Measles Maritime (Word)

Contact Investigation Outcome Reporting Forms

Attachment K - Measles Contact Investigation Outcome Reporting Form - Ma...

Cruise Ship Measles Outcome Reporting - Maritime (Word & Excel)

OMB: 0920-0900

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OMB Control No.  0920-0900

Expiration Date: XX/XX/XXXX


Measles 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. Contact Information

Last name, First name or Unique Identifier

Assigned cabin

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. 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


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


Did contact receive prophylaxis for this exposure to measles?

No, why not? Outside window for prophylaxis Within window for prophylaxis but declined

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 Exposure


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 last exposure)

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 confirmed measles 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.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleStandard TB and Air Travel Contact Investigation Outcome Reporting Form for CDC
AuthorKqm5
File Modified0000-00-00
File Created2021-01-21

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