Get the free Form 2E: Smallpox Case Household and Primary Contact Surveillance Form - bt cdc

Form 2E Smallpox Case Household and Primary Contact Surveillance Form The purpose of this form is to provide a worksheet/diary for the case household contact or other primary contact to record information about such as date of vaccination date of take daily temperature and if they develop a rash or severe adverse reaction* Note The goal is to have the information on Form 2E in a database that can be electronically updated with the date of vaccination for each individual via the vaccination...

How to fill out form 2e smallpox case

How to fill out Form 2E: Smallpox Case Household and Primary Contact Surveillance Form

1. Begin by entering the date at the top of the form.
2. Fill in the primary contact's full name.
3. Enter the address of the household.
4. Provide the phone number of the primary contact.
5. Indicate the relationship of the primary contact to the smallpox case.
6. Complete the section detailing household members, including their names and ages.
7. Record any symptoms or vaccination status for each household member.
8. Answer any additional questions related to the smallpox case.
9. Sign and date the form at the bottom before submission.

Who needs Form 2E: Smallpox Case Household and Primary Contact Surveillance Form?

1. Healthcare professionals monitoring smallpox cases.
2. Public health officials conducting surveillance.
3. Emergency responders involved in outbreak control.
4. Any individuals engaged in epidemiological research related to smallpox.

For pdfFiller’s FAQs

What is Form 2E: Smallpox Case Household and Primary Contact Surveillance Form?

Form 2E is a surveillance tool used to collect data on individuals living in the household of a confirmed smallpox case and their primary contacts to monitor for symptoms and manage public health responses.

Who is required to file Form 2E: Smallpox Case Household and Primary Contact Surveillance Form?

Healthcare providers and public health officials are required to file Form 2E for any confirmed smallpox case to ensure appropriate monitoring of contacts.

How to fill out Form 2E: Smallpox Case Household and Primary Contact Surveillance Form?

Form 2E should be completed by providing detailed information about the smallpox case, the household members, and any primary contacts, including demographic data and health status.

What is the purpose of Form 2E: Smallpox Case Household and Primary Contact Surveillance Form?

The purpose of Form 2E is to facilitate surveillance of smallpox cases by tracking household and primary contacts, enabling early detection of symptoms and outbreaks.

What information must be reported on Form 2E: Smallpox Case Household and Primary Contact Surveillance Form?

Information required includes the names and contact details of household members and primary contacts, their relationship to the case, vaccination status, and any reported symptoms.