Appendix 4-A. Case/Contact Investigation Form

San Luis Valley Region Pandemic Influenza Exercise

Case/Contact Investigation Report Form

(Fill in the blanks and circle all that apply.  Please complete form as completely as possible.)

Report Date:   ___/___/_____  (mm/dd/yyyy)

Report Time:   ___:___am/pm

*Diagnosis: Influenza Case → (must have fever (>100°F), plus cough or sore throat)

  (circle) Influenza Contact (must be household member of a case in the past 5 days)

*If an Influenza Case, Illness Onset Date: ___/___/_____   (mm/dd/yyyy)

*#Last Name:    _________________ (use alias from inject form if this is an inject case)

*#First Name:    _________________ (use alias from inject form if this is an inject case)

*#Birth Date:      ___/___/_____   (mm/dd/yyyy)

*Sex: (circle)
Female
Male

 

Race: (circle)
Unknown
American Indian/Alaskan Native
White
Pacific/Hawaiian
Asian
Black
Other

 

Ethnicity: (circle)
Unknown
Hispanic
Not Hispanic

Residence Information:   Street Address    City   County   ZIP

*#Address 1: _________________________________________________

   Address 2: _________________________________________________

Phone Numbers:	Title
*#Home:	_ _ _ - _ _ _ - _ _ _ _
*Work:	_ _ _ - _ _ _ - _ _ _ _
*Mobile	_ _ _ - _ _ _ - _ _ _ _

 

*Household Members:	Name (Last, First)	Birth Date	Phone
Member 1:	_________ , _________	___/___/______	___-___-____
Member 2:	_________ , _________	___/___/______	___-___-____
Member 3:	_________ , _________	___/___/______	___-___-____
Member 4:	_________ , _________	___/___/______	___-___-____
(Use additional forms as needed for other household members)

Case Notes or Comments:

Person filling out this form (please print):  ___________________________

Please Fax this form ASAP to Regional Epidemiologist at XXX-XXX-XXXX or call XXX-XXX-XXXX

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