TB Maritime Word

OMB Control No.  0920-0900

Expiration Date: 09/30/2017

TB Maritime Contact Investigation Outcome Reporting Form

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

1. Voyage Information on index case
CDC/QARS ID#	Arrival date	Arrival City/Port		Departure City/Port			Crew/Passenger
2. Index case clinical AND lab infoRMATION
3. PASSENGER Contact Information
Last name, First name or other identifier			Assigned cabin		Gender	DOB (mm/dd/yyyy)/Age (yrs)
4. Contact inFORMATION
Were you able to contact this person?  No, why not?  Incorrect locating info  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 exposure to index case: ___/___/___  Unknown Was this person a crew member?  No  Yes Was this person a known close contact of the index case outside of this voyage (e.g. family member)?  No  Yes Was this person frequently in close proximity to index case (e.g. cabinmate, work, or social)?  No  Yes, specify ______________ Country of birth: ______________________________ , Country of residence___________________________
5. INTERVIEW INFORMATION
Risk factors for prior TB infection (check all that apply below):  No known risk factors other than exposure to index case on this ship  Close contact with a known case of TB other than the index case  Ever lived in a country with high TB prevalence*, specify ___________________________________________  Other risk factors (i.e. history of incarceration, homelessness, IV drug use), specify____________________________________ Does person have a history of previous TB?  No  LTBI  Active TB  Unknown Has person ever received BCG vaccine?  No  Yes  Unknown Has this person ever had a TST performed prior to this investigation?  Unknown  No  Yes, date of most recent (month/year): ____/____ Result:  Negative  Positive Has this person ever had an IGRA performed prior to this investigation?  Unknown  No  Yes, date of most recent (month/year): ____/____ Result:  Negative  Positive  Indeterminate *If you are unsure whether a country the contact lived in is considered high TB prevalence (greater than 20/100,000 cases), please list it in the specified field and we will make that determination for you upon receipt of the form.
6. TB SCREENING AND EVALUATION
Was this person screened for TB infection as a part of this investigation?  No, why not?  Previous positive TB screening  Declined  Lost to follow up  Other, specify __________________  Yes, what type of testing? (check all that apply)
 TST: Date of 1st TST read: ___/___/___  Results:  Positive    Negative Date of 2nd TST read: ___/___/___  Results:  Positive    Negative  IGRA: Date of 1st IGRA: ___/___/___ Results:  Positive    Negative    Indeterminate Date of 2nd IGRA: ___/___/___ Results:  Positive    Negative    Indeterminate Was a review of signs and symptoms completed?  No  Yes Was a chest X-ray done?  No  Yes, results:  Normal  Abnormal, non-cavitary  Abnormal, cavitary Diagnosis:  No infection  LTBI  Active TB disease suspected  Active TB disease confirmed  Unknown If diagnosed with TB, was treatment prescribed?  No, why not? _____________________  Yes, date started ___/___/___
7. 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.