E
Department
of Health and Human Services Centers
for Disease Control and Prevention
OMB
Approved 0920-1032 Exp
04/30/2015 Directions: Please fax completed form to Ebola Airline Investigation at fax # 404.718.2158 after both initial interview and completion of final disposition. |
Note: If contact develops a fever ≥100.4° F or other symptoms of Ebola, immediately call EOC at 770.488.7100.
Date of initial interview: ______/_____/______Interviewed by: ______________________
Interviewer’s Agency:____________________ Interviewer’s Phone Number: __________
Interviewer’s Email:____________________________________
Passenger Information:
First Name: _____________________ Last Name: _________________________
Date of Birth: _____________ Sex: ___________
Country of Citizenship: __________________ Country of Residence:__________________
What are interviewee’s travel plans through 21 days after potential flight exposure: ________________________________________________________
Street Address for next 21 days: __________________________________________________
City:________________________ State: __________ Zip:___________
Phone numbers for next 21 days: Home: _________________ Cell:__________________ Work:___________________
Job title: ________________________________________________________
What flight(s) did the interviewee work or fly on with the index case: Provide complete flight information- including flight number, flight origination and destination
First flight:__________________________________________________________________________
Second flight: _______________________________________________________________________
Did interviewee serve in the area where the ill passenger was seated? Yes No
Did interviewee have any interactions with the index case from this flight(s)? Yes No
If yes, describe this event including description of the ill passenger, or their identity if known, location of the event, degree of contact (talking, touching, etc.) and length of time:____________________________________________________________________________________________
Did interviewee have direct contact with blood or other body fluids (including but not limited to feces, saliva, sweat, urine, and vomit) of the index case during the flight(s) mentioned above?
Yes No (If no, skip to question 5)
If yes, what protective equipment was worn? Mask Gloves Eye Protection Gown
Rubber boots or shoe covers None
If yes, describe the contact including location in the plane of the body fluid and any other individuals involved: ___________________________________________________________________________
___________________________________________________________________________________
If yes, with which body fluids did interviewee come into contact? (Check all that apply)
Tears Saliva Respiratory secretions (cough and sneeze droplets)
Vomit Urine Blood Feces Sweat
If yes, did these fluids come in contact with the interviewee’s (Read below and check all that apply):
Intact skin
Broken skin (fresh cut or scratch which bled within 24 hours before the contact; burn or abrasion that had not dried)
Mucous membrane contact (eyes, nose or mouth)
Other (Specify): ________________________________________________________
Were there any incidents during or after the flight(s) that the interviewee can recall when other individuals were in contact with the index case’s blood and/or body fluids?
Yes No
If yes, please describe situation and location in the plane: ______________________________________________________________________________________________________________________________________________________________________
What protective equipment (i.e. gloves, face mask) was the interviewee wearing if he/she was involved in cleaning the cabin? (NA if not involved in cleaning) Mask Gloves Eye Protection Gown
Rubber boots or shoe covers None
Did interviewee experience any symptoms (fever, body aches, abdominal pain, diarrhea, rash, sore throat, headache, vomiting, weakness, unusual bruising or bleeding) since the flight with the index case?
Yes No (If no, skip to question 7)
If yes, which of the following symptoms did the interviewee experience since the flight with the index case, and what were the onset date and duration of symptoms (check all that apply and list onset/duration)?
Symptom onset (MM/DD/YY) Duration (in days)
Fever ≥100.4° F _____________________ ______________
Sore throat _____________________ ______________
Body aches/muscle pain _____________________ ______________
Severe headache _____________________ ______________
Abdominal pain _____________________ ______________
Vomiting _____________________ ______________
Diarrhea _____________________ ______________
Weakness _____________________ ______________
Rash _____________________ ______________
Description of rash ___________________________________________________________
Unusual bruising or bleeding _____________________ ______________
(e.g., from gums, eyes, nose)
7. Has interviewee travelled within the last 21 days to Sierra Leone, Guinea, Liberia, or another country experiencing widespread transmission of Ebola? Yes No
If yes, to which countries did the interviewee travel (check all that apply)?
Sierra Leone Guinea Liberia Other
If any of the above countries are selected, please notify CDC by calling EOC at 770.488.7100. Interviewee will need to complete additional interview with CDC SME involving in-country exposure risk.
_________________________________________________________________________________
Classification of interviewee risk. After the HD has completed the interview, CDC will assign a risk level and communicate follow up recommendations to the HD. Call the EOC and ask to speak to Air Contact Investigation Team after the interview to complete this process. Refer to http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html for additional information.
Follow-up Actions (check all actions taken for this contact):
Active Monitoring: state or local public health authority checks with potentially exposed individual daily to assess for the presence of symptoms and fever (ie: via phone or other communication)
Direct Active Monitoring: public health authority conducts active monitoring through direct observation
Ebola Symptoms (fever, body aches, abdominal pain, diarrhea, rash, sore throat, severe headache, vomiting, weakness, unusual bruising or bleeding)
Referred for medical evaluation due to presence of symptoms
Where was (s)he referred? _________________________________________________________
What was the outcome? ___________________________________________________________
Was (s)he tested for Ebola? Yes No
Declined medical evaluation after it was recommended
Placed under conditional release
Placed under state issued quarantine order
Controlled movement: exclusion from all long-distance and local public conveyances (aircraft, ship, train, bus and subway)
Exclusion from public places (e.g., shopping centers, movie theaters), and congregate gatherings
Exclusion from workplaces for the duration of the public health order, unless approved by the state or local health department (telework is permitted)
Federal public health travel restrictions -Do Not Board (http://www.cdc.gov/quarantine/quarantineisolation.html)
Other, please describe: ____________________________________________________________
Final Disposition:
Was interviewee contacted again after the end of the 21-day incubation period?
Yes, Date of second interview: ______/_____/______ No
If yes, did interviewee develop any symptoms between the time of the flight and the end of the 21-day incubation period? Yes No
If yes, please specify symptoms, timing, and outcome of medical evaluation below:
Symptom onset (MM/DD/YY) Duration (in days)
Fever ≥100.4° F _____________________ ______________
Sore throat _____________________ ______________
Body aches/muscle pain _____________________ ______________
Severe headache _____________________ ______________
Abdominal pain _____________________ ______________
Vomiting _____________________ ______________
Diarrhea _____________________ ______________
Weakness _____________________ ______________
Rash _____________________ ______________
Description of rash ___________________________________________________________
Unusual bruising or bleeding _____________________ ______________
(e.g., from gums, eyes, nose)
Outcome of medical evaluation:_____________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Evaluating healthcare provider name/phone number: __________________________/(____)____________
Page
Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1032.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-26 |