TB Maritime (Excel)

SHIP TB Maritime Contact Investigation Outcome Reporting Form

OMB Control No. 0920-0900 Expiration Date: XX/XX/XXXX

Complete and fax this form to the CDC Quarantine Station to which the illness or death was reported. Quarantine Station jurisdictions and contact information can be found at: http://www.cdc.gov/quarantine/quarantinestationcontactlistfull.html

Contact the CDC Quarantine Station to confirm receipt of the faxed report or if you have any questions.

If you are unable to reach a CDC Quarantine Station, call +1-770-488-7100. Alternate: +1-877-764-5455 (at-sea use).

Basic Information about Contact(s)

Pertinent Medical History

TB screening and Evaluation results for this investigation

Diagnosis

Contact Number

Initials or Crew #

Crew Member/ Passenger

Sex (M/F)

Date of Birth or Age in years (MM/DD/YY)

Were you able to contact this person? Y/N

If no, why not? (contact disembarked in another country, transferred to another ship, etc) (If no, stop here)

If yes, date contacted: MM/DD/YY

Was contact interviewed? Y/N

If no, why not? (declined, other) (If no, stop here)

Date of last known exposure with index case MM/DD/YY

Was this person a known close contact of the index case outside of this voyage (e.g. family member or travel companion?) Y/N

Specify types of contact this person had with index case (shared living quarters, work or social contact?)

Country of birth

List any country this person has lived in with a high TB prevalence* Y/N

Specify any other risk factors this person has for TB (e.g. incarceration, homelessness, IV drug use)

Does person have a previous history of TB? Y/N

If yes, specify (e.g. LTBI, active TB) or NA

Has person ever received the BCG vaccine? Y/N

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

Give date of most recent TST (MM/YY) or NA

Was most recent TST positive, negative or NA?

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

Give date of most recent IGRA test (MM/YY) or NA

Was the most recent IGRA positive, negative or NA?

Was this person screened for TB as a part of this investigation? Y/N

If no, why not? (e.g. known to have TB in the past, declined, lost to follow-up) (If no, stop here)

Date of first TST reading MM/DD/YY or NA

First TST positive, negative or NA?

Date of second TST reading MM/DD/YY or NA

Second TST positive, negative or NA?

Date of first IGRA reading? MM/DD/YY or NA

First IGRA positive, negative, indeterminate, or NA

Date of second IGRA MM/DD/YY or NA

Second IGRA positive, negative, or NA

Was a review of signs and symptoms completed? Y/N

Was a chest xray done? Y/N

If xray done, was result Normal, abnormal, non-cavitary or Abnormal cavitary? (NA if not done)

What was the final diagnosis? Choices:No infection, LTBI, Active TB disease suspected, active TB disease confirmed, or unknown

If diagnosed with TB, was treatment prescribed? Y/N or, if not diagnosed, NA

If diagnosed with TB and not treated, specify reason

Country of residence

Did this person have risk factors for TB other than exposure to index case on this ship? Y/N

Was the person a close contact with a known case of TB other than the index case? Y/N

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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.

*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.

Respond with NA if not done or not applicable