Measles Contact Investigation Outcome Reporting Form - A

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

Measles 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/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

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?)

No

Yes

If 'Yes', date of last known contact to index case:____ / ____ / ____

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 INTEVENTION RELATED TO EXPOSURE ON THE FLIGHT
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)

Born before 1957

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 FLIGHT
Did contact report any signs or symptoms of measles?
If yes, check all that apply:

No (Stop here)

Fever (Max temp measured ______°C/F)

Yes
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 flight)

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 person with a confirmed case other than the index case on the flight
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.