Contact Information Form
ADVERTISEMENT
1
2
3
4CONTACT INFORMATION FORM
INDEX CASE/SUSPECT INFORMATION
(1) Last name
First
MI
(2) DOB
/
/
(3) Period of infectiousness from
/
/
to
/
/
(4) Case manager’s name:
(5) Investigator’s name (if different from case manager):
(6) Reason for investigation:
Contact investigation
Source case investigation
Administrative, no risk
(7) Drug resistance (check all that apply):
INH
RIF
EMB
PZA
Other:
CONTACT INFORMATION
(8) Last name
First name
(9) Address
Street
Apt #
City
State
Zip
(10) Phone
Home
-
-
Pager/mobile
-
-
(11) DOB
/
/
(12) Age at initial investigation
months / years (circle one)
(13) Gender
Male
Female
(14) Social security #
-
-
(15) Parent/guardian name:
EXPOSURE INFORMATION
(16) Date first identified by index case as a contact
/
/
(17) Time frame of exposure:
______/______/__________ to ______/______/__________
(18) Exposure site(s):
Home
Work
School
Jail/Prison
Shelter
Other:
(19) Relationship to case
(20) Contact is
Household
Out of household
(21) Was the contact interviewed?
Yes, if yes date
/
/
No
(22) Cumulative hours of exposure*
hours
• Frequency of exposure
times per day / week / month (circle one)
• Duration of exposure
minutes / hours (circle one) of exposure each time
• Time frame of exposure
days / weeks / months (circle one) during the infectious period
(23) Area of exposure*
Size of a car
Size of a bedroom
Size of a house
Larger than a house
(24) Ventilation*
Closed window
Air conditioning
Re-circulated air
Open window
Completely open to outside
*Calculate the client’s exposure to the TB case/suspect only during the infectious period
DEMOGRAPHIC / EMPLOYMENT INFORMATION
(25) Ethnicity
Hispanic/Latino
Non-Hispanic/Non-Latino
(26) Race
American Indian or Alaskan Native
Asian, specify
Black or African American
Native Hawaiian/ Other Pacific Islander, specify
White
(27)Country of birth
U.S.A.
Non-U.S., specify:_______________________
(28) Date arrived into U.S. ______/______/__________
(29) Country of residence or refugee camp prior to entry into U.S.
(30) Primary language
(31) Interpreter used?
Yes
No
(32) Employed?
Yes, employed at
No, reason why:
Student
Retired
Unemployed, last date of employment
/
/
(33) Health insurance
No
Yes, Health Insurance Plan
CIF August 2008
1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical