EVD Case Contact Questionnaire - English

Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/xxxx

Interviewer:_________________________
Date of Interview: ___________________

ID number:_________

Ebola Virus Disease Case Contact Questionnaire
Interviewee Name:
Ebola Virus Disease (EVD) patient:
Relationship to patient:
Address:
Phone number (home):
Email:
@

Age: _______ Gender: _____________
.
City:

State:

(work):

1. Did you have contact with the patient with ebola virus disease (EVD) while they had symptoms?
No (Skip to Question 2)
Yes IF YES: Date of LAST direct contact with the patient:
1a. IF YES: What was the nature of your contact with the patient?
No contact due to appropriate PPE
Contact with your intact skin
Contact with your broken skin (fresh cut, burn, or abrasion that had not dried)
Mucous membrane contact (eyes, nose, mouth, etc.)
Other (Specify):
1b. IF PPE Used: Check all that were used.

Gloves
Face Shield

Double gloves

Gown

Mask

Leg Cover

Glasses/goggles
Tyvek suit

2. Did you come into contact with body fluid(s) from the patient with EVD while they had
symptoms?
No (Skip to Question 3)
Yes IF YES: Date of LAST contact with the body fluids:
2a. IF YES: What was the nature of your contact with the patient?
No contact due to appropriate PPE
Contact with your intact skin
Contact with your broken skin (fresh cut, burn, or abrasion that had not dried)
Mucous membrane contact (eyes, nose, mouth, etc.)
Other (Specify):
2b. What body fluids did you contact (check all that apply)?
Tears
Saliva
Respiratory/Nasal secretions
CSF
Vomitus
Urine
Blood
Stool
Sweat
Semen/Vaginal fluid
Other (Specify):
2c. IF PPE Used: Check all that were used.

Gloves
Face Shield

Double gloves

Gown

Mask

Leg Cover

Glasses/goggles
Tyvek suit

3. If the patient with EVD has expired (died), did you have contact with the body?
No, the patient is alive. (Skip to Question 4)
No, did not contact the body and did not attend the funeral. (Skip to Question 4)
No, but attended the funeral services. Date of the funeral:
Yes, direct contact with the body. Date of LAST contact with the body:

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 Reports Clearance Officer,
1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

3a. What was the nature of your contact with the body?
No contact due to appropriate PPE
Contact with your intact skin
Contact with your broken skin (fresh cut, burn, or abrasion that had not dried)
Mucous membrane contact (eyes, nose, mouth, etc.)
Other (Specify):
2c. IF PPE Used: Check all that were used.

Gloves
Face Shield

Double gloves

Gown

Mask

Leg Cover

Glasses/goggles
Tyvek suit

4. Are/were you a healthcare worker providing health services for the patient?
No (Skip to Question 5)
Yes
5a. IF YES, in what manner did you provide health services to the patient?
Direct clinical care services (physician, nurse, clinical aide, etc.)
Laboratory services (phlebotomy, other sample collection, laboratory processing)
Custodial services (launder sheets, cleaning equipment, cleaning patient’s room)
Other (Specify):
5. Did you have any other contact with the patient (Specify):

------------------------------------------------------------------------------------------------------------------------------Classification:
High Risk
• Direct exposure to body fluids of the EVD patient
• Direct care of a confirmed or suspected EVD patient without PPE
• Laboratory worker processing body fluids without appropriate laboratory biosafety precautions
• Participation in funeral rites or body preparation of the EVD patient without appropriate PPE
Low Risk
• No high risk exposures identified
• Providing patient care while using PPE of an EVD patient
• Household member or casual contact of an EVD patient
No Known Risk
• No other high or low risk exposures identified
• Had no contact with EVD patient
Follow-up Actions:
No further follow-up required. Does not meet high or low risk criteria or last exposure was >21 days.
Fever Monitoring Recommended (for High and Low Risk only)
Who will conduct the follow up for fever monitoring?
Name
Phone Number
Fever monitoring recommended but respondent is refusing follow up
Respondent has had a fever since having contact with the patient
Where will the patient be evaluated for fever?
Who at the Department of Health was notified?

Phone Number
Interviewer’s Name: ______________________Date: ___________