0920-0900 General Land Contact Investigation Outcome Reporting For

OMB Control No.  0920-0900

Expiration Date: XX/XX/20XX

General Land Contact Investigation Outcome Reporting Form

FAX completed form to the CDC at 404.718.2158; For questions, call 404.639.7147

1. Travel Information
DGMH ID#	Arrival date	Departure city, state, country		Arrival city, state, country	Port of Entry or Border Patrol Sector:		¨ Train ¨ Bus ¨ Other: ________ Company/Route No: ______________
2. Index case
Illness suspected/probable/confirmed (circle one):__________________ Clinical information: Laboratory information:
3. Information for exposed (contact) passenger/traveler
Last name, First name			Address/Phone/email			Gender		DOB (mm/dd/yy)/Age (yrs)
4. Contact Interview Information
Were you able to contact this person? ¨ No, due to: ¨ Incorrect locating information ¨ No longer at temporary address but still in U.S. ¨ No response ¨ Returned to country of residence ¨ Didn’t attempt follow-up ¨ Other, specify _______________ (Stop here) ¨ Yes, date contacted: ___/___/___ Was contact interviewed? ¨ No, due to: ¨ Declined ¨ Lives in different jurisdiction, specify _________________ ¨ Other, specify _______________________________________________ (Stop here) ¨ Yes; actual/verified seat/location #__________ ¨Unknown ¨Does not apply Was this person a known close contact of the index case outside of this travel (e.g. family member)? ¨ No ¨ Yes: specify _____________________________________________________
5. Vaccination status
Vaccination or history of disease: ¨ Not vaccinated ¨ Vaccinated, date of most recent dose: ____/____/_____ ¨Does not apply Vaccine type (if relevant:________________________________) ¨ History of disease: Year: ¨ Antibody status established by serology: Year: _____ ¨ Unknown
6. health since Travel
Did contact report any signs or symptoms? ¨ No ¨ Yes: 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, due to: ¨ Outside window for prophylaxis ¨ Within window for prophylaxis but declined ¨ 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 confirmed case besides the index case ¨ Other, specify ______________________________________ What was the official diagnosis for this person (e.g. confirmed pertussis, active TB, LTBI)? _______________________________
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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-0900.