Form 0920-1031 Attachment B2 CDC Form EbolaRiskAssessment - French

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

Attachment B2 CDC Form EbolaRiskAssessment - French

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

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

French Translation

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 4. 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 3. 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.
- Le terme « individu atteint du virus Ebola » désigne aussi bien un cas suspect, un cas confirmé ou tout individu décédé des suites d'une maladie présentant de la fièvre, des vomissements, des diarrhées ou des saignements inexpliqués.
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.
- L'équipement de protection individuel (EPI) adapté est défini comme étant composé (au minimum) des éléments suivants : masque médical, lunettes de protection (lunettes/écran facial), gants, blouses étanches, bottes/couvre-chaussures qui doivent être portés lors de toute situation présentant un risque potentiel d'exposition.
Body fluids include urine, saliva, sweat, feces, vomit, breast milk, and semen.
- Les fluides corporels comprennent l'urine, la salive, la sueur, les selles, les vomissements, le lait maternel et le sperme.

Tell traveler: Vous nous avez été adressé pour une évaluation en matière de santé publique en raison d'un risque possible d'exposition au virus Ebola. Je vais vous poser quelques questions afin d'obtenir plus d'informations. Cela nous aidera à déterminer s'il est nécessaire de procéder à une évaluation ou une observation plus approfondie. (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.)

Au cours des 21 jours qui viennent de s'écouler (In the past 21 days):

Avez-vous été en contact avec le sang ou d'autres fluides corporels d'un individu atteint du virus Ebola ? (Did you ever come into contact with blood or other body fluids of a person with Ebola?) □ Yes □ No □ Unknown

If YES: Le contact a-t-il eu lieu d'une des manières suivantes ? (Did the contact include any of the following?) (YES to any of these = HIGH RISK, describe on p. 4):

par contact avec une aiguille ou un autre objet tranchant ? (Stuck with a needle or other sharp object?) □ Yes □ No □ Unknown
par projection dans les yeux, le nez ou la bouche ? (Splashed in the eye, nose or mouth?) □ Yes □ No □ Unknown
par contact direct de sang ou de fluides corporels avec la peau ? (Blood or body fluids directly on your skin?) □ Yes □ No □ Unknown

Avez-vous soigné des patients dans un cadre de soins médicaux quelconque lorsque vous vous trouviez au/en [insérez le nom du pays concerné] ? (Did you take care of patients in any healthcare setting while you were in [insert name of country]?)

□ YES = SOME RISK (Describe on p. 4) □ No □ Unknown

Avez-vous soigné vous-même un individu atteint du virus Ebola ou vous êtes-vous trouvé (en tant qu'observateur) dans une zone où un patient atteint du virus Ebola recevait des soins ? Nous entendons par là à la fois un contexte hospitalier et à domicile. (Did you provide direct care to anyone with Ebola while person was sick or enter an area (e.g. as an observer) where Ebola patient care was taking place? This includes household or health care setting.)
□ Yes □ No If YES, document setting:

□ Household member providing care = HIGH RISK (Describe on p. 4) □ Healthcare worker (HCW) or □ Observer – ask 2 a & b

For HCW or observer: Avez-vous porté l’EPI à chaque instant ? (Did you wear appropriate PPE at all times?) □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK (Describe on p. 4) YES (to PPE use) = SOME RISK

If YES (to PPE use): Y-avait-il des professionnels de la santé atteints du virus Ebola dans l'endroit où vous vous trouviez ? (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.4.

Avez-vous travaillé dans un laboratoire lorsque vous vous trouviez [insérez le nom du pays concerné] ? (Did you work in a laboratory in [insert name of country]?) □ Yes □ No

If YES: Avez-vous traité des fluides corporels provenant de patients atteints du virus Ebola ? (Did you process body fluids of Ebola patients?) □ Yes □ No □ Unknown

If YES (to processing body fluids): Avez-vous porté un EPI et vous êtes-vous conformé aux précautions de sécurité biologique en laboratoire en vigueur à chaque instant ? (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): Quel est le nom du laboratoire où vous avez travaillé ? (What is the name of the laboratory where you worked?)

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 SME to conduct assessment.

Avez-vous directement touché ou manipulé des dépouilles, ou avez-vous été en contact avec l’eau utilisée pour laver les dépouilles ou le linge qui recouvrait une dépouille lorsque vous vous trouviez au/en [insérez le nom du pays concerné] ? Par cela nous entendons la participation à un enterrement ou à des rites funéraires ou toute autre activité impliquant le contact avec une dépouille. (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: Portiez-vous l'EPI adéquat à chaque instant ? (Were you wearing appropriate PPE at all times?) □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK YES (to PPE use) = SOME RISK Describe on p. 4.

Avez-vous habité ou effectué des travaux ménagers (tels que le ménage ou la lessive) dans le domicile d'un individu atteint du virus Ebola pendant que celui-ci était souffrant ? (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. 4)

Avez-vous passé du temps dans la même pièce qu'un individu atteint du virus Ebola pendant que ce dernier était malade ? (Did you spend any time in the same room with any person with Ebola while the person was sick?) □ Yes □ No □ Unknown

If YES: Portiez-vous l'EPI adéquat à chaque instant ? (Were you wearing appropriate PPE at all times?) □ Yes □ No □ Unknown YES = LOW (BUT NOT ZERO)

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

Avez-vous été en contact direct avec l'individu atteint du virus Ebola (en lui serrant la main par exemple) ? (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 (How sick was the person at the time?): EARLY = LOW (BUT NOT ZERO) LATE (SEVERELY ILL) = HIGH

Vous êtes-vous trouvé dans un rayon de 3 pieds (1 mètre) de l'individu atteint du virus Ebola ? (Were you within 3 feet (1 meter) of the person with Ebola?) □ Yes □ No □ Unknown

Pendant combien de temps vous êtes-vous trouvé dans un rayon de 3 pieds (1 mètre) de l'individu atteint du virus Ebola ? (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. 4.] Time: _______ (hours) _______ (minutes)

YES AND extended period = SOME RISK

Avez-vous eu quelque autre contact que ce soit avec un individu atteint du virus Ebola ? (Did you have any other contact with a person with Ebola?) □ Yes □ No □ Unknown

[Get a description of each potential exposure then call GMTF Ebola Consultant. Describe on p. 4]

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

SIGNS OR SYMPTOMS: Avez-vous eu un ou plusieurs des symptômes suivants aujourd’hui ou au cours des dernières 48 heures ? (Today or in the past 48 hours have you had any of the following symptoms?) □ None □ Fièvre (fever) □ Maux de tête violents (severe headache) □ Douleurs musculaires (muscle pain) □ Fatigue (fatigue) □ Vomissements (vomiting) □ Diarrhée (diarrhea) □ Douleurs d'estomac (stomach pain) □ Saignements ou bleus inexpliqués (unexplained bleeding or bruising) Quand les premiers symptômes sont-ils apparus ? (When did the first symptom start?) (mm/dd/yy): ____ / ____ / ____

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

If temperature rechecked: _______ Time: __________ Temperature method: □ Oral □ Tympanic □ Noncontact

Avez-vous pris des médicaments contre la fièvre ? (Did you use any medication that reduced fever?) □ 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 a relevant country)—Complete in English

Question #______

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Time of exposure (Exact dates if possible): _________________________________________________________________________

Question #______