Case Report Form - U.s. Department Of Health And Human Services Page 2

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U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
Log of Attempts to Call Patient or Surrogate (Optional)
(This page is for health department use only; please remove it before submitting form to CDC)
Last Name: _________________________
First Name: __________________________
Date
Time
Caller
Results*
Comments** Plan
First initial & last name
(May include more than one)
__ _____________ _______
____
___________________
Call 1
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 2
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 3
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 4
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 5
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 6
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 7
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 8
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 9
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 10
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 11
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 12
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 13
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 14
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 15
__ / __ / ____
___:___
**Key for Comments:
1 Interviewed with standard questionnaire
*Key for Results:
2 Called back for more information
1 Left message with person
3 Interviewed with supplemental questionnaire
2 Left message on voicemail
4 Language barrier, indicate plan
3 Did not leave message
5 No answer
6 Phone not in service, indicate plan
7 Refused

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