General Reporting Maritime (Excel)

SHIP General 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: 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)

Prior Immunity

Intervention Related to Exposure

Symptoms Since Exposure

Diagnosis

Contact Number

Initials or Crew #

Crew Member/ Passenger

Gender (M/F)

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

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 (cabinmate, work or social contact?)

Was patient vaccinated for this disease? Y/N

If yes, date of most recent dose MM/YY

Was patient considered immune due to hisotry of the disease? Y/N

Was this person known to be immune due to serology results? Y/N

Did person receive prophylaxis for this exposure? Y/N

If yes, what was given? (vaccination, immunoglobulin, antimicrobial drug, or if something else, specify)

Date vaccination, immunoglobulin, antimicrobial drug, prophylaxis, other given MM/DD/YY

Did person have fever? Y/N

If yes to fever, what was maximum temperature measured?

Cough? Y/N

Rash? Y/N

Coryza? Y/N

Conjunctivitis? Y/N

Sore Throat? Y/N

Swollen glands? Y/N

Vomiting? Y/N

Diarrhea? Y/N

Jaundice? Y/N

Headache? Y/N

Neck stiffness? Y/N

Unusual bleeding? Y/N

Decreased consciousness? Y/N

Difficulty breathing/ shortness of breath? Y/N

Recent focal weakness and/or paralysis? Y/N

Was this contact diagnosed with the disease under investigation? Y/N/Unknown

If unknown, why? (Declined evaluation, lost to follow-up, not interviewed after incubation period or specify other)

If diagnosed with the disease, list all of the following that were positive: IgM, Paired IgG, PCR, Culture, Clinical Diagnosis, Epi-linked

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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.

Respond with NA if not done or not applicable