Form 0920-0900 Rubella Contact Investigation Outcome Reporting Form - A

Rubella Air Contact Investigation Outcome Reporting Form

OMB Control No. 0920-0900
Expiration Date: 08/31/2024

EMAIL completed form to [email protected] with the following text in the SUBJECT line: Outcome Reporting Form DGMQ ID ######

1.

FLIGHT INFORMATION (If more than one flight is listed, please circle the flight contact was on)
DGMQ ID#
Arrival date
Departure city/airport
Arrival city/airport

Index case seat

2. INDEX CASE CLINICAL AND LAB INFORMATION
3. CONTACT INFORMATION
Last name, First name

Assigned seat

Gender

DOB (mm/dd/yyyy)/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 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 exposure 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 INTERVENTION 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?  1st  2nd  3rd
Did contact report any signs or symptoms of rubella?  No (Stop here)  Yes
 Rash
 Cough
 Coryza
If yes, check all that apply:  Fever (Max temp measured ______oC/F)
 Lymphadenopathy
 Arthritis/arthralgia
 Conjunctivitis
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 rubella 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 xxxx-xxxx.