Form 0920-0900 General Land Contact Investigation Outcome Reporting For

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

TB 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 Airport/City

Arrival Airport/City

Index Case Seat

2. INDEX CASE CLINICAL AND LAB INFORMATION

3. PASSENGER CONTACT INFORMATION
Last name, First name
Assigned seat

Gender

DOB (mm/dd/yyyy) Passport Country

4. CONTACT INFORMATION
Were you able to contact this person?  Yes  No
If no, why not?  Incorrect locating info  No longer at temporary address but still in the U.S.  Returned to country of residence
 No response  Other, specify
(Skip to Section 7)
If yes, date contacted: /
/
Was contact interviewed?  Yes  No
If no, why not?  Declined  Lives in different state/territory, specify
 Other, specify
(Skip to Section 7)
Country of birth:
Country of usual residence: ______________________________
5. INTERVIEW INFORMATION
Social risk factors for prior TB infection (check all that apply below):
 No known risk factors other than flight  Close contact of the index case outside the flight
 Close contact of a person with TB disease other than the index case
 Ever lived in a country with high TB prevalence*, specify
 Other risk factors for TB exposure, specify
Has person ever received BCG vaccine?  No  Yes  Unknown
Has this person ever had a TST performed prior to this flight?
 Unknown  No  Yes, date of most recent (month/year):
/
Result:  Negative  Positive
Has this person ever had an IGRA performed prior to this flight?
 Unknown  No  Yes, date of most recent (month/year):
/
Result:  Negative  Positive  Indeterminate/borderline
Has this person been previously diagnosed with TB/LTBI?  No  LTBI  TB disease  Unknown
If yes, did they receive treatment?  Yes  No  Unknown
*If you are unsure whether a country is considered high TB prevalence (greater than 20/100,000 cases), please refer to the WHO’s list of high TB burden countries.

6. TB SCREENING AND EVALUATION
Did the person have signs and symptoms of TB? Yes  No Not evaluated
Was person screened for TB infection after exposure on this flight? (As part of this evaluation or for another reason)  Yes  No
If no, why not?  Previous positive TB screening  Declined  Lost to follow up  Other, specify
If yes, what type of testing? (check all that apply)
 TST: Date of 1st TST read:
/ /
Results:  Positive  Negative
Date of 2nd TST read:

/

/

Results:  Positive

 Negative

 IGRA: Date of 1 IGRA:

/

/

Results:  Positive  Negative Indeterminate/borderline

Date of 2nd IGRA:

/

/

Results:  Positive  Negative  Indeterminate/borderline

st

Was a chest X-ray done?  No  Yes, results:  Normal  Abnormal, non-cavitary
Diagnosis:  No infection  LTBI  TB disease  Undetermined
If diagnosed with TB disease or LTBI, was treatment prescribed? Yes, date started
7. FORM COMPLETION

 Abnormal, cavitary
/ /_____  No, why not?_________

Person(s) completing the form:__________________________________ Date form completed:_

/

/

8. COMMENTS

Public reporting burden of this collection of information is estimated to average 10 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 H-21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-0900.