Form 1 Public Health Investigation Form: Non-TB Illness

OMB Control No: 0970-0509

Expiration date: XX/XX/XXXX

Public Health Investigation Form: Non-TB Illness Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information

Child

Last name:

First name:

DOB:

A#:

Gender:

Program

Program name:

Person completing form & date:

Exposure Information

Illness of exposure: ____________________________

Source of potential exposure: ____________________________________

Date of first potential exposure: ____ / ____ / ______

Date of last potential exposure: ____ / ____ / ______

Exposure details (e.g., child was potentially exposed for 4 hours a day in class for 5 consecutive days):

Was child screened for illness-specific signs/symptoms upon notification of exposure?

No

Yes, date: ____/____/______

If screened, did child have illness-specific signs/symptoms?

No

Yes

If Yes, was child evaluated by a healthcare provider?

No

Yes (Complete Medical Assessment Form)

Public Health Actions

Select No or Yes for each question below. If Yes, enter the information in the corresponding table.

Medications given:

No

Yes

Medication name

Date started

Date discontinued

Dose

Directions

Psychotropic

No

Yes

No

Yes

Immunizations administered and/or indicated because of this exposure, but not given:

No

Yes

Vaccine name

Date administered OR if indicated, but not given, state reason

Lab testing performed:

No

Yes

Illness

Test

Specimen Collection Date

Specimen Source

Result

Was child quarantined?

No

Yes, quarantine start date: ____/____/______ , quarantine end date: ____/____/______

Outcome of ORR public health investigation (Check one):

Pending

Cleared

Diagnosed with illness of exposure (Complete Medical Assessment Form)

Incomplete evaluation, reason (e.g., runaway, age-out): _________________________________________________________

Comments:

The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 5 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0509 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.