General Contact Investigation Outcome Reporting Form - A

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

General 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:____ / ____ / ____
When was person interviewed?

During incubation period

After incubation period

At both times

5. IMMUNITY
Vaccination or history of disease:
Not vaccinated

Vaccinated, date of most recent dose: ___/___/___

History of disease

Immunity established by
serology

No applicable vaccine

Unknown

6. HEALTH SINCE FLIGHT
Did contact report any signs or symptoms?

No

Yes: Date of symptom onset ___/___/___ ; check all that apply:

Fever (Max temp measured ______°C/F)
Sore throat

Swollen glands

Unusual bleeding

Cough

Vomiting

Decreased consciousness

Recent onset of focal weakness and/or paralysis

7. PUBLIC HEALTH INTERVENTION
Did contact receive prophylaxis for this exposure?

Rash
Diarrhea

Coryza
Jaundice

Conjunctivitis
Headache

Neck stiffness

Difficulty breathing/shortness of breath
Other, specify _________________________________

No, why not?

Outside window for prophylaxis

Within window for prophylaxis but declined

No applicable prophylaxis

Other, specify: ______________________

Yes, please indicate what s/he received and the date(s):
Antimicrobial drug; specify____________, date received: ___/___/___
Immunoglobulin; date received: ___/___/___

Vaccination; 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:
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.