Rubella Contact Investigation Outcome Reporting Form - A

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

Rubella 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 Rubella-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. RUBELLA INTEVENTION RELATED TO EXPOSURE ON THE FLIGHT
Did contact receive intervention for this exposure to rubella (not routinely recommended)?
No
Yes, please indicate what s/he received and the date:
Immunoglobulin; date received: ___/___/___

Other, specify _______________________________________

Reason for intervention: ____________________________________________________________________________

7. HEALTH SINCE FLIGHT
Is this person pregnant?

No

N/A

Yes; what trimester at time of the flight?

Did contact report any signs or symptoms of rubella?

No (Stop here)

Yes

1st

2nd

3rd

If yes, check all that apply:

Fever (Max temp measured ______°C/F)
Conjunctivitis

Lymphadenopathy

Rash

Cough

Coryza

Arthritis/arthralgia

8. DIAGNOSIS
Was this person diagnosed with rubella?
No
Unknown, why?
Declined medical evaluation

Not interviewed after incubation period (max of 23 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 rubella exposures this person may have had in the 23 days prior to symptom onset:
Visited/lives in a country with endemic rubella
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.