Form 1 Public Health Investigation Form: Active TB

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

Minor

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., minor was potentially exposed for 4 hours a day in class for 5 consecutive days):

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

No

Yes, date: ____/____/______

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

No

Yes

If Yes, was minor evaluated by a healthcare provider?

No

Yes (Complete Health 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

Name

Date started

Date discontinued

Dose

Directions

Psychotropic?

Discharged with med?

No

Yes

No

Yes

No

Yes

No

Yes

Immunizations administered and/or indicated, but not given:

No

Yes

Vaccine name

Date administered

If indicated, but not given, state reason

Lab testing performed:

No

Yes

Illness

Test

Result

Specimen Source

Specimen Collection Date

Was minor quarantined?

No

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

Was discharge delayed due to potential exposure?

No

Yes, estimated end date of delayed discharge: ____/____/______

Outcome of ORR contact investigation (Check one):

Cleared

Incomplete evaluation, reason (e.g., runaway, age-out): __________________________________________________________ Diagnosed with illness of exposure (Complete Health Assessment Form)

Comments:

2 of 3

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.