Form 0920-25AU Contact Tracing Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

ATTACHMENT 6. CONTACT TRACING SURVEY

To be completed using information from initial interview:

Patient ID #:__________________________ Date of interview: _____________________________

Date of symptom onset: ______________________ Date of return from travel: ____________________

Period of interest: _________________________through ______________________________________

(date of return from travel through 6 weeks days after symptom onset, or date of interview, whichever is earliest)

What sex were you assigned at birth, on your original birth certificate?

o Female o Male o Other o Prefer not to answer/decline

How do you currently describe yourself? (check all that apply)

o Female o Male o Transgender o Prefer not to answer/decline

o I use a different term: ___________________________________________________

Did you have sexual or intimate contact with anyone between the time you returned from travel [give date] through [end of period of interest]? Further information if needed: sexual contact includes things like oral, anal, and vaginal sex or touching the genitals (penis, testicles, labia, and vagina) or anus (butt) of another person.

o Yes o No à End of interview

If yes, can you provide some information about your sexual partners during that time period?

o Yes o No à End of interview

During the period of interest, how many different people did you have oral, vaginal or anal sex with?

_____________

Complete the following section for each sexual partner:

Partner name: ____________________________ Phone number: _______________________________

Did this partner travel with you before your illness? o Yes à move on to next partner o No

Do we have permission to contact this partner? o Yes o Noà move on to next partner

Date of earliest sexual encounter during the period of interest: __________________________________

Date of latest sexual encounter during the period of interest: ___________________________________

Total number of sexual encounters with this partner during period of interest: _____________________

During this time period, what kinds of sexual contact did you have with this partner?

o Oral-penile o Oral-vaginal o Oral-anal

o Penile-vaginal o Penile-anal o Don't know

o None of the above, specify: ___________________________________________________

If yes to oral-penile:

Did you or your partner use a condom during these oral-penile sexual exposures?

o Yes, always o Yes, but not always o No o N/A

If yes to penile-vaginal, or penile-anal:

Did you or your partner use a condom during these penile-vaginal and/or penile-anal sexual exposures?

o Yes, always o Yes, but not always o No o N/A

If yes to oral-vaginal:

Did you or your partner use any type of barrier contraceptive such as a dental dam during these oral-penile sexual exposures?

o Yes, always o Yes, but not always o No o N/A

Did you or your partner use any other types of barrier contraceptive such as an internal condom or diaphragm during these sexual exposures?

o Yes, always o Yes, but not always o No o N/A

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).