Assessment on Ebola Inquiries and Preparedness

Attachment B: Instrument- Web Version

State, Teritorrial, and Local Domestic Inquiry Assessment

State/Local Health Department Assessment on Ebola Viral Disease (Ebola) Inquiries and Preparedness 
Form approved OMB No. 0920­0879 Expiration date: 04/30/2017 

The purpose of this assessment is to collect data on domestic inquiries and health department preparedness for the Ebola Viral Disease (Ebola) 
response. A domestic inquiry refers to any communication about a person who has presented to a U.S. health care setting for medical evaluation, 
and is ill with possible symptoms of Ebola. Such persons will be referenced as a Person under Investigation (PUI) for this assessment. A person who 
has had a high or low­risk exposure to an Ebola patient is considered a contact. This collection of information is estimated to take up to12 minutes 
to complete. Thank you for your participation! 

Public reporting burden of this collection of information is estimated 12 minutes to complete this assessment, 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D­74, Atlanta, Georgia 30333; ATTN: 
PRA (0920­0879) 

1. Name of State/Local Health Department

*2. Since April 1, 2014, has your health department received inquiries about persons

possibly exposed to Ebola? (If no, please skip to question #13)

j Yes
k
l
m
n
j No
k
l
m
n

3. What is your earliest date of inquiry?

4. How many inquiries have you received between your earliest inquiry date and July 9th,
2014?

5. How many inquiries did you receive for the month of July?

6. How many inquiries did you receive for the month of August?

7. How many inquiries did you receive for the month of September?

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State, Teritorrial, and Local Domestic Inquiry Assessment
8. Have you contacted CDC for any of these inquiries?

j Yes
k
l
m
n
j No
k
l
m
n

9. Which Ebola­affected countries were your PUIs associated with? (please check all that
apply)
c Liberia
d
e
f
g

c Guinea
d
e
f
g

c Sierra Leone
d
e
f
g
c Nigeria
d
e
f
g

c Senegal
d
e
f
g

c Democratic Republic of Congo
d
e
f
g

10. From which country did the majority of your PUIs come from? (Please check one)
j Liberia
k
l
m
n

j Guinea
k
l
m
n

j Sierra Leone
k
l
m
n
j Nigeria
k
l
m
n

j Senegal
k
l
m
n

j Democratic Republic of Congo
k
l
m
n

11. Which entity was your primary source of notification for PUIs? (Please check one)
j Hospital/Health Center
k
l
m
n
j Quarantine station
k
l
m
n

j Law enforcement/Military
k
l
m
n

j Customs and border control agencies
k
l
m
n
j Airport personnel
k
l
m
n

j Other (please specify)
k
l
m
n

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State, Teritorrial, and Local Domestic Inquiry Assessment
12. What were your primary reasons for contacting the CDC about a PUI? (check all that
apply)
c PUI had a low/high risk exposure status
d
e
f
g
c PUI had an unknown exposure status
d
e
f
g
c Uncertain about need for PUI testing
d
e
f
g

c Assessed that PUI testing is indicated and need CDC assistance with testing protocols
d
e
f
g
c Other (please specify)
d
e
f
g

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6  

13. If a person is identified as a PUI by your department, who would be the immediate next
entity (outside of the state/local health department) that your department notifies? (please
check one)
j CDC EOC Ebola Response Team
k
l
m
n

j Division of Global Migration and Quarantine
k
l
m
n
j Customs and border control agencies
k
l
m
n
j Other (please specify)
k
l
m
n

14. After reaching out to your primary notification agency (in question 13), please check all
other entities you contact about the PUI? (please check all that apply)
c CDC EOC Ebola Response Team
d
e
f
g

c Division of Global Migration and Quarantine
d
e
f
g
c Customs and border control agencies
d
e
f
g
c Other (please specify)
d
e
f
g

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State, Teritorrial, and Local Domestic Inquiry Assessment
15. Did your state set up special teams or procedures to handle Ebola inquiries in
response to the West African outbreak?

j Yes
k
l
m
n
j No
k
l
m
n

If yes, please describe: 

5
6

16. Do you currently have a database to keep track of PUIs/or future PUIs?

j Yes
k
l
m
n
j No
k
l
m
n

17. Questions 17­19 refer to tracing of contacts who had a high or low risk exposure to a
person with confirmed or suspected Ebola virus disease.
Do you have an identified individual(s) within your department who is responsible for PUI
follow­up and contact tracing?

j Yes
k
l
m
n
j No
k
l
m
n

18. Has your health department officially completed 21 day follow­up/monitoring of any
individuals following a high­risk or low­risk exposure?

j Yes
k
l
m
n
j No
k
l
m
n

19. Is your health department currently tracking a PUI for 21 days following a high­risk or
low­risk exposure?

j Yes
k
l
m
n
j No
k
l
m
n

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State, Teritorrial, and Local Domestic Inquiry Assessment
20. Do you have a protocol for tracking probable or suspected contacts?

j Yes
k
l
m
n
j No
k
l
m
n

21. If you answered yes to question 20, what data management methods do you use to
trace contacts? (please check all that apply)
c Database/excel spreadsheet
d
e
f
g
c Paper contact forms
d
e
f
g

c Other (please specify)
d
e
f
g

22. Have you ever contacted the CDC for guidance on any of the following:
Laboratory handling of 

Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

specimens
Healthcare setting/EMS 
infection control
Monitoring and Movement 
of PUIs and Contacts
Shipping of specimens and 
lab testing

23. Have you conducted health center trainings on protocols for contacting the health
department for suspected Ebola cases?

j Yes
k
l
m
n
j No
k
l
m
n

If Yes, what is your ealiest session date? 

24. If you answered no to question 23, what type of guidance have you given to health
centers for PUI identification? (please check all that apply)
c Written or electronic materials from the CDC
d
e
f
g

c Written or electronic materials generated by your health department
d
e
f
g
c Telephone guidance
d
e
f
g

c Other (please specify)
d
e
f
g

5
6  

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State, Teritorrial, and Local Domestic Inquiry Assessment
25. Have you developed health department­specific protocols for advising healthcare
providers on:
Yes

No

j
k
l
m
n

j
k
l
m
n

Specimen handling

j
k
l
m
n

j
k
l
m
n

Patient transport

j
k
l
m
n

j
k
l
m
n

Infection control practices 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Evaluating patients with 
suspected Ebola

(includes PPE and 
decontamination guidance)
Waste removal

26. If you answered yes to any training area in Question 25, have you utilized CDC
guidance on preparedness in the preparation of the training protocol? (If no, skip to
question #28)

j Yes
k
l
m
n
j No
k
l
m
n

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State, Teritorrial, and Local Domestic Inquiry Assessment
27. If yes you answered yes to Question 26, what documents have you used? (please
check all that apply)
c Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons under Investigation for Ebola Virus Disease in 
d
e
f
g
the United States (http://www.cdc.gov/vhf/ebola/hcp/interim­guidance­specimen­collection­submission­patients­suspected­infection­ebola.html) 

c Interim Guidance Regarding Compliance with Select Agent Regulations for Laboratories Handling Patient Specimens that are known or 
d
e
f
g
Suspected to Contain Ebola Virus (http://www.cdc.gov/vhf/ebola/hcp/select­agent­regulations.html) 

c Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure
d
e
f
g

c Guidance on Air Medical Transport for Patients with Ebola Virus Disease(http://www.cdc.gov/vhf/ebola/hcp/monitoring­and­movement­of­
d
e
f
g
persons­with­exposure.html) 

c Interim Guidance for Emergency Medical Services (EMS) Systems and 9­1­1 Public Safety Answering Points (PSAPs) for Management of 
d
e
f
g
Patients with Known or Suspected Ebola Virus Disease in the United States (http://www.cdc.gov/vhf/ebola/hcp/interim­guidance­emergency­
medical­services­systems­911­public­safety­answering­points­management­patients­known­suspected­united­states.html) 

c Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings (http://www.cdc.gov/vhf/ebola/hcp/clinician­information­us­
d
e
f
g
healthcare­settings.html) 

c Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals(http://www.cdc.gov/vhf/ebola/hcp/patient­management­us­
d
e
f
g
hospitals.html) 

c Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. 
d
e
f
g
Hospitals (http://www.cdc.gov/vhf/ebola/hcp/infection­prevention­and­control­recommendations.html) 

c Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries
d
e
f
g
(http://www.cdc.gov/vhf/ebola/hcp/guidance­safe­handling­human­remains­ebola­patients­us­hospitals­mortuaries.html) 

c Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus(http://www.cdc.gov/vhf/ebola/hcp/environmental­
d
e
f
g
infection­control­in­hospitals.html) 

c Recommendations for Breastfeeding/Infant Feeding in the Context of Ebola (http://www.cdc.gov/vhf/ebola/hcp/recommendations­
d
e
f
g
breastfeeding­infant­feeding­ebola.html) 

28. Have you distributed guidance or training materials to health centers or EMS/First
responders for the handling of suspected Ebola patients?

j Yes
k
l
m
n
j No
k
l
m
n

29. Is there any additional guidance or clarification of existing guidance from CDC that you
would like to have?
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