TB Air Contact Investigation Outcome Reporting Form

TB 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 Airport/City
Arrival Airport/City

Index Case Seat

2. INDEX CASE CLINICAL AND LAB INFORMATION

3. PASSENGER CONTACT INFORMATION
Last name, First name

Assigned seat

Gender

DOB (mm/dd/yyyy)/Age (yrs)

4. CONTACT INFORMATION
Were you able to contact this person?
 No, why not?  Incorrect locating info  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: ___/___/___
Country of birth: ______________________________ , Country of residence___________________________
5. INTERVIEW INFORMATION
Risk factors for prior TB infection (check all that apply below):
 No known risk factors other than flight  Close contact of a person with a known case of TB other than the person on flight
 Ever lived in a country with high TB prevalence*, specify ___________________________________________
 Other risk factors (i.e. history of incarceration, homelessness, IV drug use), specify____________________________________
Does person have a history of previous TB?  No  LTBI  Active TB  Unknown
Has person ever received BCG vaccine?  No  Yes  Unknown
Has this person ever had a TST performed prior to this flight?
 Unknown  No  Yes, date of most recent (month/year): ____/____ Result:  Negative  Positive
Has this person ever had an IGRA performed prior to this flight?
 Unknown  No  Yes, date of most recent (month/year): ____/____ Result:  Negative  Positive  Indeterminate
*If you are unsure whether a country the contact lived in is considered high TB prevalence (greater than 20/100,000 cases), please list it in the specified
field and we will make that determination for you upon receipt of the form.

6. TB SCREENING AND EVALUATION
Was person screened for TB infection after exposure on this flight?
 No, why not?  Previous positive TB screening  Declined  Lost to follow up
 Yes, what type of testing? (check all that apply)
 TST: Date of 1st TST read: ___/___/___ Results:  Positive  Negative
Date of 2nd TST read: ___/___/___ Results:  Positive

 Other, specify __________________

 Negative

st

 IGRA: Date of 1 IGRA: ___/___/___ Results:  Positive  Negative  Indeterminate
Date of 2nd IGRA: ___/___/___ Results:  Positive  Negative  Indeterminate
Was a review of signs and symptoms completed?  No  Yes
Was a chest X-ray done?  No  Yes, results:  Normal  Abnormal, non-cavitary  Abnormal, cavitary
Diagnosis:  No infection  LTBI  Active TB disease suspected  Active TB disease confirmed  Unknown
If diagnosed with TB, was treatment prescribed?  No, why not? _____________________  Yes, date started ___/___/___
7. 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.