Ebola Sexual Transmission Investigation Form - English

Form Approved

OMB No. 0920-xxxx

Exp. Xx/xx/xxxx

			Outbreak ID: VHF ID: Laboratory ID:
Investigation Form for possible sexual transmission of Ebola to a partner of an Ebola survivor
Note: This form is to be used to determine whether epidemiologic evidence exists in support of transmission of Ebola virus disease from a survivor to a sexual partner after recovery from acute Ebola infection. In this form, the “case” is the reported new Ebola case for whom sexual transmission is suspected.
Case ID number: ______________________ Is case confirmed? □ Yes □ No If No, STOP	Date of case report: ____ /____ /____ MM DD YY
Has the Ebola case had any sexual contact (vaginal, oral, anal) with an Ebola survivor since the survivor was discharged from an ETU?				□ Yes □ No □ Unk
If no or unknown, STOP and tick “No evidence of sexual exposure during the incubation period” on page 3 (transmission classification)
If yes, was a condom used?				□ Every time □ Sometimes □ Never
What is the survivor’s Case ID number?
Was this case followed as a contact of the above-referenced survivor?				□ Yes □ No □ Unk
Does the case have any epidemiologic risk factors listed on the Ebola case investigation form?				□ Yes □ No
If no, confirm by asking again about risk factors on case investigation form
Please enter the following dates as accurately as possible. The letters assigned to each date (A, B, C, D) will facilitate performing time interval calculations. After you have entered the date, use the table on page 2 to determine the day of the year, and enter that number to the right of the date (day of year column). Day of year*
Date of symptom onset in case		A= _____/_____/_____ ________ MM DD YY
Date of last contact (ANY contact) with survivor while survivor was symptomatic and before survivor was admitted to ETU		B= _____/_____/_____ ________ MM DD YY
Date of last (most recent) sexual contact with survivor after survivor was discharged from ETU		C= _____/_____/_____ ________ MM DD YY
Date survivor was discharged from ETU		D= _____/_____/_____ ________ MM DD YY

Public reporting burden of this collection of information is estimated to average 30 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).

The following table assigns a number to each day of the year and can be used to easily subtract one date from another, particularly if they are in different months.

To use the table, find the month in the top row, and find the day of the month in the far left column. Then locate the place where the Month and Day intersect.

In the example highlighted below, August 23^rd is the 235^th day of the year, and October 1^st is the 274^th day. If the date of symptom onset was October 1^st, and the date of last sexual contact was August 23^rd, the interval would be (274-235) or 39 days.

	Month
Day	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct	Nov	Dec
1	1	32	60	91	121	152	182	213	244	274	305	335
2	2	33	61	92	122	153	183	214	245	275	306	336
3	3	34	62	93	123	154	184	215	246	276	307	337
4	4	35	63	94	124	155	185	216	247	277	308	338
5	5	36	64	95	125	156	186	217	248	278	309	339
6	6	37	65	96	126	157	187	218	249	279	310	340
7	7	38	66	97	127	158	188	219	250	280	311	341
8	8	39	67	98	128	159	189	220	251	281	312	342
9	9	40	68	99	129	160	190	221	252	282	313	343
10	10	41	69	100	130	161	191	222	253	283	314	344
11	11	42	70	101	131	162	192	223	254	284	315	345
12	12	43	71	102	132	163	193	224	255	285	316	346
13	13	44	72	103	133	164	194	225	256	286	317	347
14	14	45	73	104	134	165	195	226	257	287	318	348
15	15	46	74	105	135	166	196	227	258	288	319	349
16	16	47	75	106	136	167	197	228	259	289	320	350
17	17	48	76	107	137	168	198	229	260	290	321	351
18	18	49	77	108	138	169	199	230	261	291	322	352
19	19	50	78	109	139	170	200	231	262	292	323	353
20	20	51	79	110	140	171	201	232	263	293	324	354
21	21	52	80	111	141	172	202	233	264	294	325	355
22	22	53	81	112	142	173	203	234	265	295	326	356
23	23	54	82	113	143	174	204	235	266	296	327	357
24	24	55	83	114	144	175	205	236	267	297	328	358
25	25	56	84	115	145	176	206	237	268	298	329	359
26	26	57	85	116	146	177	207	238	269	299	330	360
27	27	58	86	117	147	178	208	239	270	300	331	361
28	28	59	87	118	148	179	209	240	271	301	332	362
29	29		88	119	149	180	210	241	272	302	333	363
30	30		89	120	150	181	211	242	273	303	334	364
31	31		90		151		212	243		304		365

Using the days of the year associated for the dates on page 1*, calculate the following time intervals in number of days, using the formulas provided:
Time between last contact of any kind while the survivor was ill with acute Ebola and case’s symptom onset:						(A - B) =
Interval from last sexual contact prior to symptom onset in the case:						(A - C) =
Answer the following questions based on the calculations above:
Is (A -B) ≥21? Is (A -C)<2 and only sexual contact? Is (A -C) ≤21?						□ Yes □ No □ Yes □ No □ Yes □ No
Answer the following questions about the case:
Did the case reside in an area with other Ebola cases in the 21 days before symptom onset?						□ Yes □ No
Did the case travel to an area with ongoing Ebola transmission during the 2-21 days before symptom onset?						□ Yes □ No
Use the table below to determine the risk classification, based on the responses to questions 1-5 above:
Question 1	Question 2	Question 3	Question 4	Question 5	Risk Classification
Yes	No	Yes	Yes	No	Possible sexual transmission of Ebola virus from an Ebola survivor
Yes	No	Yes	No	Yes	Possible sexual transmission of Ebola virus from an Ebola survivor
Yes	No	Yes	No	No	Probable sexual transmission of Ebola virus from an Ebola survivor
	Yes	No			No evidence of sexual exposure during incubation period/Infection unlikely due to sexual exposure to the survivor
No					Exposure to survivor during acute illness in incubation period is possible
Transmission Classification (tick one) Possible sexual transmission of Ebola virus from an Ebola survivor □ In a community with ongoing transmission of Ebola, possible sexual transmission of Ebola virus is when a sex partner of a confirmed Ebola survivor has a confirmed Ebola infection with symptom onset > 2 days after having sex with the survivor, > 21 days after last contact while the survivor was ill with acute Ebola, and further investigation of the sex partner’s travel history and community contacts could not rule out other potential sources of Ebola exposure Probable sexual transmission of Ebola virus from an Ebola survivor □ In a community without ongoing transmission of Ebola, probable sexual transmission of Ebola virus is when a sex partner of a confirmed Ebola survivor has a confirmed Ebola infection with symptom onset > 2 days after having sex with the survivor, > 21 days after last contact while the survivor was ill with acute Ebola, and further investigation of the sex partner’s travel history and community contacts identified no other potential source of Ebola exposure No evidence of sexual exposure during the incubation period □ Exposure to survivor during acute illness in incubation period is possible □
Additional comments: Assessment of sexual contact during survivor’s recovery period based on answers on page 1 Timing between last (most recent) sexual contact with survivor after survivor’s ETU discharge (C – D) = ________ Is (C -D) ≤ 90? □ Yes □ No If no, then (C – D) > 90.

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