General Air Contact Investigation Outcome Reporting Form

General Contact Investigation Outcome Reporting Form_Air_redline.docx

Contact Investigation Outcome Reporting Forms

General Air Contact Investigation Outcome Reporting Form

OMB: 0920-0900

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OMB Control No.  0920-0900

Expiration Date: 08/31/2024


General 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. Passenger Contact Information

Last name, First name

Assigned seat

Sex

DOB (mm/dd/yy)/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 U.S. No response

Returned to country of residence HD didn’t attempt follow-up Other, specify _________ (Stop here)

Yes, date initially 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: ___/___/___

When was person interviewed? During incubation period After incubation period At both times

5. Immunity

Vaccination or history of disease: Not vaccinated Vaccinated, date of most recent dose: ___/___/___ History of disease Immunity established by serology No applicable vaccine Unknown

6. health since flighT

Did contact report any signs or symptoms? No Yes: Date of symptom onset ___/___/___ ; check all that apply:

Fever (Max temp measured ______oC/F) Cough Rash Coryza Conjunctivitis

Sore throat Swollen glands Vomiting Diarrhea Jaundice Headache Neck stiffness

Unusual bleeding Decreased consciousness Difficulty breathing/shortness of breath

Recent onset of focal weakness and/or paralysis Other, specify _________________________________

7. Public health intervention


Did contact receive prophylaxis for this exposure?

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 include the date(s):

Antimicrobial drug; specify____________, date received: ___/___/___ Vaccination; date received: ___/___/___

Immunoglobulin; 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:

Exposed to a person with a probable or confirmed 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

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