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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