Form 0920-25AU Contact Tracing Survey

Form Approved

OMB No. 0920-1446

Exp. Date: 3/31/2025

ATTACHMENT 6. CASE INTERVIEW FORM TO IDENTIFY SEXUAL CONTACTS

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1446).

To be completed using information from initial interview:

Patient ID #:__________________________ Date of interview: _____________________________

Date of symptom onset: ______________________ Date of return from travel: ____________________

Period of interest: date of illness onset through 6 weeks after symptom onset, or date of interview, whichever is earliest

Date of symptom onset:	through	Six weeks after symptom onset or date of interview (whichever is earliest):
(MM/DD/YY) ___/___/___		(MM/DD/YY) ___/___/___

What is your sex?

o Female o Male

Did you have sexual or intimate contact with anyone between the time you became ill [give date] through [end of period of interest]? Further information if needed: sexual contact includes things like oral, anal, and vaginal sex or touching the genitals (penis, testicles, labia, and vagina) or anus (butt) of another person.

o Yes o No à End of interview

If yes, can you provide some information about your sexual partners during that time period?

o Yes o No à End of interview

During the period of interest, how many different people did you have oral, vaginal or anal sex with?

_____________

Complete the following section for each sexual partner:

Partner name: ____________________________ Phone number: _______________________________

Did this partner travel with you before your illness? o Yes o No

[If partner traveled] Did they also get sick within two weeks of returning? o Yes à move on to next partner o No o Unknown

Do we have permission to contact this partner? o Yes o Noà move on to next partner

Date of earliest sexual encounter during the period of interest: __________________________________

Date of latest sexual encounter during the period of interest: ___________________________________

Total number of sexual encounters with this partner during period of interest: _____________________

During this time period, what kinds of sexual contact did you have with this partner?

o Oral-penile o Oral-vaginal o Oral-anal

o Penile-vaginal o Penile-anal o Don't know

o None of the above, specify: ___________________________________________________

If yes to oral-penile:

Did you or your partner use a condom during these oral-penile sexual exposures?

o Yes, always o Yes, but not always o No o N/A

If yes to penile-vaginal, or penile-anal:

Did you or your partner use a condom during these penile-vaginal and/or penile-anal sexual exposures?

o Yes, always o Yes, but not always o No o N/A

If yes to oral-vaginal:

Did you or your partner use any type of barrier contraceptive such as a dental dam during these oral-vaginal sexual exposures?

o Yes, always o Yes, but not always o No o N/A

Did you or your partner use any other types of barrier contraceptive such as an internal condom or diaphragm during these sexual exposures?

o Yes, always o Yes, but not always o No o N/A

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