Data Request to Health Departments

Form Approved

OMB No. 0920-0932

Expires 05/31/2015

Appendix D: Data Request to Health Departments

CDC is conducting an assessment of the Ebola CARE+ program. The objectives of the CARE+ program are to increase travelers’ knowledge of Ebola symptoms, awareness of active monitoring requirements, intentions to participate, knowledge of how to seek medical care safely, and trust in the US public health system, and to remove barriers to participation in active monitoring. The ultimate goal is to improve travelers’ initiation into and retention in active monitoring.

CDC has conducted surveys with travelers to get their perspective on their experience with the program and their initiation into and retention in active monitoring. In order to complete the evaluation, we are seeking feedback from health departments on the monitoring of these travelers. The travelers whose CARE IDs are listed below have consented to participate in the surveys that are a part of this program evaluation. CDC did not obtain participant consent for obtaining information about them from you (the health department) since it could have affected their responses to survey questions, their interactions with you, and their participation in active monitoring, and potentially biased our evaluation. However, since the travelers have completed their monitoring, there are no potential harms that could result from collecting this information.

Your response to this data collection request is completely voluntary. Whether your organization chooses to participate and any information you provide will not impact your organization’s relationship with CDC. The evaluation is only intended to capture the impact of the CARE+ program on travelers’ participation in monitoring as described above, and will not assess health departments’ performance in conducting monitoring. The evaluation, including traveler interviews and this information collection, has been approved by CDC as a program evaluation that does not represent human subjects research. The CDC evaluation team is willing to answer any questions that you may have about this evaluation project. The CDC point of contact is Christine Prue ([email protected]) and she can be reached at (404) 639-2273.

The evaluation team is requesting eight data points that we believe that the CARE+ program was intended to influence including:

1. Date of traveler arrival in jurisdiction

2. Date and time of first contact with the traveler [mm/dd/year; time of day]

3. End date of active monitoring

4. Preferred phone number for contacting and reporting [###-###-####]

5. Did the traveler ever report a fever or Ebola symptoms? [yes or no]

6. Was contact with traveler ever lost for more than 48 hours? [yes or no]

7. Did the traveler complete monitoring and reporting requirements to the end of the reporting period? [yes or no]

8. Reason traveler did not complete monitoring and reporting requirements (e.g., transferred to another jurisdiction, left U.S., etc.), if applicable.

If you are able to participate in this evaluation, please provide this information for the CARE ID numbers listed below.

Thank you for your assistance. We believe this evaluation will offer the public health community an opportunity to learn from the Ebola response experience in a way that could inform future programs that involve education and active monitoring of travelers for the control of infectious diseases.

List of CARE ID numbers

[CARE ID #]

SAMPLE FORM .

CARE ID #	Date Traveler arrived in jurisdiction	Date of first contact with Traveler	Time of first contact with Traveler	End date of active monitoring	Preferred phone number for contacting and reporting	Did the traveler ever report a fever or Ebola symptoms?	Was contact with traveler ever lost for more than 48 hours?	Did the traveler complete monitoring and reporting requirements to the end of the reporting period?	Reason traveler did not complete monitoring and reporting requirements
###	MM/DD/YR	MM/DD/YR	HH:MM AM/PM	MM/DD/YR	###-###-####	YES/ NO	YES/NO	YES/NO	CONTACT NEVER MADE TRANSFERRED TO OTHER U.S. JURISDICTION LEFT THE U.S. DURING REPORTING PERIOD OTHER (Please specify) NOT APPLICABLE, TRAVELER COMPLETED MONITORING

Public reporting burden of this collection of information is estimated to average 240 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-0932).