Rubella Maritime (Word)

OMB Control No.  0920-0900

Expiration Date: XX/XX/XXXX

Rubella Maritime Contact Investigation Outcome Reporting Form

FAX completed form to the CDC at 404.718.2158; For questions, call 404.639.7147

Voyage Information
CDC/QARS ID#	Arrival date	Departure city/port		Arrival city/port			Index case cabin
2. Index case clinical AND lab information
3. Contact Information
Last name, First name or Unique Identifier			Assigned cabin		Gender	DOB (mm/dd/yyyy)/Age (yrs)
4. Contact/Interview information
Were you able to contact this person?  No, why not?  Incorrect locating information  No longer at temporary address but still in the U.S.  No response  Returned to country of residence  Didn’t attempt follow-up  Other, specify _____________ (Stop here)  Yes, date contacted: ___/___/___ Was contact interviewed?  No, why not?  Declined  Lives in different jurisdiction, specify _________________  Other, specify ________________________________________________ (Stop here)  Yes; actual/verified cabin #________ , date of last known contact with index case: ___/___/___ Was this person a known close contact of the index case outside of this voyage (e.g. family member)?  No  Yes Was this person a crew member?  No  Yes, was this person frequently in close proximity to index case besides sharing living quarters (i.e. work or social)?  No  Yes, specify _______________________________________
5. immunity
MMR (or other rubella-containing vaccine) or history of disease:  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  Unknown
6. Rubella intervention related to exposure
Did contact receive intervention for this exposure to rubella (not routinely recommended)?  No  Yes, please indicate what s/he received and the date :  Immunoglobulin; Date received:___/___/____  Other, specify ______________________________________________ Reason for intervention: ______________________________________________________________________________
7. health since exposure
Is this person pregnant?  No  N/A  Yes; what trimester at time of the voyage?  1st  2nd  3rd Did contact report any signs or symptoms of rubella?  No (Stop here)  Yes If yes, check all that apply:  Fever (Max temp measured ______oC/F)  Rash  Cough  Coryza  Conjunctivitis  Lymphadenopathy  Arthritis/arthralgia
8. DIAGNOSIS
Was this person diagnosed with rubella?  No  Unknown, why?  Declined medical evaluation  Not interviewed after incubation period (max of 23 days after last exposure)  Lost to follow-up  Other, specify _________________________________________________  Yes, how was diagnosis made? (Check all that apply)  IgM  Paired IgG  PCR  Culture  Epi-linked  Clinical diagnosis  Other, specify______________ 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 confirmed rubella case besides the index case on the ship  Other, specify _________________________________________
9. 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 D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0900.