XDR TB Contact Tracing Worksheet

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					                                   XDR TB Contact Tracing Worksheet


We are attempting to document that all passengers and crew members have been contacted for this XDR
TB investigation. We ask your assistance with completing this form. Please document if and when the
communication has been established with the contact, and fax completed form to Dr. Ann Buff at CDC at
fax #: 404-639-8604. If you have any questions, please call Dr. Buff at 404-639-5313. Thank you!


Person Completing Worksheet: __________________________ Name of Agency: ____________________
Name of Passenger/Flight crew member: ____________________________________


Please make at least 3 attempts to contact the passenger:
Attempt # 1 date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)          spoke with passenger
        left message on machine      left message with person    (Name: ____________________)
       Comments: ______________________________________________________________________
                   ______________________________________________________________________


Attempt # 2 date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)          spoke with passenger
        left message on machine      left message with person    (Name: ____________________ )
       Comments: ______________________________________________________________________
                   ______________________________________________________________________


Attempt # 3 date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)          spoke with passenger
        left message on machine      left message with person    (Name: ____________________ )
       Comments: ______________________________________________________________________
                   ______________________________________________________________________


If unable to reach this passenger, please check reason:
        no known phone # or address       wrong phone #          wrong address
        phone is disconnected       other: specify __________________________________________
       Comments: ______________________________________________________________________
                   ______________________________________________________________________




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When communicating with passenger, please read this:


Hello, I am [your name and agency]. You may have been notified that you were possibly exposed to a person
with extensively drug-resistant tuberculosis (XDR TB) when you were on an airline flight in May 2007. First, I’d
like to verify what flight you took, please:


   Air France flight #385/Delta #8517 on May 12/13 (flight from Atlanta, GA to Paris, France was scheduled to
      depart on 8:55pm on May 12, but the flight was delayed and left early in the morning on May 13)
   Czech Air flight #104 on May 24 from Prague, Czech Republic to Montreal, Canada departed at        12:25pm


We recommend that you contact your State TB Controller at your earliest convenience so you can be referred for
TB testing. Your State TB Controller is: ________________________________
              Phone #: (_______) __________-__________


If you choose to receive TB testing through your private physician, we would still ask that you contact your State
TB Controller prior to your appointment and inform them that you were a passenger on one of these flights. Your
State TB Controller can work with your physician to ensure appropriate TB testing and follow-up.




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