Ebola Entry Screening Risk Assessment Form - English

Health and Human Services, Centers for Disease Control and Prevention

OMB approved 0920-0821

Exp XX/XX/XXXX

Traveler Name: _________________________________ Date (mm/dd/yy): ___________________________

Passport Country: _______________________________ Passport Number: ___________________________

EBOLA ENTRY SCREENING RISK ASSESSMENT FORM

Instructions to CDC staff:

• Tell traveler: You were referred for public health assessment because of possible exposure to Ebola. I am going to ask you a few questions to get more information. This will help us decide if you need additional evaluation or monitoring.

• Complete the SIGNS OR SYMPTOMS section for the past 48 hours using checkboxes and record date of first symptom onset. Measure and record temperature. Record whether fever-reducing medications were taken within the past 12 hours, including dose and last time taken. Ask additional questions as needed. Describe any illness on page 3.

• Read the EXPOSURE ASSESSMENT QUESTIONS to the traveler. All questions refer to the past 21 days. Relevant countries are those with either widespread transmission or cases in urban settings with uncertain control measures (see http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html).

• All questions must be completed. Check YES, NO or UNKNOWN (as applicable). Ask additional questions as needed to get as complete a description as possible of all pertinent activities during the past 21 days and potential exposures. Obtain dates of all potential exposures and document on page 3 along with a narrative description of the exposure situation.

• Complete ASSESSMENT and DISPOSITION sections on page 3.

  • Document whether symptomatic and describe any illness.

  • Check exposure risk level and provide a justification. For high/some risk, document last potential exposure date.

  • Document notification of Global Migration Task Force (GMTF) Ebola Consultant on call

  • Check disposition and document notification of state/local health department(s) (S/L HD).

  • Sign and date form.

Definitions (for the purpose of this form) – explain each to traveler at first mention:

• “Person with Ebola” includes confirmed or suspect cases or any person who died of an illness that included fever, vomiting, diarrhea, or unexplained bleeding. If not a confirmed case, get more information about illness/death circumstances.

• Appropriate personal protective equipment (PPE) is wearing (at a minimum): facemask, eye protection (goggles/face shield), gloves, impermeable gown, boots/shoe covers during every potential exposure.

• Body fluids include blood, urine, saliva, sweat, feces, vomit, breast milk, and semen.

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Relevant country(ies): _________________________________________________________________________________________

Dates in country(ies) (mm/dd/yy):____ / ____ / ____ to ____ / ____ / ____ □ Resides in relevant country (list departure date)

If traveler was not in a relevant country or was last there more than 21 days ago, no further assessment is needed. Document on page 3 as no identifiable risk and provide justification.

REASON FOR REFERRAL TO CDC (check all that apply): □ measured temp ≥ 100.4^oF □ visibly symptomatic □ self-reported fever

□ self-reported vomiting/diarrhea □ contact with Ebola patient □ in healthcare facility (HCF)/laboratory □ dead body/funeral

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SIGNS OR SYMPTOMS (past 48 hours): □ None □ Fever □ Severe headache □ Muscle pain □ Fatigue □ Vomiting □ Diarrhea □ Stomach pain □ Unexplained bleeding/bruising Onset date of earliest symptom (mm/dd/yy):____ / ____ / ____

Measured temperature: _______ Time: __________ Temperature method: □ Oral □ Tympanic □ Noncontact

If temperature rechecked: _______ Time: __________ Temperature method: □ Oral □ Tympanic □ Noncontact

Reported use of fever-reducing medication (past 12 hours)? □ Yes □ No □ Unknown

If YES: Medication name: ____________________________ Dose: ________________ Time since last dose: _______(hours)

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EXPOSURE ASSESSMENT QUESTIONS – In the past 21 days, while you were in [name of relevant country]:

1. Did you ever come into contact with or have other potential exposure to blood or other body fluids of a person with Ebola (this includes while wearing PPE)? Note to interviewer: As applicable, ask about activities such as cleaning/disinfecting contaminated areas or spraying in HCF doffing areas (i.e. before PPE removal) or of dead bodies/body bags. □ Yes □ No □ Unknown

1. If YES: Did the contact include any of the following? (YES to any of these = HIGH RISK, describe on p. 3):

1. Getting stuck with a needle or other sharp object? □ Yes □ No □ Unknown

2. Getting splashed in the eye, nose or mouth? □ Yes □ No □ Unknown

3. Getting blood or body fluids directly on your skin? □ Yes □ No □ Unknown

2. If NO to i – iii above: Did you wear appropriate PPE at all times that you were potentially exposed to blood or body fluids? □ Yes □ No □ Unknown NO (to PPE use) = HIGH RISK YES (to PPE use) = SOME RISK (Describe on p. 3)

2. Did you take care of patients in any healthcare setting or did you work as a phlebotomist (drawing blood)? □ Yes □ No

YES = SOME RISK (Describe on p. 3)

3. Did you provide direct care to anyone with Ebola while that person was sick or enter an area (e.g. as an observer) where Ebola patient care was taking place? This includes household or healthcare settings. Note to interviewer: Please clarify context; for travelers that report visiting Ebola treatment units (ETUs) this question refers only to areas of the ETU where PPE is typically required, such as patient care areas. □ Yes □ No If YES, document setting:

□ Household member providing care = HIGH RISK (Describe on p. 3.)

□ Healthcare worker (HCW) providing patient care □ Nonclinical activities □ Observer – check as applicable and ask 3 a & b

1. Did you wear appropriate PPE at all times? □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK YES (to PPE use) = SOME RISK (Describe on p. 3.)

2. If YES (to PPE use): Were any healthcare workers or other staff in facility diagnosed with Ebola? □ Yes □ No □Unknown If YES, get more information to assess whether unrecognized infection control breaches (HIGH RISK) may have occurred. (Describe on p. 3.)

4. 4. Did you work in a laboratory? □ Yes □ No Name of laboratory:________________________________________________

   1. If YES: Did you handle specimens of Ebola patients or was the lab associated with an ETU? □ Yes □ No □ Unknown

1. If YES (to handling specimens of Ebola patients/lab associated with ETU): Did you wear appropriate PPE and follow standard lab biosafety precautions at all times? □ Yes □ No □ Unknown

Consult the list of laboratories for which CDC is confident that biosafety precautions are followed. If laboratory is not on list, get a description of all lab-related activities, including activities outside the laboratory environment such as phlebotomy or entering a patient care area to pick up specimens. Together with GMTF Consultant, call CDC Emergency Operations Center (770-488-7100) and ask for the Laboratory Task Force on-call to conduct assessment.

Appropriate PPE plus biosafety precautions = LOW (BUT NOT ZERO) RISK

Appropriate PPE but not all biosafety precautions followed (based on SME assessment) = SOME RISK

No PPE/biosafety precautions or PPE breach = HIGH RISK

NOTE: Use questions 2 and 3, as applicable, to assess and document any activities in patient care areas (e.g., phlebotomy, picking up specimens).

5. Were you around dead bodies or did you go to a funeral? □ Yes □ No

   1. If YES: Did you directly touch or handle dead bodies or have contact with the water used to wash dead bodies or the cloth that covered a dead body? This might include participating in funeral or burial rites or any other activities that involved handling dead bodies. □ Yes □ No □ Unknown

   2. i. If YES (to touching bodies or other exposure): Did you wear appropriate PPE at all times? □ Yes □ No □ Unknown

NO (to PPE use) = HIGH RISK YES (to PPE use) = SOME RISK (Describe on p. 3.)

6. Did you live or work (such as cleaning or doing laundry) in the same household as a person with Ebola while that person was sick?

□ Yes □ No □ Unknown

Ebola patient’s date of symptom onset (if known) (mm/dd/yy): ____ / ____ / ____

Dates traveler lived or worked in household during person’s illness: ____ / ____ / ____ to ____ / ____ / ____

YES (household member during symptomatic period) = HIGH/SOME RISK (Get more information. Describe on p. 3.)

7. Were you ever near a person with Ebola while the person was sick and you were not wearing PPE? □ Yes □ No □ Unknown

a. Were you within 3 feet (1 meter) of the person with Ebola? □ Yes □ No □ Unknown

1. If YES: Get an estimate of time and a description of activities. Describe on p. 3. Time: _____ (hours) _____ (minutes) YES AND extended period = SOME RISK

2. b. Did you touch the person with Ebola (e.g. shaking hands)? □ Yes □ No □ Unknown

If YES: Get more information about stage of illness: EARLY (mildly ill) = LOW (BUT NOT ZERO) LATE (severely ill) = HIGH

ASSESSMENT

□ Asymptomatic □ Symptomatic For symptomatic travelers – description of illness: __________________________________

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Exposure Risk Level: □ High risk □ Some risk □ Low (but not zero) risk □ No identifiable risk

For HIGH/SOME risk, date of last high/some risk exposure: ____ / ____ / ____

Description of all pertinent activities and any potential exposure situations and justification for exposure risk level assignment:

___________________________________________________________________________________________________________

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□ GMTF Ebola Consultant called Time: ________ Name(s) of GMTF Consultant(s):______________________________________

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DISPOSITION (check one)

□ Medical evaluation required □ Released to continue travel without S/L HD notification

□ S/L HD notified –> select one: □ notified before traveler released □ notified after traveler released

S/L HD/point of contact: ______________________________________________________________________ Time: ________

□ Other (describe): __________________________________________________________________________________________

Additional notes (including justification of disposition for symptomatic travelers, if applicable): ___________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Medical Officer: _______________ _____________________________________ Port of Entry: _____________________________

Medical Officer Signature: ____________________________________________________ Date: ____________________

Form completed by (if other than medical officer): _________________________________________________________________

Signature: ____________________________________________ Title: _________________________________________________

The legal authorities for this collection are sections 311 and 361-368 of the Public Health Service Act.

NOTE: While cooperation with CDC during this proposed risk assessment is voluntary, if an individual refuses to provide the requested information, or is not truthful about the information provided during screening or an illness investigation, CDC may, if it is reasonably believed that the individual is infected with or has been exposed to Ebola, quarantine, isolate, or place the individual under surveillance under 42 CFR 71.32 and 71.33.

Public reporting burden of this collection of information is estimated to average 15 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 0920-0821.