0920-0900 General Contact Investigation Outcome Reporting Form - A

OMB Control No. 0920-0900
Expiration Date: 5/31/2021

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?

Yes, date contacted:

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)

/

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?)
If 'Yes', date of last known contact to index case:
When was person interviewed?

/

No

Yes

/

During incubation period

After incubation period

At both times

5. IMMUNITY
Vaccination or history of disease:
Not vaccinated

Does not apply

History of disease

Immunity established by
serology

No applicable vaccine

Unknown

6. HEALTH SINCE FLIGHT

Did contact report any signs or symptoms?

No

Fever (Max temp measured
Sore throat
Unusual bleeding

Swollen glands

Yes: Date of symptom onset
°C/F)

Cough

Vomiting

Decreased consciousness

Recent onset of focal weakness and/or paralysis

/

Rash
Diarrhea

/

; check all that apply:
Coryza
Jaundice

Conjunctivitis
Headache

Difficulty breathing/shortness of breath
Other, specify

Neck stiffness

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
Immunoglobulin; date received:

, 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.