Measles Contact Investigation Outcome Reporting Form_Track Change

OMB Control No.  0920-0900

Expiration Date: XX/XX/XXXX10/31/2017

Measles Air Contact Investigation Outcome Reporting Form

FAX completed form to the CDC at 404.471.8121404.718.2158; For questions, call 404.639.7147

Flight Information (If more than one flight is listed, please circle the flight contact was on)
CDC/QARS ID#	Arrival date	Departure city/airport		Arrival city/airport			Index case row
2. Index case clinical AND lab information
3. Contact Information
Last name, First name			Assigned seat		Gender	DOB (mm/dd/yyyy)/Age (yrs)
4. Contact/Interview information
Were you able to contact this person?  No, why not?  Incorrect locating information  No longer at temporary address but still in the U.S  Missed HD appointment  No response  Returned to country of residence  HD 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 seat #_________ Was this person a known close contact of the index case outside of this flight (e.g. family member)?  No  Yes If “Yes”, date of last known exposure to index case: ___/___/___
5. immunity
MMR (or other measles-containing vaccine) or history of disease:  Not vaccinated  One dose of vaccine  Two doses of vaccine  Three doses of vaccine  Immunized, number of doses unknown  History of disease  Immunity established by serology  Unknown
6. measleS intervention related to exposure on the flight
Did contact receive prophylaxis for this exposure to measles?  No, why not?  Outside window for prophylaxis  Within window for prophylaxis but declined  Born before 1957  Immune (by vaccination or history of measles prior to flight)  Other, specify: ______________________  Yes, please indicate what s/he received and the date:  MMR or other measles-containing vaccine; date received: ___/___/___  Immunoglobulin; date received: ___/___/___
7. health since flight
Did contact report any signs or symptoms of measles?  No (Stop here)  Yes; If yes, check all that apply:  Fever (Max temp measured ______oC/F)  Rash  Cough  Coryza  Conjunctivitis
8. DIAGNOSIS
Was this person diagnosed with measles?  No  Unknown, why?  Declined medical evaluation  Not interviewed after incubation period (max of 21 days after flight)  Lost to follow-up  Other, specify ________________________________  Yes, how was diagnosis made? (Check all that apply)  IgM  Paired IgG  PCR  Culture  Epi-linked  Clinical diagnosis  Other, specify:______________ Check any of the following potential measles exposures this person may have had in the 21 days prior to symptom onset:  Visited/lives in a country with endemic measles  Exposed to a person with a confirmed measles case besides other than the index case on the flight  Other, specify: _________________________________________
9. 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.