Active Monitoring Survey - English

Form Approved

OMB No. 0920-xxxx

Expires xx/xx/xxxx

Health and Human Services

Centers for Disease Control and Prevention

Intro

Hello. Welcome to the Ebola CARE hotline. Press 1 or stay on the line for English. Appuyez sur 2 pour le français.

This phone line will help you make sure that you and your loved ones are healthy and safe after your recent travel from a country with an Ebola outbreak. We’ll ask you some questions and help connect you with a doctor if needed.

Begin ID

To begin, we will need the ID number from the back of your CARE card. The CARE card was given to you at the airport with your CARE kit.

No card

If you do not have a CARE card, press 3 now.

No card connect

I’m going to connect you with someone at the Centers for Disease Control and Prevention to help you. Please hold.

Enter ID

Please enter the ID number from your CARE card.

You entered

You entered

Correct ID

Is this correct? Press 1 for yes. Press 3 for no.

Re-enter ID

Please re-enter the ID number from your CARE card.

No recognize ID

I’m sorry. I’m don’t recognize that number. I’m going to connect you with someone who can help. Please hold.

Now registered

Thank you. You’re now registered in our system. Next, please answer some questions about how you’re feeling today.

Intro 2

Thanks for calling the Ebola CARE hotline.

Call back

Hi. This is the Ebola CARE Hotline. We’re calling back to see how you’re feeling.

Take temp Q

Did you take your temperature today?

Take Temp YN

If you took your temperature, press 1. If you did not take your temperature, press 3.

Take Temp Q and YN

Did you take your temperature today? If you took your temperature, press 1. If you did not take your temperature, press 3.

Fever Q

Was your temperature 100.4 degrees Fahrenheit or 38 degrees Celsius or higher?

Fever YN

Press 1 for yes. Press 3 for no.

Fever Q and YN

Press 1 if your temperature was at or above 100.4 degrees Fahrenheit or 38 degrees Celsius. Press 3 if it was lower.

Lost Therm

If you’ve lost your thermometer and are unable to take your temperature, please press 1. We’ll connect you with someone at the Centers for Disease Control and Prevention. If you can’t take your temperature for a while and want to call back later, press 3.

Call back 15

If you have your thermometer, please take your temperature now. We’ll call you back in 15 minutes.

Therm close loop

Please find your thermometer and take your temperature at a convenient time. It may help to take your temperature everyday before lunch and then again before dinner, as part of your daily routine. We won’t call you back again, but please take your temperature and call this number as soon as you can. Doing so will help to make sure that you and your loved ones stay safe and healthy.

Fever Confirm

You have indicated that you have a fever.

Connect with CDC

I will now connect you with someone at the Centers for Disease Control and Prevention. If necessary, that person will help you connect with the health department in your area to arrange a visit with a doctor. Please hold.

Symptoms Q

Next, do you have other symptoms like severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, or unexplained bleeding or bruising?

Symptoms YN

Press 1 for yes. Press 3 for no.

Symptoms Q and YN

Next, do you have other symptoms like severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, or unexplained bleeding or bruising? Press 1 for yes. Press 3 for no.

Symptoms confirm

You have indicated that you have symptoms.

Connect with CDC 2

I will now connect you with someone at the Centers for Disease Control and Prevention. If necessary, that person will help you connect with the health department in your area to arrange a visit with a doctor. Please hold.

Continue to monitor

Thank you. Please continue to monitor your symptoms and take your temperature two times a day. Call this number each day to check in. Protect yourself and your family. Report Ebola symptoms right away.

Health questions

If you have questions about your health or if you’d like to talk more about your symptoms, please press 3 to be connected with someone at the Centers for Disease Control and Prevention.

General info questions

If you have general questions about Ebola, please press 1 to be connected to a CDC-INFO representative. Otherwise, please hang up to end the call.

Public reporting burden of this collection of information is estimated to average 4 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-xxxx).