Daily Direct Active Monitoring Tracking Report - email

Attachment C1 - Daily Direct Active Monitoring email Template

Directions to respondent:

Please report the following information for each traveler in your email:

Traveler information	City
	State
	State assigned ID
	CDC Id / Traveler's Health ID
	CDC Risk Category (High, Some)
	Healthcare Worker (y/n)
	Citizenship Status (if not U.S. Citizen)
	Arrival in Jurisdiction Date
	U.S. Entry Airport
	If other
	U.S. Entry Date
	Hospital Identified (y/n)
	Local Hospital
	Transport Plan to Hospital (y/n)
	Travelling During Monitoring Period (y/n)
	Summary of travel plans
	Comments
Daily Monitoring	Date of Last Some or High Risk Exposure
	Today's Date
	Contacted?
	Reason for No Contact
	Symptom (y/n)
	Description of Symptoms
	Referred for Evaluation (y/n)
	Referred for testing?(y/n)
	Comments

Public reporting burden of this collection of information is estimated to average 4 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/ASTDR Information Collection Review Office, 1600 Clifton Rd NE, MS-D74, Atlanta, Georgia 30333: ATTN:PRA (0920-xxxx)

Dictionary

Variable Name	Variable Description	Response
State assigned ID	A unique ID for the traveler, ascribed by the state conducting the direct active monitoring (DAM), should stay the same throughout the DAM reporting period (typically 21 days)	text
Traveler Health Declaration ID	A unique ID for the traveler, ascribed by CDC when form is received from CBP; should stay the same throughout the DAM reporting period (typically 21 days)	text
State	State that is conducting the DAM and reporting	text
CDC Risk Category (High, Some, Low)	Risk category according to CDC's Interim Guidance for the Monitoring and Movement of persons with potential exposure to ebola virus disease*	some or high*
HCW	Was the traveler a healthcare worker treating patients in W. Africa	y/n
Hospital Identified	Has a hospital been identified that the travel will be taken to if he or she becomes symptomatic?	y/n
Hospital Name	Name of hospital identified that the traveler will be taken to if he or she becomes symptomatic	text
Transfer Plan	Is a transfer plan in place for moving the traveler to the hospital if he or she becomes symptomatic	y/n
Travel Plans	Does the person have travel plans during the monitoring period	yes/no
Travel Plans	Summary of person's plans for travel within the monitoring period and jurisdiction's plans for continued monitoring	text
Date of person's last exposure	Date person was last exposed to the event that put them in the some or high category	Date
Date of entry into the US	Date person was last exposed to the event that put them in the some or high category	Date
Days until DAM completed	Number of days until the 21 day incubation period is over (=Today's date -Date of last exposure)	Number (0-21)
Date 21 days post-exposure	Date the 21 day incubation period should end (=exposure +21)	Date
Date of last DAM (as of midnight) 1	Day for which this report reflects (normally yesterday)	Date
If no, why (Txt)	If not, why not; could reflect "DAM Period Completed"	text
Total Number of Days DAM was required	Total number of days that DAM was required; will usually be (= Today - Date of Entry to U.S) but might defer for unique situations (DAM officially began 10/27/14)	Number
Number of Days until DAM is completed	Total number of days until DAM period is completed (# of days required minus number of days completed or missed)	Number
Total Number of Days DAM completed	Total number of days that DAM was completed successfully (based on "y" on tracking worksheet)	Number
Total Number of Days DAM missed	Total number of days that DAM was missed (based on "n" on tracking worksheet)	Number
% of days completed	Percentage of number of days DAM completed within the required period	Percent
Symptom (y/n)	Did traveler have fever or other symptom such as severe headache, muscle pain, vomitting, diarrhea, stomach pain, unexplained bruising or bleeding	yes/no
Refered for Evaluation (y/n)	Was the person referred for medical evaluation?	yes/no
Refered for testing (y/n)	Was the person referred for testing for EVD?	yes/no
High risk includes any of the following:
	Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of a person with Ebola while the person was symptomatic
	Exposure to the blood or body fluids (including but not limited to feces, saliva, sweat, urine, vomit, and semen) of a person with Ebola while the person was symptomatic without appropriate personal protective equipment (PPE)(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html)
	Processing blood or body fluids of a person with Ebola while the person was symptomatic without appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) or standard biosafety precautions
	Direct contact with a dead body without appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) in a country with widespread Ebola virus transmission(http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html)
	Having lived in the immediate household and provided direct care to a person with Ebola while the person was symptomatic
Some risk includes any of the following:
	In countries with widespread Ebola virus transmission(http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html): direct contact while using appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) with a person with Ebola while the person was symptomatic
	Close contact in households, healthcare facilities, or community settings with a person with Ebola while the person was symptomatic
	Close contact is defined as being for a prolonged period of time while not wearing appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) within approximately 3 feet (1 meter) of a person with Ebola while the person was symptomatic