Appendix A.
Mpox Backward Contact Listing Form
Name of Case:_____________________________________________________________
Date of Contact Relation to Date of first Date of last Type of
Full Name Age Sex Occupation Address Remarks
birth number case exposure exposure contact
Indicate Last Name, First Name, Middle Name Age: Indicate mm/dd/yyyy Specify Specify Specify Specify house # street/purok/subdivision, mm/dd/yyyy mm/dd/yyyy Type 1 Specify in remarks
D - days contact occupation relationship barangay, municipality/city, province, Type 2 if symptomatic or asymptomatic
M - months information with case region Type 3
Yr. - years Include other observations
Sex: during exposure, if any
F - Female
M - Male
Types of contact:
Type 1– Direct contact with skin lesions of a confirmed Mpox case - vesicles, pustules, crusts etc. (including sexual contact) OR direct contact with a confirmed animal case.
Type 2 – Direct contact with body fluids of confirmed Mpox case (blood, urine, vomitus, feces, stool, sputum etc.)
Type 3 – Sharing of common space with case (e.g. vehicle, household, shared room/workstation, flight, etc.) If type 3, specify venue in remarks.
Backward contact – persons exposed to a suspect/probable/confirmed case, 21 days prior to symptom onset of the case.
Backward contact tracing is conducted to identify potential sources of infection.
Appendix B. Mpox Forward Contact Listing Form
Name of Case:_____________________________________________________________
No. of Date of first Date of last
Date of Contact Relation to Type of Laboratory
Full Name Age Sex Occupation household Address contact with contact
birth number case contact done
members case with case
Indicate Last Name, First Name, Middle Name Age: Indicate mm/dd/yyyy Specify Please Spec- Specify Specify House # Street/Purok/ mm/dd/yyyy mm/dd/yyyy Type 1 Y-yes
D - days contact ify Occupa- relationship Subdivision, Barangay, Municipality/ Type 2 N-no
M - months information tion with case City, Province, Region Type 3 If yes. specify
Yr. - years test and result
Sex:
F - Female
M - Male
Types of contact:
Type 1– Direct contact with skin lesions of a confirmed Mpox case - vesicles, pustules, crusts etc. (including sexual contact) OR direct contact with a confirmed animal case.
Type 2 – Direct contact with body fluids of confirmed Mpox case (blood, urine, vomitus, feces, stool, sputum etc.)
Type 3 – Sharing of common space with case (e.g. vehicle, household, shared room/workstation, flight, etc.) If type 3, specify venue in remarks.
Forward contact – persons exposed to suspect/probable/confirmed case from date of onset of symptom to isolation of the case.
Forward contact tracing is conducted to identify exposed persons for symptom monitoring until 21 days post-exposure from suspect/probable/confirmed case.
Appendix C. Mpox Forward Contact Monitoring Form
Name of Case:___________________________________________________________
Date of last Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day
Full Name follow-up 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Remarks
mm/dd/yyyy (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S) (A/S)
Indicate Last Name, 21 days from Specify status on the day of monitoring: Specify
First Name, Middle date of last A - asymptomatic remarks/
Name contact S - symptomatic observations
during
monitoring,
If any
Monitored by: _____________________________________ Reviewed and Approved by: ______________________________________
(Printed Name over Signature) (Printed Name over Signature)
