Risk Assessment for Travelers from Ebola outreak-affecte

Emergency Submission to Supplement OMB Control Number 0920-0821 in the context of Screening Travelers for Ebola Risk

Attachment C Ebola Risk Assessment clean

Risk Assessment for Travelers from Ebola outreak-affected countries

OMB: 0920-1031

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1031 can be found here:

2014-11-19 - No material or nonsubstantive change to a currently approved collection

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Health and Human Services, Centers for Disease Control and Prevention

OMB approved 0920-0821

Exp 08/31/2015

Traveler Name: _________________________________ Date (mm/dd/yy): ___________________________

Passport Country: _______________________________ Passport Number: ___________________________

RISK ASSESSMENT FOR TRAVELERS FROM EBOLA OUTBREAK-AFFECTED COUNTRIES

Instructions to CDC staff:

Read the following risk assessment questions to the traveler. Get a description of any high-risk or some-risk activities identified. Dates of exposure must be obtained.
NOTE: “person with Ebola” includes confirmed or suspect cases or unexplained sudden deaths in outbreak-affected areas. For the purpose of this document, appropriate personal protective equipment (PPE) is defined as: wearing gloves, gown, and face protection including goggles or face shield plus face mask during every potential exposure.
The form must be completed through question 5. Check YES, NO or UNKNOWN. If a HIGH risk exposure is identified in 1-5, you may stop. If only exposure is “household contact”, also complete question 6.
Describe on page 3 of this form any high-risk or some-risk exposures identified.
Check overall exposure assessment.
Complete signs/symptom section using checkboxes. Record measured temperature and date of first symptom onset. Record whether fever-reducing medications were taken, including dose and last time taken.
Check disposition.

Complete and sign evaluator section. Tell patient: There is an Ebola outbreak going on in [insert country name]. I am going to ask you a few questions to assess any exposures you might have had to Ebola. This will help us decide if you need additional evaluation or monitoring.

In the last 21 days, did you ever come into contact with blood or other body fluids of a person with Ebola?

□ Yes □ No □ Unknown

If YES: Did the contact include any of the following (YES to any of these = high risk):

Stuck with a needle or other sharp object? □ Yes □ No □ Unknown
Splashed in the eye, nose or mouth? □ Yes □ No □ Unknown
Blood or body fluids directly on your skin? □ Yes □ No □ Unknown

In the last 21 days, did you provide direct care to anyone with Ebola while person was sick? This includes household or health care setting. □ Yes □ No □ Unknown

If YES: Did you wear appropriate PPE at all times? □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK

In the last 21 days, did you work in a laboratory in [Ebola-affected country]? □ Yes □ No □ Unknown

If YES: Did you process body fluids of Ebola patients? □ Yes □ No □ Unknown

If YES (to processing body fluids): Did you wear appropriate PPE and follow standard lab biosafety precautions at all times? □ Yes □ No □ Unknown

NO (to PPE use or biosafety precautions) = HIGH RISK

In the last 21 days, did you directly handle dead bodies in [Ebola-affected country]? This might include participating in funeral or burial rites or any other activities that involved handling dead bodies. □ Yes □ No □ Unknown

If YES: Did you wear appropriate PPE at all times? □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK

In the last 21 days, did you live or work (such as cleaning or doing laundry) in the same household as a person with Ebola while that person was sick?

□ Yes □ No □ Unknown

Confirm Ebola patient’s date of symptom onset (if known) and dates traveler lived or worked in same household.

Onset date (mm/dd/yy): ____ / ____ / ____ Dates in same household: ____ / ____ / ____ to ____ / ____ / ____

YES (household member during symptomatic period) = SOME RISK

In the last 21 days, have you spent time in the same room with any person with Ebola while the person was sick?

□ Yes □ No □ Unknown

If YES: Were you wearing appropriate PPE at all times? □ Yes □ No □ Unknown

If NO (to PPE use): Ask the following:

Did you have any direct contact with the person with Ebola (e.g. shaking hands)? □ Yes □ No □ Unknown

YES = SOME RISK

Were you within 3 feet (1 meter) of the person with Ebola? □ Yes □ No □ Unknown

How long were you within 3 feet of the person with Ebola? [Get an estimate of time and distance and a description of activities then consult leadership/SME.] Time: _______ (hours) _______ (minutes)

YES AND extended period = SOME RISK

Did you have any other contact with a person with Ebola? □ Yes □ No □ Unknown

[Get an estimate of time and distance and a description of each activity then consult leadership/SME.]

THIS SECTION TO BE COMPLETED BY SCREENER BASED ON ASSESSMENT

Overall Exposure Assessment: □ High risk □ Some risk □ No known exposure

Country: _____________________________________ Dates in country: _____________________________________________

Signs or Symptoms Identified:

□ Fever □ Severe headache □ Muscle pain □ Vomiting □ Diarrhea □ Stomach pain

□ Unexplained bleeding or bruising Onset date (mm/dd/yy): ____ / ____ / ____

Measured temperature: _______ Temperature method: □ Oral □ Tympanic □ Noncontact

Reported use of fever-reducing medication? □ Yes □ No □ Unknown

If YES: medication name: __________________________ Dose: ____________________ Time since last dose: _______________

Disposition:

Medical evaluation required
Conditional release
Self-monitoring
Other: _____________________________________________________________________________________________

Evaluator:

Name: _________________________________________________ Signature: _______________________________________

Title: ___________________________________________________ Location: ________________________________________

□ Medical Officer consulted Name: ______________________________________ Date: _______________

Description of high-risk or some-risk exposures

Question #______

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Time of exposure (Exact dates if possible): _________________________________________________________________________

Question #______