Influenza A Trace Back

Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form

For Investigation of Contacts Potentially Exposed to Persons with Suspected or Confirmed Pandemic or Novel Influenza A Virus Infection

Novel and Pandemic Influenza A Virus Infection Contact Trace Forward Form – For Investigation of Contacts Potentially Exposed to Persons with Suspected or Confirmed Pandemic or Novel Influenza A Virus Infection

State/Local case ID# _______________ Date of case-patient Illness onset __________________

CDC case ID # _______________ Date of case-patient Illness notification __________________

Contact Group ID# _______________

**NOTE: A contact of a case-patient is anyone who came within 1 meter or 3 feet of the case-patient, by for example, taking care of, speaking to, directly touching, or handling case-patient items**

Close Contacts—Family, friends, and other persons who live with or take care of the case-patient

Last Name	First Name	DOB	Age	Gender	Relationship with case*	Telephone	Email	Address	Date of Last Contact with Case	Under Follow-up
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						

* Family member(specify), friend, other(specify)

Medical Contacts—Doctors, nurses, or others healthcare workers

Last Name	First Name	DOB	Age	Gender	Relationship with case**	Telephone	Email	Address	Date of Last Contact with Case	Under Follow-up
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						

** Specify type of type of healthcare worker

Work or School Contacts—Co-workers, classmate, employers, teachers, or other members of workplace or school

Last Name	First Name	DOB	Age	Gender	Relationship with Case***	Telephone	Email	Address	Date of Last Contact with Case	Under Follow-up
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						
				 M  F						

** specify co-worker, employee, employer, etc