Ebola Airline Exposure Assessment Airport or Other Staff

Department of Health and Human Services

Centers for Disease Control and Prevention

OMB Approved

0920-0900

Exp xx/xx/xxxx

ID Number________

Ebola Exposure Assessment Airport or Other Port of Entry Staff

Directions: Please fax completed form to Ebola Airline Investigation at fax # 404.718.2158 after both initial interview and completion of final disposition.

***Note: If interviewee is determined to have a fever ≥101.5° F, immediately call EOC at 770.488.7100.

Date of initial interview: ________________ Interviewed by: _________________________________

1. Name: __________________________________________________ Age:_____________

Sex: ____ Country of Birth: ______________ Country of Residence: ________________________

Travel Plans through insert date:­ ____________________________________________________

Address: _______________________________________________________________________

Phone numbers- home: ________________ cell:_________________ work:__________________

Job title: _______________________________________________________________________

Circle insert conveyance in which interviewee was involved: [(insert conveyance) information]

[(insert conveyance) information]

2. Did interviewee have any interactions with sick passengers from this [conveyance]? Yes No

If yes, describe this event including location, degree of contact (talking with or touching) and length of time: ________________________________________________________________________

3. Did interviewee have contact with any body fluids while working with the [conveyance] circled above? Yes No (If no, skip to question 4)

If yes, were masks or gloves worn?

Describe the contact including location of the body fluid in the [port] and any other individuals involved: _______________________________________________________________________

If yes, which body fluids did interviewee come into contact with? (Check all that apply)

Tears Saliva Respiratory secretions (cough and sneeze droplets)

Vomit Urine Blood Stool Sweat

If yes, did these fluids come in contact with the interviewee’s:

Intact skin

Broken skin (fresh cut or scratch which bled within 24 hours before the contact; burn or abrasion that had not dried)

Mucous membrane contact (eyes, nose or mouth)

Other (Specify): _________________________________________________________

4. Were there any incidents that the interviewee can recall when other staff were in contact with a person’s body fluids while working with the [conveyance]?

Yes No

If yes, please describe situation and location in the [port], including time of the occurrence: _______________________________________________________________________________

_______________________________________________________________________________

5. What protective equipment (i.e. gloves, face mask) was the interviewee wearing when he/she was working (if any)? _________________________________________________________________

6. Please check all symptoms interviewee has had since [exposure]:

Fever ≥101.5° F Sore throat Body aches/muscle pain Headache

Abdominal pain Vomiting Diarrhea Weakness

Rash Hiccups Unusual bleeding (e.g. from gums, eyes or nose)

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Classification of interviewee risk (Consult the CDC to classify each contact after interview. Refer to http://www.cdc.gov/vhf/ebola/hcp/case-definition.html for additional information):

High Risk: The index case’s body fluids came in contact with the interviewee’s bare skin or mucous membranes (eyes, mouth, nose)

Some Risk: Interviewee had close contact* with the index case but not body fluids; or was only exposed on protected areas of the body (e.g. on hands while wearing gloves).

No Known Risk: Interviewee did not have some risk or high risk exposures above.

Follow-up Actions:

Ebola information distributed

Fever watch: For all contacts regardless of classification of risk, provide fever watch form that should be reviewed at least weekly.

Referred for medical evaluation due to presence of symptoms. If yes,

Where were they referred? _________________________________________________________

What was the outcome? ___________________________________________________________

Declined medical evaluation after it was recommended

Was interviewee placed under conditional release? Yes No

Was interviewee placed under state issued quarantine order? Yes No

Final Disposition:

Was interviewee contacted again after [Fill in the date of the last day of the incubation period]?

Yes, Date of second interview: __________ No

If yes, did interviewee develop any symptoms of Ebola between the time of flight and [Fill in date]? Yes No

If yes, please describe the symptoms, timing and outcome of medical evaluation below: ____________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

Evaluating healthcare provider name/phone number: ________________________/(____)__________

* Close contact is defined as a) being within approximately 3 feet (1 meter) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., droplet and contact precautions–see Infection Prevention and Control Recommendations); or b) having direct brief contact (e.g., shaking hands) with an EVD case while not wearing recommended personal protective equipment (i.e., droplet and contact precautions–see Infection Prevention and Control Recommendations). At this time, brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact.

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Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0900.