Hospitalization vnne Satiiniin rye 2 okt eT | Neopia adelaide) | teebial aacharge cate —]—1— . ‘seed tote Aeznuniel vention or Intubation required Sui hospitalized VN Unk Died of ths Mness Dean dle _/__/__ Pease fin the det dt tration onto Porson Seeon | | YNune Tht patent raceve prophyadstretnent | speciy ned Antic Anvil Oar Number of days actually taken Treatment start date __/_/_Treatmentend date _/__/_ | eceica coke nn amg af Diraion Guys Wonks HORS Did patient take Indication PEP PrEP Treatment for disease incidental Other ‘Unk Prescribing provider medication as prescribed Yes No - Why not Fores arm Tag a1 abo}2) > fae PCR or #2- ilar — tue Raprol 43-wohla - Rapca Qu HA 10fnf2t - tate PER We Permission received to use case name in conversations with contacts wake) Case Name GE en ene es aS PART I: Identifying Sources of Infection souerersttina Callicn, —opne OE Port Land Part I: collect locations of potential exposure and transmission for each date below: »Aderosses and phone numbers of work & high rsk settings * Dates and tes vised (favalabl, time of arval and length of stay) STravelinfomation (2... deparure & arrival cites, method of transpor, transport company, fight number) + Remember to ask about stops at Feattheae faites, schools and childcare centers Information about Contaets « Narves and phone numbers of contacts, Relaton o case “Ate contacts eymptomate? eaRuicsr EXPOSURE PERIOD a3