0920-0900 Measles Aircraft Contact Investigation Outcome Reporting

OMB Control No. 0920-0900
Expiration Date: xx/xx/20xx

Measles Aircraft Contact Investigation Outcome Reporting Form
Return completed form by secure email to [email protected] (preferred) or fax to 404-471-8121 with the following text in the SUBJECT line:
Outcome Reporting Form DGMH ID ######

1.

FLIGHT INFORMATION
DGMH ID#
Arrival date

Departure city/airport

Arrival city/airport

Index case seat

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? Yes
No
If no, why not?
Incorrect locating information
No longer at temporary address but still in the U.S.
No response
HD didn’t attempt follow-up
Other, specify _____________________ (Skip to Section 9)
Returned to country of residence
If yes, date contacted: /
/
Was contact interviewed? Yes
No
If no, why not?
Declined
Lives in different jurisdiction, specify: ____________________________
Other, specify ________________________________________________________________________
(Skip to Section 9)
If yes; actual/verified seat #
Was this person a known close contact of the index case outside of this flight (e.g. family member)?  Yes  No
If yes, date of last known exposure to index case:
/ /
When was person interviewed? (check all that apply)
During first six days after flight?
During first 21 days after flight?
After incubation period (max 21 days after flight)?
5. IMMUNITY
MMR (or other measles-containing vaccine) or history of disease (select one):
Not vaccinated
One dose of vaccine
Two doses of vaccine
Three doses of vaccine
Immunized, number of doses unknown
History of disease
Born before 1957
Immunity established by serology
Unknown
6. MEASLES INTERVENTION RELATED TO EXPOSURE ON THE FLIGHT
Did contact receive prophylaxis for this exposure to measles?  Yes
No
If no, why not (select one)?
Outside window for prophylaxis
Within window for prophylaxis but declined
History of measles prior to flight
Born before 1957
Immune (by vaccination or serology)
Other, specify: ___________________________________
If yes, please indicate what s/he/they received and the date:
MMR or other measles-containing vaccine; date received:
Immunoglobulin; date received:
/ /
7. HEALTH SINCE FLIGHT
Did contact report any signs or symptoms of measles?
No (Skip to Section 9)
Yes
Unknown
If yes, check all that apply:
Fever (Max temp measured ______oC/F)
Rash
Cough
Coryza
Conjunctivitis
Check any of the following potential measles exposures this person may have had in the 21 days prior to symptom onset:
Visited/lives in a country with endemic measles
Exposed to a person with a confirmed measles case other than the index case on the flight
Other, specify: _______________________________________
8. DIAGNOSIS
Was this person diagnosed with measles?
Yes
No
Unknown
If unknown, why? Declined medical evaluation
Not interviewed after incubation period (max of 21 days after flight)
Lost to follow-up
Other, specify ____________________________________
If yes, how was diagnosis made? (Check all that apply)
IgM
Paired IgG
PCR
Culture
Epi-linked
Clinical diagnosis
Other, specify: ________________ __________
9. FORM COMPLETION
Person(s) completing form: ____________________________________________________
10. COMMENTS

Date form completed:

/

/

_

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 H21-8, Atlanta,
Georgia 30333; ATTN: PRA 0920-0900.