Form 0920-0900 Rubella Aircraft Contact Investigation Outcome Reporting

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

Rubella 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
 Returned to country of residence  HD didn’t attempt follow-up  Other, specify ___________________ (Skip to Section 9)
If yes, date contacted:
/
/
Was contact interviewed?  Yes  No
 No, why not?  Declined
 Lives in different jurisdiction, specify
 Other, specify
(Skip to Section 9)
 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:
 At both times
When was person interviewed?
 During incubation period
 After incubation period
5. IMMUNITY
MMR (or other rubella-containing vaccine) or history of disease:  Yes  No
 Not vaccinated
 One dose of vaccine
 Two doses of vaccine
 Three doses of vaccine
 Immunized, number of doses unknown
 History of disease
 Immunity established by serology
6. RUBELLA INTERVENTION RELATED TO EXPOSURE ON THE FLIGHT
Did contact receive intervention for this exposure to rubella (not routinely recommended)?  Yes  No
If yes, please indicate what s/he/they received and the date:
 Immunoglobulin; Date received:
/ /
 Other, specify:
Reason for intervention:

 Unknown

7. HEALTH SINCE FLIGHT
Is this person pregnant?  No  N/A  Yes; what trimester at time of the flight?  1st  2nd  3rd
Did contact report any signs or symptoms of rubella?  Yes
 No (Skip to Section 9)
o
If yes, check all that apply:  Fever (Max temp measured
C/F)
 Rash
 Cough
 Coryza
 Conjunctivitis
 Lymphadenopathy
 Arthritis/arthralgia
Check any of the following potential rubella exposures this person may have had in the 23 days prior to symptom onset:
 Visited/lives in a country with endemic rubella
 Exposed to a person with a confirmed rubella case other than the index case on the flight
 Other, specify
8. DIAGNOSIS
Was this person diagnosed with rubella?  Yes  No
 Unknown
If unknown, why?  Declined medical evaluation  Not interviewed after incubation period (max of 23 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 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.