General Reporting Maritime (Word)

OMB Control No.  0920-0900

Expiration Date: XX/XX/XXXX

General 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
CDC/QARS ID#	Arrival date	Departure city/port		Arrival city/port			Index case cabin
2. Index case clinical AND lab infoRMATION
3. Passenger Contact Information
Last name, First name or Unique Identifier			Assigned cabin		Gender	DOB (mm/dd/yy)/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.  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 contact with index case: ___/___/___ Was this person a known close contact of the index case outside of this voyage (e.g. family member)?  No  Yes Was this person a crew member?  No  Yes, was this person frequently in close proximity to index case besides sharing living quarters (i.e. work or social)?  No  Yes, specify: _______________________________________
5. Immunity
Vaccination or history of disease:  Not vaccinated  Vaccinated, date of most recent dose: ____/____/_____  History of disease  Immunity established by serology  Unknown
6. health since exposure
Did contact report any signs or symptoms?  No  Yes; check all that apply:  Fever (Max temp measured ______oC/F)  Cough  Rash  Coryza  Conjunctivitis  Sore throat  Swollen glands  Vomiting  Diarrhea  Jaundice  Headache  Neck stiffness  Unusual bleeding  Decreased consciousness  Difficulty breathing/shortness of breath  Recent onset of focal weakness and/or paralysis  Other, specify _________________________________
7. Public health intervention
Did contact receive prophylaxis for this exposure?  No, why not?  Outside window for prophylaxis  Within window for prophylaxis but declined  Other, specify _________________  Yes, please indicate what s/he received and include the date(s):  Antimicrobial drug; specify____________, date received: ___/___/___  Vaccination; date received: ___/___/___  Immunoglobulin; date received: ___/___/___  Other, specify: _____________, date received: ___/___/___
8. DIAGNOSIS
Was this person diagnosed with the disease in question?  No  Unknown, why?  Declined medical evaluation  Not interviewed after incubation period  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 exposures this person may have had recently for the disease in question:  Exposed to a confirmed case besides the index case on the ship  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.