COVID-19 Contact Tracing Form

C OVID-19 Contact Tracing Form

I. Interview Information

Date of interview: MM / DD /YYYY

Contact Tracer Name: Last: First: _________________

Interviewee Name: Last:_____________________________ First:__________________

Who is providing information for this form? (select one)

• DHS COVID-19 Positive Individual

Do you have symptom(s)? Yes ____No____

Do you telework fulltime? Yes ____No____

If Yes, were you physically present at a DHS worksite 48 hours before symptom(s) onset through the last date you worked? (Symptomatic individuals) Yes____ No____

If No, were you at a DHS worksite 2 days prior to a positive specimen collection or until the time you were isolated?

(Asymptomatic individuals) Yes ____ No____

If Yes, to either question, proceed with the interview and data collection. If No, data collection is not necessary.

• DHS Exposed Individual

• Other, specify person Last: ______________________ First:

If other, what is the relationship to the COVID-19 positive or exposed individual: _____________________________

DHS COVID-19 Positive Individual or Exposed Individual Information:

Worksite address: _______________________________ _________

City: ______________________ State: ________________ Zip code: ______________

Personal phone number: (___) _________________ ( ­__Mobile or ___Home)

Work phone number: (___) _______________

Work email address: ____________________

Where is your primary site of work [e.g., department, floor, desk location]? ______________________________

Supervisor Name: Last: _________________________First: __________________

Supervisor’s Phone Number: Email: _______________________________

II. DHS COVID-19 Positive Individual’s Work Activity
Please list all work activities, floors visited, meetings attended (including lunches, etc.) that you participated in starting 48 hours before the illness onset. (Symptomatic individuals) FROM: MM / DD / YYYY THROUGH: The last date worked at a DHS worksite: MM / DD / YYYY OR Please list all work activities, floors visited, meetings attended (including lunches, etc.) that you participated in starting 2 days prior to a positive specimen collection or until the time you were isolated. (Asymptomatic individuals) FROM: MM / DD / YYYY THROUGH: The last date worked at a DHS worksite: MM / DD / YYYY This may not be all 14 days. If the COVID-19 positive individual indicates visiting meeting rooms, ask them to identify where they sat in the meeting room. Use that information to inform whether others in meeting room were in 6 ft range for at least 15 minutes. (See the description of close contact1 in the work place, in the footnote below).
	Notes
Date of symptom onset: MM / DD / YYYY
	Locations/Notes		Locations/Notes
1 day before symptom onset MM / DD / YYYY		2 day before symptom onset MM / DD / YYYY
1 day after symptom onset MM / DD / YYYY		2 days after symptom onset MM / DD / YYYY
3 days after symptom onset MM / DD / YYYY		4 days after symptom onset MM / DD / YYYY
5 days after symptom onset MM / DD / YYYY		6 days after symptom onset MM / DD / YYYY
7 days after symptom onset MM / DD / YYYY		8 days after symptom onset MM / DD / YYYY
9 days after symptom onset MM / DD / YYYY		10 days after symptom onset MM / DD / YYYY

11 days after symptom onset MM / DD / YYYY		12 days after symptom onset MM / DD / YYYY
13 days after symptom onset MM / DD / YYYY		14 days after symptom onset MM / DD / YYYY

	III. Exposed Individual(s)
Please complete the table below for all close contact exposures to a DHS COVID-19 positive individual which occurred 48 hours from the date of illness onset through the last date worked at a DHS worksite (symptomatic individuals)OR 2 days prior to a positive specimen collection or until the date the COVID-19 positive individual was isolated (asymptomatic individuals)
	Name (First and Last)	Location of Exposed Individuals (e.g., department, floor, desk location)	Phone Number (mobile or home) and Work Email	Date of last exposure to the DHS COVID-19 Positive Individual MM/DD/YYYY

Add additional rows as needed

1 Close contact exposure in the work place- 15 minutes within 6ft; 10-29 minutes of very close contact e.g., (1) Intimate contact (such as eating together); (2) Huddle meeting in a small room (3) Sharing of a laptop (4) One-on-one or group conversation in very close quarters or small room; Less than 10 minutes- Not a close contact

The DHS COVID-19 Contact Tracing Form constitutes recommendations based on the Center for Disease Control and Prevention guidance.

WARNING: This document is FOR OFFICIAL USE ONLY (FOUO). It contains information that may be exempt from public release under the Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C 552a). It is to be controlled, stored, handled, transmitted, distributed, and disposed of in accordance with DHS policy relating to FOUO information and is not to be released to the public or other personnel who do not have a valid "need-to-know" without prior approval of an authorized DHS official.

Paperwork Reduction Act Burden Notice: Public reporting burden for this form is estimated to average 20 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the information. This collection of information is voluntary. You are not required to submit to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for this collection to: Office of the Chief Human Capital officer OCHCOPrivacyOfficer@hq.dhs.gov