Form DD Form 2990 DD Form 2990 Ebola Virus Disease Exposure Risk Evaluation

This form must be completed electronically when possible. Handwritten forms will be accepted.
OMB No. 0720OMB approval expires

EBOLA VIRUS DISEASE EXPOSURE RISK EVALUATION
(IN THEATER USE ONLY)

The public reporting burden for this collection of information is estimated to average 12 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Suite 02G09, Alexandria,
VA 22350-3100 (0720-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it
does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ADDRESS.

PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting the personal information requested by this form and how it may be used.
AUTHORITY:

10 U.S.C. 1074f, Medical Tracking System for Members Deployed Overseas; 42 U.S.C. 264-272, Quarantine and Inspection, Executive Order 13295, Revised List of
Quarantinable Communicable Diseases; 42 CFR Part 70, Interstate Quarantine; 42 CFR Part 71, Foreign Quarantine; DoDI 6490.03, Deployment Health;
and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): Your information may be used for the purpose of collecting certain communicable disease(s) data IAW regulations providing for the apprehension, detention, or
conditional release of individuals to prevent the introduction, transmission, or spread of suspected communicable diseases, pursuant to section 361(b) of the Public
Health Service Act. Your information will be collected in order to identify any health concerns and, if necessary, refer you for additional assessment and/or care.
ROUTINE USE(S):

Use and disclosure of your records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at:
http://dpclo.defense.gov/privacy/SORNsIndex/BlanketRoutineUses.aspx and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164),
as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the
containment of certain communicable diseases.

DISCLOSURE:

Mandatory. To protect the health of the public from Ebola, a highly infectious virus of significant public health threat, you are hereby required to provide the
requested information. Care will not be denied if you decline to provide the requested information, but you may not receive the care you deserve and may face
administrative delays.

INSTRUCTIONS:

DoD personnel must IMMEDIATELY report any potential Ebola Virus Disease [EVD] exposure while deployed in an Ebola outbreak country
or region. Prompt medical evaluation is critical. You are required to truthfully answer all questions. Failure to disclose the requested medical
information regarding potential EVD contact or exposure risks while deployed to an Ebola outbreak area may result in UCMJ and/or criminal
punishment. If you do not understand a question, please discuss the question with a healthcare provider.

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DEMOGRAPHICS
Last Name:

First Name:

Middle Initial:

Social Security Number:

Today’s Date (dd/mmm/yyyy):

Date of Birth (dd/mmm/yyyy):

Gender:

Service Branch:

Component:

Pay Grade:

⃝ Air Force
⃝ Active Duty
⃝ Army
⃝ National Guard
⃝ Navy
⃝ Reserves
⃝ Marine Corps
⃝ Civilian Government Employee
⃝ Coast Guard
⃝ Contractor
⃝ Civilian Expeditionary Workforce
⃝ USPHS
⃝ Other Defense Agency (List):
⃝ Other (List):

⃝ E1
⃝ E2
⃝ E3
⃝ E4
⃝ E5
⃝ E6
⃝ E7
⃝ E8
⃝ E9

⃝ Male

⃝ Female

⃝ O1
⃝ O2
⃝ O3
⃝ O4
⃝ O5
⃝ O6
⃝ O7
⃝ O8
⃝ O9
⃝ O10

⃝ W1
⃝ W2
⃝ W3
⃝ W4
⃝ W5
⃝ Other

Home Station/Unit:
Current Contact Information:

Point of contact who can always reach you:

Phone:

Name:

Cell:

Phone:

DSN:

Email:

Email:

Address:

Address:
Deployment location(s):

⃝ Liberia ⃝ Sierra Leone

Deployed Station/Unit:

⃝ Guinea

⃝ Senegal

⃝ Nigeria

⃝ Other:

Duties while deployed:

Date arrived in theater (dd/mmm/yyyy):

DD FORM 2990, 20141022 DRAFT

Page 1 of 4 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE EXPOSURE RISK EVALUATION
(IN THEATER USE ONLY)
Deployer’s SSN (Last 4 digits):
COMPLETED BY DESIGNATED MEDICAL PROVIDER ONLY – Provider Review, Interview, Exposure Risk Evaluation

PART I - A : Ebola Virus Disease Risk Assessment [Mark all that apply . If “Yes” document date, time & type of MOST
SOME RISK OF EXPOSURE: One or more of the following within the past 21 days.
1.
Close contact with an Ebola Virus Disease (EVD) patient in any of the following settings:
household, living quarters, work, or community? If yes, document date, time and type of
contact and/or exposure.
Date (dd/mmm/yyyy):

Time:

recent exposure.]

Yes

No

⃝

⃝

⃝

⃝

Yes

No

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

Type:

Close contact is defined as:
a.

Being within approximately 3 feet (1 meter) of an EVD patient for a prolonged period of time while not
wearing recommended personal protective equipment (PPE) or PPE was compromised.

b.

Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment (PPE) or PPE was compromised.
(Brief interactions, such as walking by a person, do not constitute close contact.)

2.

Other close contact with EVD patients in healthcare facilities or community settings? If
yes, document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

Time:

Type:

Close contact is defined as:
a.

b.

Being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area
for a prolonged period of time (e.g., health care personnel, household members) while not wearing
recommended personal protective equipment (PPE) (standard droplet and contact precautions) or PPE
was compromised.
Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment (PPE) or PPE was compromised.

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(Brief interactions, such as walking by a person or moving through a hospital, do not constitute close
contact.)

HIGH RISK OF EXPOSURE: One or more of the following within the past 21 days.
3.

Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids
of an EVD patient? If yes, document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

4.

Time:

Type:

Processing blood or body fluids of a confirmed EVD patient without appropriate personal
protective equipment (PPE), standard biosafety precautions or PPE was compromised? If
yes, document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

6.

Type:

Direct skin contact with, or exposed to, blood or body fluids of an EVD patient without
appropriate personal protective equipment (PPE) or PPE was compromised? If yes,
document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

5.

Time:

Time:

Type:

Direct contact with a dead body without appropriate personal protective equipment
(PPE), or PPE was compromised in a country where an EVD outbreak is occurring? If yes,
document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

DD FORM 2990, 20141022 DRAFT

Time:

Type:
Page 2 of 4 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE EXPOSURE RISK EVALUATION
(IN THEATER USE ONLY)
Deployer’s SSN (Last 4 digits):
PART I -B: Ebola Virus Disease Clinical- Evaluation
:
[Mark all that apply.]
1.
Ask “Are you currently experiencing any of the following signs and symptoms?”
o
a. Fever (temperature of > 100.4 F)
⃝ Don’t Know
b. Subjective fever ( e.g., chills, night sweats)
c. Severe headache
d. Joint and muscle aches
e. Abdominal/stomach pain
f. Vomiting
g. Diarrhea
h. Unexplained bruising or bleeding
i . New skin rash
j. Other (describe in block #5)
2.
Ask “Have you taken any fever-reducing medications within the past twelve [12] hours?”
(e.g ., aspirin, Tylenol , Motrin, Ibuprofen )

3.

Conduct and record temperature check.
Temperature:
Time:

4.

Date and time of onset of symptoms . Date(dd/mmm/yyyy):

5.

Comments:

Time:

Yes
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝

No
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝

⃝

⃝

⃝ N/A

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DD FORM 2990, 20141022 DRAFT

Page 3 of 4 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE EXPOSURE RISK EVALUATION
(IN THEATER USE ONLY)
Deployer’s SSN (Last 4 digits):
PART I-C: Ebola Virus Disease Risk Category [Mark ONLY one.]
Disposition Guidance: Document risk category in the individual’s medical record.
Asymptomatic:
•

⃝
No Known
Exposure

Return to duty and continue twice daily unit monitoring for exposure risk and clinical
symptoms.

Symptomatic (Fever WITH or WITHOUT other symptoms)
•
•

Evaluation by medical authority.
Implement infection control precautions.

Asymptomatic:
•
•

⃝
Some Risk of
Exposure

Symptomatic: (Fever WITH or WITHOUT other symptoms)
•
•
•

(“Yes” to
questions 1 or 2,
PART I-A)
⃝

Evaluation by medical authority.
Isolate and separate from “High Risk individuals. Implement infection control precautions.
Evacuate from theater via regulated movement to a DoD designated medical facility capable
of providing care for EVD patients IAW official policy.

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Asymptomatic:
•
•

High Risk
Exposure
(“Yes” to
questions
3, 4, 5, or 6,
PART I-A)

Evaluate for potential medical evacuation IAW official policy.
If determined to be “minimal risk” return to duty and begin twice daily monitoring by medical
authorities for 21 days.

Evaluation by medical authorities.
Quarantine and evacuate from theater via regulated movement to a DoD designated facility
capable of monitoring for signs and symptoms and providing care for EVD patients IAW official
policy.

Symptomatic: (Fever or other symptoms)
•
•
•

Evaluation by medical authorities.
Isolate and separate from “Some Risk” individuals. Implement infection control precautions.
Evacuate from theater via regulated movement to a DoD designated facility capable of
providing care for EVD patients IAW official policy.

Provider’s Name:

Title:

⃝ MD ⃝ DO

Date (dd/mmm/yyyy):

⃝ PA

⃝ Nurse Practitioner

⃝ I certify this assessment process has been completed.

DD FORM 2990, 20141022 DRAFT

⃝ Adv Practice Nurse

Time:

⃝ Other:

Provider’s Signature:

Page 4 of 4 Pages