Person Under Investigation (PUI) for Ebola Form - United

E bola Virus Disease - Person Under Investigation (PUI) Form

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Person Under Investigation (PUI) for Ebola Form – United States

State/Local ID: __________________

CDC ID: _______________________

Instructions: Please complete the following form for each person under investigation for Ebola virus disease. If the person tests positive for Ebola, please use the please use information gathered from this form to populate the Ebola Virus Disease Case Investigation Form – United States form (Form 1).

Public reporting burden of this collection of information is estimated to average 10 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).

Patient Information
Date of form completed : MM / DD / YYYY Date PUI identified: MM / DD / YYYY Form Administrator Name (Last, First): _____________________________ Affiliation: ______________________________________ City: ________________________ State: ________ Zip: __________County: _____________________________ Phone number: ________________________ Email address: ___________________________________________ Patient Information Patient Name (Last, First): ___________________________________ Sex:  Male  Female Date of birth: MM / DD / YYYY Age Group:  Adult  Pediatric (<18 years) Age: _________ Citizenship:____________________ Country of Residence:  U.S.  Other (specify): ___________________ Number of household contacts: ________ Patient Hospitalization Is the patient currently admitted to a hospital?  Yes  No Date of admission: MM / DD / YY Facility Name:__________________________________ City: _______________________ State: _________ Physician Name (Last, First): ______________________ Contact Information: __________________________ Is the patient being treated under isolation precautions?  Yes  No Date of isolation: MM / DD / YY Was the patient transferred from a previous health care facility?  Yes  No Facility Name:__________________________________ City: _______________________ State: _________
Medical History and Symptom Onset		III. Epidemiologic Risk Factors
Medical History:		1. Have you had contact with a suspect or known case of Ebola in the 3 weeks before you became ill?  Yes  No  Unknown If yes, name: ___________________________ State/Local ID: __________ CDC ID: ________ If yes, please describe: 2. Did you travel outside the United States in the 3 weeks before becoming ill?  Yes  No Country (1) : ___________________________ MM / DD / YYYY to MM / DD / YYYY Country (2) : ___________________________ MM / DD / YYYY to MM / DD / YYYY 3. Did you provide health care for any known/ suspect cases of Ebola?  Yes  No If yes, please describe:
Have you experienced any of the following symptoms?	If yes, date symptom began (___/___/____)
 Fatigue
 Fever/Feverish Temp:_____
 Headache
 Stomach pain
 Muscle pain
 Diarrhea
 Unexplained bruising/bleeding
 Vomiting
 Other:

IV. Laboratory Testing

Test 1

Originating Facility: _________________________________ City: _____________________State: ___________

Point of Contact: _________________________________

Phone Number: _________________________________ E-mail: __________________________________

Where was testing performed?  LRN: ____________________________________  CDC

Specimen ID: ____________________________

Test Performed (PCR, BioFire Defense FilmArray): __________________ Test Date: MM / DD / YYYY

Result:  Positive  Negative  Inconclusive Result Date: MM / DD / YYYY

Test 2

Originating Facility: _________________________________ City: _____________________State: ___________

Point of Contact: _________________________________

Phone Number: _________________________________ E-mail: __________________________________

Where was testing performed?  LRN: ____________________________________  CDC

Specimen ID: ____________________________

Test Performed (PCR, BioFire Defense FilmArray): __________________ Test Date: MM / DD / YYYY

Result:  Positive  Negative  Inconclusive Result Date: MM / DD / YYYY

Test 3

Originating Facility: _________________________________ City: _____________________State: ___________

Point of Contact: _________________________________

Phone Number: _________________________________ E-mail: __________________________________

Where was testing performed?  LRN: ____________________________________  CDC

Specimen ID: ____________________________

Test Performed (PCR, BioFire Defense FilmArray): __________________ Test Date: MM / DD / YYYY

Result:  Positive  Negative  Inconclusive Result Date: MM / DD / YYYY

Test 4

Originating Facility: _________________________________ City: _____________________State: ___________

Point of Contact: _________________________________

Phone Number: _________________________________ E-mail: __________________________________

Where was testing performed?  LRN: ____________________________________  CDC

Specimen ID: ____________________________

Test Performed (PCR, BioFire Defense FilmArray): __________________ Test Date: MM / DD / YYYY

Result:  Positive  Negative  Inconclusive Result Date: MM / DD / YYYY

FORM 1: PUI FormV2_11_18_2014