General Contact Investigation Outcome Reporting Form (La

Contact Investigation Outcome Reporting Forms

Attachment K - General Contact Investigation Outcome Reporting Form - La...

State/Local General Contact Reporting (Land)

OMB: 0920-0900

Document [docx]
Download: docx | pdf

OMB Control No.  0920-0900

Expiration Date: XX/XX/XXXX

General Land Contact Investigation Outcome Reporting Form

FAX completed form to the CDC at 404.718.2158; For questions, call 404.639.7147


1. Travel Information

CDC/QARS ID#

Arrival date

Departure city, state

Arrival city, state

Point of Entry

Train Bus

Company/Route No:

2. Index case clinical AND lab infoRMATION




3. Passenger Contact Information

Last name, First name

Address/Phone/email

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 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 seat/location #__________

Was this person a known close contact of the index case outside of this travel (e.g. family member)? No Yes

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 Travel


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

Other, specify ______________________________________

What was the official diagnosis for this person (e.g. confirmed pertussis, active TB, LTBI)? _______________________________

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 Created2021-01-20

© 2024 OMB.report | Privacy Policy