Ebola Exposure Questionnaire for Cleaning Crew

OMB Approved

0920-1032

Exp 04/30/2015

Department of Health and Human Services

Centers for Disease Control and Prevention

Ebola Exposure Questionnaire for Cleaning Crew

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:

1. 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 interviewee clean on which the index case traveled?:__________________________

Provide complete flight information- including flight number, flight origination and destination

First flight:__________________________________________________________________________

Second flight: _______________________________________________________________________

2. Did interviewee have any interactions with sick passengers 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:_________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­________________________­___________________________________________________________________________________

3. Did interviewee have direct contact with blood or other body fluids (including but not limited to feces, saliva, sweat, urine and vomit) while cleaning the flight(s) mentioned above?

Yes No (If no, skip to question 4)

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 of the body fluid cleaned 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): ____________________________________________________________

4. Were there any incidents after the flight(s) that the interviewee can recall when other individuals were in contact with a person’s blood and/or body fluids while cleaning this flight(s)?

Yes No

If yes, please describe situation and location in the plane: ______________________________________________________________________________________________________________________________________________________________________

What protective equipment (i.e. gloves, face mask) was the interviewee wearing when he/she was cleaning the cabin? Mask Gloves Eye Protection Gown Rubber boots or shoe covers

None

5. Did interviewee experience any symptoms (fever, body aches, abdominal pain, diarrhea, rash, sore throat, severe headache, vomiting, weakness, unusual bruising or bleeding) since the flight with the index case?

Yes No (If no, skip to question 6)

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)

6. 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: __________________________/(____)____________

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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.