Form 0920-0900 TB Air Contact Investigation Outcome Reportinig Form

OMB Control No. 0920-0900
Expiration Date: 6/30/2018

TB Air Contact Investigation Outcome Reporting Form
FAX completed form to the CDC at 404.471.8121/EMAIL questions to [email protected]
1. FLIGHT INFORMATION (If more than one flight is listed, please circle the flight contact was on)
CDC/QARS ID #

Arrival Date

Departure Airport/City

Arrival Airport/City

Index Case Row

Sex

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

2. INDEX CASE CLINICAL AND LAB INFORMATION

3. PASSENGER CONTACT INFORMATION
Last name, First name

Assigned seat

4. CONTACT 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.

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?)
If 'Yes', date of last known contact to index case:____ / ____ / ____
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 flight
Close contact of a person with a known case of TB other than the person on flight
Ever lived in a country with high TB prevalence*, specify _________________________________
*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.
Other risk factors (i.e. history of incarceration, homelessness, IV drug use), specify _________________________________
Does person have a history of
previous TB?

No

LTBI

Has person ever received BCG
vaccine?

No

Yes

Active TB

Unknown

Unknown

Has this person ever had a TST performed prior to this flight?
Unknown

No

Yes, date of most recent (month/year): ____ / ____

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

Result:

Negative

Positive

No

Yes

Unknown

No

Yes, date of most recent (month/year): ____ / ____

Result:

Negative

Positive

Indeterminate

6. TB SCREENING AND EVALUATION
Was person screened for TB infection after exposure on this flight?
No, why not?

Previous positive TB screening

Declined

Lost to follow up

Other, specify _____________________

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

IGRA:

Date of 1st TST read: ____ / ____ / ____

Results:

Positive

Negative

Date of 2nd TST read: ____ / ____ / ____ Results:

Positive

Negative

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:

Diagnosis:

No infection

If diagnosed with TB, was treatment
prescribed?

LTBI

Normal

Active TB disease suspected

Abnormal, non-cavitary
Active TB disease confirmed

No, why not? _______________________________

Abnormal, cavitary
Unknown

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.