Form 0920-0900 TB Maritime Contact Investigation Worksheet

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Overview

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TB Maritime Contact Investigation Worksheet														OMB Approved Control No. 0920-0900 Expiration Date: XX/XX/XXXX
Centers for Disease Control and Prevention
Ship Name:
									*High risk contacts include children less than 5 years of age; persons with medical risk factors such as silicosis, diabetes, leukemias and lymphomas, carcinoma of the head or neck and lung, weight loss of >10% ideal body weight, recent gastrectomy or jejunoileal bypass surgery; and severely immunosuppressed (i.e., those who are HIV infected or taking immunosuppressive therapy).
									^TB signs or symptoms include: fever, chills, persistent cough, breathing difficulties, blood in sputum, night sweats, weight loss, and fatigue.
									¥Latent TB Infection (LTBI) with M. tuberculosis manifests as a specific immune response (+TST or IGRA) in the absence of clinical and radiological disease but with capacity to reactivate and cause clinical disease at a later time.
Demographic Information					Epidemiologic History				Contact Management
Contact Number	Initials	Age	Country of Birth	Country of Residence	Contact Type (Crew/Passenger)	Date of last exposure to case	Does contact have a previous history of a TB diagnosis? (Y/N)	High-risk contact*? (Y/N)	Is contact still on the vessel? (Y/N)	If contact is no longer on the vessel, was the vessel company (if crew) or CDC (if passenger) notified? (Y/N)	Was contact interviewed? (Y/N)	Does this person have any signs or symptoms of TB^? (Y/N)	If a chest X-ray was done, did it show any signs of TB? (Y/N)	If a high-risk contact* without TB signs/symptoms, how was contact assessed for latent TB (LTBI)¥?	Results of high-risk contact LTBI screening
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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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-0900.

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Crew	Y	TST	Positive
Passenger	N	IGRA	Negative
		Not Done	Indeterminate