI Active TB Unknown


Has person ever received BCG vaccine? No Yes Unknown


Has this person ever had a TST performed prior to this investigation?

Unknown No Yes, date of most recent (month/year): ____/____ Result: Negative Positive


Has this person ever had an IGRA performed prior to this investigation?

Unknown No Yes, date of most recent (month/year): ____/____ Result: Negative Positive Indeterminate


*If you are unsure whether a country the contact lived in is considered high TB prevalence (greater than 20/100,000 cases), please list it in the specified field and we will make that determination for you upon receipt of the form.


6. TB SCREENING AND EVALUATION



Was this person screened for TB infection as a part of this investigation?


No, why not? Previous positive TB screening Declined Lost to follow up Other, specify __________________


Yes, what type of testing? (check all that apply)

TST: Date of 1st TST read: ___/___/___  Results: Positive   Negative


Date of 2nd TST read: ___/___/___  Results: Positive   Negative

IGRA: Date of 1st IGRA: ___/___/___ Results: Positive   Negative   Indeterminate


Date of 2nd IGRA: ___/___/___ Results: Positive   Negative   Indeterminate


Was a review of signs and symptoms completed? No Yes


Was a chest X-ray done? No Yes, results: Normal Abnormal, non-cavitary Abnormal, cavitary


Diagnosis: No infection LTBI Active TB disease suspected Active TB disease confirmed Unknown


If diagnosed with TB, was treatment prescribed? No, why not? _____________________ Yes, date started ___/___/___

7. Comments


Public reporting burden of this collection of information is estimated to average 5 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 0920-0900.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleStandard TB and Air Travel Contact Investigation Outcome Reporting Form for CDC
AuthorKqm5
File Modified0000-00-00
File Created2021-01-21

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