Form 1 Public Health Investigation Form: Non-TB Illness

Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness

ORR Public Health Investigation Form_Non-TB Illness

Public Health Investigation Form: Non-TB Illness - Reporting Time

OMB: 0970-0509

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OMB Control No: 0970-0509

Expiration date: XX/XX/XXXX


Public Health Investigation Form: Non-TB Illness

Unaccompanied Children’s Program

Office of Refugee Resettlement (ORR)

General Information

Child


Last name:

First name:


DOB:

A#:


Gender:

Program

Program name:

Person completing form & date:


Exposure Information


Illness of exposure: ____________________________


Source of potential exposure: ____________________________________

Date of first potential exposure: ____ / ____ / ______

Date of last potential exposure: ____ / ____ / ______

Exposure details (e.g., child was potentially exposed for 4 hours a day in class for 5 consecutive days):





Was child screened for illness-specific signs/symptoms upon notification of exposure?

  • No

  • Yes, date: ____/____/______

If screened, did child have illness-specific signs/symptoms?

  • No

  • Yes

If Yes, was child evaluated by a healthcare provider?

  • No

  • Yes (Complete Medical Assessment Form)

Public Health Actions

Select No or Yes for each question below. If Yes, enter the information in the corresponding table.

Medications given:

  • No

  • Yes

Medication name

Date started

Date discontinued

Dose

Directions

Psychotropic






  • No

  • Yes






  • No

  • Yes

Immunizations administered and/or indicated because of this exposure, but not given:

  • No

  • Yes

Vaccine name

Date administered OR if indicated, but not given, state reason





Lab testing performed:

  • No

  • Yes

Illness

Test

Specimen Collection Date

Specimen Source

Result











Was child quarantined?

  • No

  • Yes, quarantine start date: ____/____/______ , quarantine end date: ____/____/______


Outcome of ORR public health investigation (Check one):

  • Pending

  • Cleared

  • Diagnosed with illness of exposure (Complete Medical Assessment Form)

  • Incomplete evaluation, reason (e.g., runaway, age-out): _________________________________________________________


Comments:








The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 5 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0509 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected].

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBuckley, Kirsten (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2023-12-11

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