TB Air Contact Investigation Outcome Reporting Form (redline)

TB Contact Investigation Outcome Reporting Form_Air_redline.docx

Contact Investigation Outcome Reporting Forms

TB Air Contact Investigation Outcome Reporting Form (redline)

OMB: 0920-0900

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OMB Control No.  0920-0900

Expiration Date: 08/31/2024

TB Air Contact Investigation Outcome Reporting Form

FAX completed form to the CDC at 404.471.8121/EMAIL questions to [email protected]

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 Row







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 Other, specify __________________


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   Negative

IGRA: Date of 1st 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.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleStandard TB and Air Travel Contact Investigation Outcome Reporting Form for CDC
AuthorKqm5
File Modified0000-00-00
File Created2021-11-08

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