Rubella Air Contact Investigation Outcome Reporting Form (redline)

Rubella Contact Investigation Outcome Reporting Form_Air_redline.docx

Contact Investigation Outcome Reporting Forms

Rubella Air Contact Investigation Outcome Reporting Form (redline)

OMB: 0920-0900

Document [docx]
Download: docx | pdf

OMB Control No.  0920-0900

Expiration Date: 08/31/2024

Rubella 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 city/airport

Arrival city/airport

Index case row







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

If yes, check all that apply: Fever (Max temp measured ______oC/F) Rash Cough Coryza

Conjunctivitis Lymphadenopathy 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 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.


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

© 2024 OMB.report | Privacy Policy