Form 0920-0900 State/Local General Outcome Reporting

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

General 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
Diagnosis: __________________
_

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?  Yes  No
If 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 ____________________ (Skip to Section 9)
If yes, date initially 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)?  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:
o
 Fever (Max temp measured
C/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?  Yes
 No
If no, why not?
 Outside window for prophylaxis
 Within window for prophylaxis but declined
 No applicable prophylaxis
 Other, specify:
If yes, please indicate what prophylaxis was 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? Yes  No  Unknown
If no or unknown, why?  Declined medical evaluation
 Not interviewed after incubation period
 Lost to follow-up
 Other, specify
If yes, how was diagnosis made? (Check all that apply)
 Paired IgG
 PCR
 Culture  Epi-linked  Clinical diagnosis
 Other, specify
 IgM
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
 Visited/lives in a country with high burden of disease
Other, specify
9. FORM COMPLETION
Person completing form: ____________________________________________

Date form completed:

/

/

10. 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.