| Close Contact ID# |
Close Contact Initials (e.g., Jane Doe = JD) |
Traveler type (crew or passenger) |
Date of Birth (MM/DD/YYYY) |
Country of Residence |
Embarkation Date (MM/DD/YYYY) |
Disembarkation Date (MM/DD/YYYY) |
Case initials (e.g., Jane Doe = JD) close contact was exposed to |
If known, how was contact exposed (i.e., cabinmate, dining mate, travel companion, shared excursion, etc.)? |
Does person have risk factors for severe illness? |
Is person fully vaccinated? |
Vax Dose #1 Date (MM/DD/YYYY) |
Vax Dose #1 Manufacturer |
Vax Dose #2 Date (MM/DD/YYYY) |
Vax Dose #2 Manufacturer |
Vax Booster Date (MM/DD/YYYY) |
Vax Booster Manufacturer |
Was close contact tested for COVID-19? |
Type of testing received |
Date specimen collected (MM/DD/YYYY) |
Testing result |
If positive, was this close contact (now a case) reported via EDC? |
Was close contact quarantined? |
Quarantine Start Date (MM/DD/YYYY) |
End of Quarantine Test Date (MM/DD/YYYY) |
End of Quarantine Test Type |
End of Quarantine Test Result |
Quarantine End Date¥ (MM/DD/YYYY) |
If close contact disembarked while in quarantine, disembarkation test type? |
Disembarkation Day Test Date (MM/DD/YYYY) |
Disembarkation Day Test Result |
If positive, was this close contact (now a case) reported via EDC? |