EVD Contact Tracing Form - United States

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Ebola Virus Disease (Ebola) Contact Tracing Form – United States

State/Local ID: __________________

CDC ID: _______________________

Instructions: Please complete the following form for each contact of an Ebola case. Use the “Notes” portion of each section to record additional information about potential exposures or other information that may aid the investigation. If the contact is a health care worker, please use information gathered from the Ebola Tracking Form for Healthcare Workers with Direct Patient Contact or other applicable questionnaires to assist with assessing overall exposure history and PPE use.

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).

1. Interview Information

Date form completed : MM / DD / YYYY

Interviewer Information

Interviewer Name (Last, First): ___________________________________________________________

State/Local Health Department (HD): ______________________________________________________

Business Address: ____________________________________________________________________

City: ________________________ State: ________ Zip: __________County: ___________________

Phone number: ________________________ Email address: _________________________________

Informant Information

Who is providing information for this form?

 Contact

 Other Name (Last, First): _________________________ Relationship to contact: ______________

Phone number: _________________ E-mail address: _____________________________

Reason contact unable to provide information:

 Contact is a minor  Other ____________________________________________

Was this form administered via a translator? □ Yes □ No

If yes, in which language was this form administered? ________________________________________

Translator Name (Last, First): ___________________________________________________________

Phone Number: ___________________ E-mail address: ____________________________________

Notes:

2. Ebola Case information (Case associated with contact)

At the time of this report, what is the status of the person being investigated for Ebola?

□ Lab-confirmed □ Person Under Investigation (PUI) in US □ Suspected case (outside US) □ Probable case (outside US)

Date of illness onset of PUI or (suspected, probable or lab-confirmed) Ebola case: MM / DD / YYYY

Notes:

3. Demographic and contact information

Patient Name (Last, First): ___________________________________ Sex:  Male  Female

Date of birth: MM / DD / YYYY Age:__________ Pediatric (<18 years old) contact?  Yes  No

Citizenship:_____________________________

Country of residence:  United States  Other (specify): ____________________________

Contact Information

U.S. residence

Home Street Address: ______________________________________________________ Apt. # _______

City: ________________________ County: _________________ State: ________ Zip: _____________

Phone number: ________________________ E-mail address: __________________________________

Non-U.S. residence (if primary residence is not US)

Home Street Address: _______________________________________________ Apt. # ______________

City/Village: ________________________ State/County/District/Prefecture: ________________________

Occupational information

Occupation: ____________________________ Name of Business/Organization:_______________________

Supervisor name (Last, First): ____________________________________

Supervisor phone number: _________________ E-mail address: _________________________________

Business address: ______________________________________________________ Suite. # __________

City: ________________________ County: _________________ State: ________ Zip: _______________

Do you have any pets in your household?:  Yes  No

If yes, provide species and number________________________________________________________

Notes:

4. Exposure history

1. Did you have contact with an Ebola case or a PUI OR the blood or body fluids of an Ebola case or PUI outside of a healthcare setting?

 Yes (Complete Part A [Community contact])  No

2. Do you work in a healthcare setting and have contact with an Ebola case or a PUI OR the blood or body fluids of an Ebola case or PUI through your work?

 Yes  No

If yes, which of the following best describes your occupation?

 Health Care Worker (Complete Part B)  Laboratory Worker (Complete Part C)

 Environmental Decontamination/Cleaning Staff (Complete Part D)

A. Contact with a confirmed or suspected case of Ebola outside of a health care setting (community contact)

1. What is your relationship to the Ebola case or PUI? Choose one.

 Partner/spouse  Family member  Co-worker  Friend/acquaintance

 Classmate  Visited same healthcare facility/care area as Ebola patient

 Neighbor/community member  Other ___________________________________________

2. Please list each date of contact with the Ebola case or PUI and describe that contact: __________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

3. Do you live in the same house as the Ebola case or PUI?  Yes  No

4. Did you have any casual contact with an Ebola case or PUI (brief interaction, such as walking by him/her or being in the same room for a very short period of time) in which you did not directly touch him/her?

 Yes  No  Unknown If yes, list each date of contact: ________________________________

5. Did you have any contact with blood or body fluids from the Ebola case or PUI while he/she was ill (including contact with contaminated objects or surfaces such as bedding or clothing)?

 Yes  No  Unsure

If yes, what body fluids were you in contact with, and what was the most recent date you had contact? Check all that apply.

 Blood  Feces  Vomit  Urine  Sweat

 Tears  Respiratory secretions (e.g. sputum, nasal mucus)  Saliva

 Semen or vaginal fluids  Other, specify:_________________________________________

List each date of contact: ____________________________________________________________

6. Were you within approximately 3 feet of the Ebola case or PUI or in his/her room or care area for a prolonged period of time (at least one hour) while he/she was ill?

 Yes  No  Unknown If yes, list each date of contact: ________________________________

7. Did you share a bathroom or use the same tub or toilet as an Ebola case or PUI while he/she was ill?

 Yes  No  Unknown If yes, list each date of contact: ________________________________

8. Did you perform any caregiving activities or household assistance for an Ebola case or PUI (helping to bathe or feed the case; washing clothes or dishes)?

 Yes  No  Unknown If yes, list each date of contact: ________________________________

9. Did you share transport with an Ebola case or PUI (car, bus, plane, taxi, etc.)?

Yes No  Unknown

If yes, please provide for all shared transport: Date of Travel: MM / DD / YYYY

Name of airline and flight number: ____________________________________________________

Origin: ___________________________ Destination: ___________________________________

Transit Points: ____________________________________________________________________

Notes:

B. Health Care Worker Exposure

1. What is your specific health care-associated job?

 Doctor  Nurse  Clinical Assistant/Technician  Volunteer  Admin. position  Other: ________________________________________________________

2. Please list each date of contact with the Ebola case or PUI and provide a description of that contact: __________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

3. Did you have any casual contact with an Ebola case or PUI (brief interaction, such as walking by him/her or being in the same room for a very short period of time) in which you did not directly touch him or her?

 Yes  No  Unknown

If yes, list each date of contact: ___________________________________________________________

4. Did you have contact with blood or body fluids of an Ebola case or PUI while he/she was ill (including contact with contaminated objects or surfaces such as bedding or clothing), including while you were wearing PPE?

 Yes  No  Unknown

If yes, list each date of contact: ___________________________________________________________

If yes, what body fluids were you in contact with? Check all that apply.  Blood  Feces  Vomit

 Urine  Sweat  Tears  Saliva  Respiratory secretions (e.g. sputum, nasal mucus)  Semen or vaginal fluids  Other:______________________________________________________

If yes, what PPE did you use on these occasions? Check all that apply.  None  Gown (impermeable)

 Facemask  N95 mask or other respirator  Eye protection (goggles or face shield)  Body suit

 Gloves  Other: _________________________________________________________________

If PPE was used, did someone watch you put on the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you take off the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you caring for the patient each time?  Yes  No  Unknown

5. Were you within approximately 3 feet of an Ebola case or PUI or n his/her room or care area for a prolonged period of time (at least one hour)?  Yes  No  Unknown

If yes, list each date of contact: ___________________________________________________________

If yes, what PPE was worn on these occasions? Check all that apply.  None  Gown (impermeable)

 Facemask  N95 mask or other respirator  Eye protection (goggles or face shield)  Body suit

 Gloves  Other: _________________________________________________________________

If PPE was used, did someone watch you put on the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you take off the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you caring for the patient each time?  Yes  No  Unknown

6. Did you have any direct contact with an Ebola case or PUI (e.g. shaking hands) no matter how brief, including while you were wearing PPE?  Yes  No  Unknown

If yes, list each date of contact: ___________________________________________________________

If yes, what PPE was worn on these occasions? Check all that apply.  None  Gown (impermeable)

 Facemask  N95 mask or other respirator  Eye protection (goggles or face shield)  Body suit

 Gloves  Other: _________________________________________________________________

If PPE was used, did someone watch you put on the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you take off the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you caring for the patient each time?  Yes  No  Unknown

Please provide additional information, particularly on any possible blood or body fluid exposure:

C. Laboratory Worker Exposure

1. What body fluids were you in contact with? Check all that apply.

 Blood  Urine  Other:___________________________________________________________

2. Please list all dates of blood/body fluid exposure:

   Fluid	Date(s) of exposure
   Blood
   Urine
   Other (specify)
   Other (specify)
   Other (specify)

3. What PPE was worn on these occasions? Check all that apply.  None  Gown (impermeable)

 Facemask  N95 mask or other respirator  Eye protection (goggles or face shield)  Body suit

 Gloves  Other: __________________________________________________________________

If PPE was used, did someone watch you put on the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you take off the PPE each time?  Yes  No  Unknown

Please provide additional information, particularly on any possible blood/body fluid exposure:

D. Environmental Exposure

1. Which aspects of the patient care environment did you clean or decontaminate? Check all that apply.

 General room or area (including floors, walls, furniture)

 Linens (including patient clothing, sheets, pillows, towels)

 Patient care equipment (including bedside commode, IV or urinary catheter tubing, intubation equipment)

 Other (specify): _____________________________________________________________________

2. What body fluids were you in contact with? Check all that apply.  Blood  Feces  Vomit

 Urine  Sweat  Tears  Respiratory secretions (e.g. sputum, nasal mucus)  Saliva  Semen or vaginal fluids  Other:______________________________________________________

3. Please list all dates of blood/body fluid exposure:

   Fluid	Date(s) of exposure
   Blood
   Urine
   Feces
   Vomit
   Sweat
   Tears
   Respiratory secretions
   Saliva
   Semen
   Vaginal Fluids
   Other (specify)
   Other (specify)

4. What PPE was worn on these occasions? Check all that apply.  None  Gown (impermeable)

 Facemask  N95 mask or other respirator  Eye protection (goggles or face shield)  Body suit

 Gloves  Other: __________________________________________________________________

If PPE was used, did someone watch you put on the PPE each time?  Yes  No  Unknown

If PPE was used, did someone watch you take off the PPE each time?  Yes  No  Unknown

Please provide additional information, particularly on any possible blood/body fluid exposure:

Follow-up Actions (choose one)

For the most recent Table: Summary of CDC Interim Guidance for Monitoring and Movement of People Exposed to Ebola Virus, visit http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html#table-monitoring-movement.

No further follow-up required. No identifiable risk or exposure was >21 days ago.

Active monitoring recommended (for some asymptomatic Low (but not zero) risk exposures only)

Last exposure date: MM / DD / YYYY Last day of monitoring: MM / DD / YYYY

Who will conduct the follow-up for symptom monitoring?

Name/Affiliation: _________________________________________________________

Phone number and contact information: ______________________________________

Direct active monitoring recommended (for asymptomatic High risk or Some risk exposures or some asymptomatic Low (but not zero) risk exposures)

High risk exposure Some risk exposure Low (but not zero) risk exposure

Last exposure date: MM / DD / YYYY Last day of monitoring: MM / DD / YYYY

Who will conduct the follow-up for symptom monitoring?

Name/Affiliation: _________________________________________________________

Phone number and contact information: ______________________________________

Rapid isolation, notification of public health authorities, and medical evaluation are recommended. Respondent has had High risk, Some risk, or Low (but not zero) exposure and has fever, severe headache, muscle pain, diarrhea, vomiting, stomach pain, or unexplained bleeding or bruising within 21 days of contact with the suspect/known case of Ebola or the blood/body fluids of a suspect/known case of Ebola.

Highest temperature recorded: ________°F

Fever onset date: MM / DD / YYYY

Symptoms: _____________________________________________________________________

Where will the patient be medically evaluated? ________________________________________

NOTES: