Form 0920-1031 Attachment B1 CDC Form Ebola Risk Assessment - English

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

Attachment B1 CDC Form Ebola Risk Assessment - English

Ebola Risk Assessment for Travelers from Outbreak-affected Countries (English)

OMB: 0920-1031

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Health and Human Services, Centers for Disease Control and Prevention

OMB approved 0920-1031

Exp 04/30/2015

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

Passport Country: _______________________________ Passport Number: ___________________________

RISK ASSESSMENT FOR TRAVELERS FROM COUNTRIES WITH WIDESPREAD EBOLA VIRUS TRANSMISSION

Instructions to CDC staff:

Read the following risk assessment questions to the traveler. All questions refer to the past 21 days. Relevant countries are those with either widespread transmission or localized transmission with uncertain control measures.
Questions 1-6 must be completed. Check YES, NO or UNKNOWN. If a HIGH risk exposure is identified in questions 1-6, you may stop. If no high risk exposures are identified in questions 1-6, also complete question 7.
Get a description of any potential exposures identified or any situation where exposure is uncertain and document on page 3. Dates of exposure must be obtained. Ask additional questions as needed to get as complete a description as possible. Call Global Migration Task Force (GMTF) Ebola Consultant on-call for high or some risk exposures or when risk is uncertain.
Complete assessment section on page 2. 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 and record state/local health department (S/L HD) notification.
Complete and sign evaluator section. Medical officer must co-sign for any public health action beyond releasing the traveler.
NOTE: “Person with Ebola” includes confirmed or suspect cases or any person who died of an illness that included fever, vomiting, diarrhea, or unexplained bleeding. If not a confirmed case, get more information about illness/death circumstances.
For the purpose of this document, appropriate personal protective equipment (PPE) is defined as wearing (at a minimum): facemask, eye protection (goggles/face shield), gloves, impermeable gown, boots/shoe covers during every potential exposure.
Body fluids include urine, saliva, sweat, feces, vomit, breast milk, and semen.

Tell traveler: You were referred for public health assessment because of possible exposure to Ebola. I am going to ask you a few questions to get more information. This will help us decide if you need additional evaluation or monitoring.

Country: _____________________________________ Dates in country (mm/dd/yy): ____ / ____ / ____ to ____ / ____ / ____ (If was not in a relevant country or was there > 21 days ago, no assessment needed. Complete on page 2 as no identifiable risk.)

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, describe on p. 3):

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

Did you take care of patients in any healthcare setting while you were in [insert name of country]? YES = SOME RISK (Describe on p. 3)
Did you provide direct care to anyone with Ebola while that person was sick or enter an area (e.g. as an observer) where Ebola patient care was taking place? This includes household or healthcare setting. □ Yes □ No If YES, document setting:

□ Household member providing care = HIGH RISK (Describe on p. 3) □ Healthcare worker (HCW) or □ Observer – ask 2 a & b

For HCW or observer: Did you wear appropriate PPE at all times? □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK (Describe on p. 3) YES (to PPE use) = SOME RISK

If YES (to PPE use): Were any healthcare workers in facility diagnosed with Ebola? If YES, get more information to assess whether unrecognized infection control breaches (HIGH RISK) occurred. Call GMTF Ebola consultant. Describe on p. 3.

Did you work in a laboratory in [insert name of 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

YES (to PPE use or biosafety precautions): Ask name of laboratory and consult attached list of laboratories for which CDC is confident that biosafety precautions are followed. If laboratory is not on list, call CDC Emergency Operations Center (770-488-7100) and ask for the Laboratory Task Force on-call to conduct assessment.

Did you directly touch or handle dead bodies or have contact with the water used to wash dead bodies or the cloth that covered a dead body in [insert name of 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 YES (to PPE use) = SOME RISK Describe on p. 3.

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) = HIGH/SOME RISK (get more information, describe on p. 3)

Did you spend any 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 YES = LOW (BUT NOT ZERO)

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

Get more information about stage of illness: EARLY = LOW (BUT NOT ZERO) LATE (SEVERELY ILL) = HIGH

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 a description of activities then consult. Describe on p. 3.] Time: _____ (hours) _____ (minutes) YES AND extended period = SOME RISK

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

[Get a description of each potential exposure then call GMTF Consultant. Describe on p. 3]

EXPOSURE ASSESSMENT: □ High risk □ Some risk □ Low (but not zero) risk □ No identifiable risk

SIGNS OR SYMPTOMS: □ None □ Fever □ Severe headache □ Muscle pain □ Fatigue □ Vomiting □ Diarrhea □ Stomach pain □ Unexplained bleeding or bruising Onset date of earliest symptom (mm/dd/yy): ____ / ____ / ____

MEASURED TEMPERATURE: _______ Time: __________ Temperature method: □ Oral □ Tympanic □ Noncontact

If temperature rechecked: _______ Time: __________ 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 □ Coordinated disposition with S/L HD □ Released to continue travel

Other (describe): _____________________________________________________________________________________

S/L HD notification:_____________________________________________________________________ Time: ______________

Evaluated by: _____________________________________________ Signature: ______________________________________

Title: ___________________________________________________ Location: ________________________________________

□ Medical Officer consulted Name: __________________________________________ Time: ______________

Medical Officer signature (for any action other than released):______________________________ Date: ______________

DESCRIPTION OF ANY EXPOSURES IDENTIFIED (other than being in relevant country)

Question #______

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Time of exposure (Exact dates if possible): _________________________________________________________________________

Question #______