0920-0900 General Contact Investigation Outcome Reporting Form (La

OMB Control No. 0920-0900
Expiration Date: XX/XX/XXXX

General Land Contact Investigation Outcome Reporting Form
FAX completed form to the CDC at 404.718.2158; For questions, call 404.639.7147
1. TRAVEL INFORMATION
CDC/QARS ID#

Arrival date

Departure city,
state, country

Arrival city, state,
country

Port of Entry or
Border Patrol
Sector:

 Train  Bus _ Other:
Company/Route No:

2. INDEX CASE
ILLNESS SUSPECTED/PROBABLE/CONFIRMED (CIRCLE ONE):__________________
CLINICAL INFORMATION:
LABORATORY INFORMATION:

3. INFORMATION FOR EXPOSED (CONTACT) PASSENGER/TRAVELER
Address/Phone/email
Last name, First name

Gender

DOB (mm/dd/yy)/Age (yrs)

4. CONTACT INTERVIEW INFORMATION
Were you able to contact this person?
 No, due to:  Incorrect locating information  No longer at temporary address but still in 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, due to:  Declined  Lives in different jurisdiction, specify _________________
 Other, specify _______________________________________________ (Stop here)
 Yes; actual/verified seat/location #__________  Unknown  Does not apply
Was this person a known close contact of the index case outside of this travel (e.g. family member)?  No  Yes:specify
5. IMMUNITY
Vaccination or history of disease:
 Not vaccinated
 Does not apply
 History of disease
 Immunity established by serology
 Unknown
 Vaccinated Vaccination Type:_______________ Manufacturer: ______________ Date of Doses: __/__/__; __/__/__; __/__/__
6. HEALTH SINCE TRAVEL
Did contact report any signs or symptoms?  No  Yes, Date of earliest symptom onset ____/___/___ ; check all that apply:
 Fever (Max temp measured ______oC/F)
 Cough
 Rash
 Coryza
 Conjunctivitis
 Sore throat
 Swollen glands
 Vomiting
 Diarrhea
 Jaundice
 Headache
 Neck stiffness
 Unusual bleeding  Decreased consciousness
 Difficulty breathing/shortness of breath
 Recent onset of focal weakness and/or paralysis  Loss of sense of smell  Loss of sense of taste  Fatigue
 Other, specify _________________________________
7. PUBLIC HEALTH INTERVENTION
Did contact receive prophylaxis for this exposure?
 No, due to:
 Outside window for prophylaxis
 Within window for prophylaxis but declined
 Other, specify _________________
 Yes, please indicate what s/he received and include the date(s):
 Antimicrobial drug; specify____________________, date received: ___/___/___  Vaccination; date received: ___/___/___
 Immunoglobulin; date received: ___/___/___
 Other, specify _________________________; date received: ___/___/___
8. DIAGNOSIS
Was this person diagnosed with the disease in question?
 No
 Unknown, why?  Declined medical evaluation  Not interviewed after incubation period
 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 exposures this person may have had recently for the disease in question:
 Exposed to a confirmed case besides the index case
 Other, specify ______________________________________
What was the official diagnosis for this person (e.g. confirmed pertussis, active TB, LTBI)? _______________________________
9. COMMENTS

OMB Control No. 0920-0900
Expiration Date: XX/XX/XXXX

General Land Contact Investigation Outcome Reporting Form
FAX completed form to the CDC at 404.718.2158; For questions, call 404.639.7147
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.