Contact Exit Questionnaire

Project ID number:_______________

Attachment 5. Contact Exit Questionnaire

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Contact Exit Questionnaire

[Exit Interview: to be conducted at end of 21-day monitoring or at the time the contact has been identified as having an Ebola Alert illness. All questions relate to the time since the index patient was removed from the household. Use a calendar or recent events to provide a point of reference for the respondent.]

The following questions relate to events since [NAME OF CASE PATIENT] was removed from the household.

101	Have you been a patient in a hospital?	[GO TO 102] No (0) [GO TO 101A] Yes (1)
A	[If YES to 101] Date of admission	__ __ / __ __ / __ __ D D M M Y Y
B	Date of discharge	__ __ / __ __ / __ __ D D M M Y Y
102	Have you been treated in an outpatient facility for any illness?	[GO TO 103] No (0) [GO TO 102A] Yes (1)
A	[If YES to 102] Date of visit: [Continue on additional page if necessary]	__ __ / __ __ / __ __ D D M M Y Y
103	Have you visited a traditional healer?	[GO TO104] No (0) [GO TO 103A] Yes (1)
A	[If YES to 103] When did you visit the traditional healer? [Continue on additional page if necessary]	__ __ / __ __ / __ __ D D M M Y Y
104	Have you attended a funeral?	[GO TO 105] No (0) [GO TO 104A] Yes (1)
A	[If YES to 104] Did the person die of ebola?	[GO TO 105] No (0) [GO TO 104B] Yes (1) [GO TO 105] Don’t know (8)
B	What was the date of the funeral?	__ __ / __ __ / __ __ D D M M Y Y
C- F	Did you………? [Circle all that apply]. CODE = 0 if not circled = 1 if circled [Continue on additional page if necessary]	Wash or clean the body (C) Dress or wrap the body (D) Carry the body (E) Clean the bowels of the body (F)
105	Have you had direct contact with or spent significant time (> 1 hour) close to someone else who has been diagnosed with Ebola or who has been very ill with fever, diarrhea, vomiting or bleeding?	[END OF INTERVIEW] No (0) [GO TO 105A] Yes (1)
A	[IF YES TO 105] What is the name of the person? Name:	_______________________________ (Code: _____)
B	Date of last contact:	__ __ / __ __ / __ __ D D M M Y Y

END OF INTERVIEW

[CONCLUDE INTERVIEW. REVIEW QUESTIONNAIRE TO BE SURE ALL QUESTIONS HAVE BEEN ANSWERED. MAKE ANY CORRECTIONS THAT ARE NEEDED. THANK THE PARTICIPANT FOR THEIR TIME.]

Public reporting burden of this collection of information is estimated to average 5 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).

Public reporting burden of this collection of information is estimated to average 5 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).

Contact Exit Questionnaire, V1.2, 13 Jan 2015