Inventory of ICs - Y1Q3

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

CONSENT/PARENTAL PERMISSION FORM
Suspected chikungunya or dengue virus infections among community service volunteers in the
Dominican Republic, 2014

The US Centers for Disease Control and Prevention is working with Amigos de las Américas, Inc., and
the Texas Department of Health to investigate possible chikungunya virus infections among volunteers
and staff. Chikungunya is a disease characterized by fever and joint pains. The virus that causes this
disease is transmitted by the same mosquito that transmits another virus called dengue virus. Dengue
virus has been present in the Dominican Republic for many years. Chikungunya virus was only recently
introduced into the Dominican Republic.
We are trying to find out how many volunteers and staff deployed to the Dominican Republic this
summer got chikungunya or dengue. We will try to identify people who got infected but who may not
have known they were infected. We also want to know, of those who got ill with a fever, how many
were infected by the chikungunya or dengue viruses. Finally, we are trying to get information about the
daily practices of people who got infected. With this information, we will try to figure out factors that
may have contributed to chikungunya and dengue virus infections and what are effective avoidance
measures.
We would like to ask that you/your child fill out a questionnaire that we have developed to try to answer
the questions in the above paragraph. We expect that it will take about 20 minutes to complete. We
would also like to take approximately 1 ½ tablespoons of blood, which we will use to test whether you
have/your child has been recently infected with the viruses that cause chikungunya and dengue. As is
standard procedure in these types of investigations, if any of the blood sample is left over, we would like
to store it for future chikungunya and dengue testing. We will NOT perform any genetic or HIV testing
on it or test for other diseases.
We will give you the results of your/your child’s test, but they will not be available in time to be useful
in making any decisions about your health care. If the test shows that you/your child had a recent
chikungunya or dengue virus infection, we will also inform the health department in the state where you
live.
In addition to the questionnaire, we are aware that Amigos de las Américas, Inc., collects health
information on a weekly health log for each participant as well as clinical information when a participant
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 (0920-1011)

becomes ill. This information may be helpful to us in determining when people became ill as well as the
extent of their illness. Therefore we would like to obtain this information for volunteers whose illnesses
are compatible with chikungunya or dengue.
All the information you/your child give(s) us will be kept private to the extent possible, and only the
investigators working on the investigation will be able to see it. There is a small risk though that
personnel not involved with the investigation could see your information. Reports of the investigation
will be summaries, and no information will be shared with others, including Amigos de las Américas,
Inc., that can identify you or your child personally. Answering the questions is completely voluntary,
and you/your child can stop answering questions any time. You/your child can also decide not to
answer any particular question. The same applies to the blood specimens.
Do you have any questions? If not, please read the statements below and if you agree, sign and date the
form where indicated. If you do not agree to any of the following statements, please draw a line through
the statement you do not agree with and initial next to the line.
·
·
·
·

I agree to answer questions
I agree to have my or my child’s blood drawn
I agree to allow my or my child’s blood to be stored for future chikungunya and dengue testing
I agree to allow Amigos de las Américas, Inc., to furnish my or my child’s weekly health log and
related health information to investigators
· I agree to be contacted by investigators or Amigos de las Américas, Inc., in the future in case any
clarifications to data already collected are needed, and to receive chikungunya and dengue test
results and information

Participant Name: ___________________________

Date: _______________________

Parent/Guardian Name:_______________________

Signature:__________________________

ASSENT FOR MINORS <18 YEARS OF AGE
Suspected chikungunya or dengue virus infections among community service volunteers in the
Dominican Republic, 2014

We are working with the U.S. Centers for Disease Control and Prevention to try to determine if there
were volunteers or staff that experienced an illness called ‘chikungunya’ in the Dominican Republic.
This disease causes fever and body pain, and is transmitted by the same mosquitoes that transmit dengue
virus. Chikungunya virus was only recently introduced into the Dominican Republic and illnesses from
this virus have been reported. We are trying to find out how many people may have been infected
among the volunteers and staff deployed to the Dominican Republic this summer. We will try to
identify people who got infected but who may not have known that they were infected and, of those who
got ill with a fever, how many had symptoms due to chikungunya or dengue. In addition, we are trying
to get information about the daily practices of people who got sick to try to figure out factors that may
have contributed to chikungunya and dengue virus infections and what might be effective avoidance
measures.
To do that, we would like to ask you some questions about things that you were doing during your time
in the Dominican Republic . We would also like to take approximately 1 ½ tablespoons of blood, which
we will use to test for evidence of having been recently infected with the viruses that cause chikungunya
and dengue. This would mean that we would put a small needle in your arm and take some of your
blood. It might pinch a little at first, but should not be too painful. This is to test for chikungunya and
dengue. Your parent/guardian has given their permission for you to answer these questions and give
some blood. You may now choose whether or not to proceed with participation in this investigation.
· I agree to answer the questionnaire
· I agree to have my blood drawn

Name:_____________________________________

Signature:_____________________________________

Date:______________________

Unique ID # (e.g., SJ-1-A-1):_____________________

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Suspected chikungunya or dengue virus infections among community service volunteers in
the Dominican Republic, 2014

What is your name?______________________________(Last, First,MI)
This page will be removed after a unique identifier is applied and accuracy is checked.
None of your answers to any of the questions in this questionnaire will be shared with staff from your service
organization.

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 (0920-1011)

Unique ID # (e.g., SJ-1-A-1):_____________________

**********************************************************************

Demographic Information and Previous Travel History
**********************************************************************
0. What is your age? _____
1. Sex: □ Male

□ Female

2. What countries outside of the continental United States have you ever visited before this trip to the
Dominican Republic (please also list such places as Puerto Rico, the US Virgin Islands, and Guam)?
_______________________________________________________________________________________
_______________________________________________________________________________________
_________________________________
3. Have you received the yellow fever vaccine in the past? □ Yes □ No

□ Don’t know

4. Have you received the Japanese encephalitis vaccine in the past? □ Yes □ No

□ Don’t know

**********************************************************************

Trip Illness History
**********************************************************************
5. Have you experienced a fever since you arrived in the Dominican Republic?
□Yes □ No
If yes, please specify as accurately as possible the following information about each of your illnesses
with fever on the next page. If no, skip to Question 6.

Unique ID # (e.g., SJ-1-A-1):_____________________

Illness with fever #1
5.1a. What date did you become ill (approximately)? : Month: ___________ Day: __________
5.1b. Please check all that apply
□ Chills
□ Headache
□ Runny nose
□ Sore throat
□ Red eyes
□ Eye pain/pain behind eyes
□ Cough
□ Nausea/Vomiting
□ Diarrhea
□ Abdominal pain/discomfort
□ Muscle pain □ Calf pain
□ Joint pain
□ Red or swollen joints
□ Skin rash
□ Minor bleeding (e.g., petechiae (small red/purple sometimes raised spots on skin), gum bleed,
nosebleed, excessive or unusual bruising)
□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy menses)
5.1c. If you had joint pain, indicate the locations where you had the pain

5.1d. Approximately how long did this illness last? ______ days
5.1e. Did you activate your emergency CALM plan because of this illness?
□ Yes □ No
5.1f. Did you go to the doctor because of this illness?

□ Yes

5.1g. What was the diagnosis?
□Chikungunya □ Dengue □ Viral syndrome □ I don’t know
□ Other: If other, please specify ________________________
5.1h. Were you hospitalized for this illness? □ Yes

□ No

□ No

Unique ID # (e.g., SJ-1-A-1):_____________________

Illness with fever #2
5.2a. What date did you become ill (approximately)? : Month: ___________ Day: __________
5.2b. Please check all that apply
□ Chills
□ Headache
□ Runny nose
□ Sore throat
□ Red eyes
□ Eye pain/pain behind eyes
□ Cough
□ Nausea/Vomiting
□ Diarrhea
□ Abdominal pain/discomfort
□ Muscle pain □ Calf pain
□ Joint pain
□ Red or swollen joints
□ Skin rash
□ Minor bleeding (e.g., petechiae (small red/purple sometimes raised spots on skin), gum bleed,
nosebleed, excessive or unusual bruising)
□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy menses)
5.2c. If you had joint pain, indicate the locations where you had the pain

5.2d. Approximately how long did this illness last? ______ days
5.2e. Did you activate your emergency CALM plan because of this illness? □ Yes
5.2f. Did you go to the doctor because of this illness?

□ Yes

□ No

5.2g. What was the diagnosis?
□Chikungunya □ Dengue □ Viral syndrome □ I don’t know
□ Other: If other, please specify ________________________
5.2h. Were you hospitalized for this illness? □ Yes

□ No

*****If more than two illness with fever, please request additional answer sheets*****

□ No

Unique ID # (e.g., SJ-1-A-1):_____________________

**********************************************************************

Experiences at Study Site
**********************************************************************
6. Did the house that you were staying at have:
6.1. Screens on the window? □ Yes
□ No
6.2. Screens on the doors?
□ Yes
□ No
6.3. Air-conditioning?
□ Yes
□ No
7. Do you remember being bitten by mosquitoes during your 2014 trip to the Dominican Republic?
□ Yes
□ No (Skip to question 8)
7.1 If yes, please indicate the time of day when you were bitten by mosquitoes most often (please
choose a single answer)
a) morning
b) afternoon
c) early evening
d) late evening
8. How frequently did you apply/use insect repellent during your trip to the Dominican Republic?
a) Once daily
b) Multiple times a day (Please specify number of times per day ______)
c) Not every day, but when I noticed mosquitoes were around.
d) Never (Skip to question 9)
e) Other (Please specify________________________________________)
8.1 Did the repellent have any of the following active ingredients (Please circle all that apply)?
a) DEET (specify percent: _____)
b) Picaridin
c) Oil of Lemon Eucalyptus (or PMD)
d) IR3535
e) Other (Please specify _______________________________________)
f) I do not know what the active ingredient was.
9. Did you treat your clothing with insecticide (permethrin) before you traveled to the Dominican Republic?
□ Yes
□ No (Skip to Question 10)
9.1 If yes, did you retreat your clothing at any time during your trip to the Dominican Republic?
□ Yes
□ No

Unique ID # (e.g., SJ-1-A-1):_____________________

10. Which of the following did you also do during your travel to the Dominican Republic to protect yourself
from being bitten by mosquitoes? (Please circle all that apply):
a) Wore long sleeves shirts
b) Wore long pants
c) Wore a hat
d) Wore close-toed shoes (such as tennis shoes)
e) Bed nets
f) Mosquito coils
g) Used insecticide aerosols (to spray in room and not on skin)
h) None of these
i) Other (Please specify _____________________________________)
11. Did you travel to other areas (outside of your service location) of the Dominican Republic?
□Yes
□ No
11.1 If yes, please indicate places and days spent there:
Location 1: _____________________ #days ______
Location 2: _____________________ #days ______
Location 3: _____________________ #days ______
**********************************************************************

Pre-Travel Health Preparation for the June/July 2014 Trip to the Dominican Republic
**********************************************************************
12. Did you seek pre-travel advice from a healthcare provider (doctor, nurse, nurse practitioner, or physician
assistant) before your summer 2014 trip to the Dominican Republic?
□ Yes
□ No (skip to question 18)
12.1. If yes, what type of clinic did you go to prior to your trip to the Dominican Republic?
a) Your primary care provider or personal medical provider (e.g. pediatrician, family practitioner,
nurse practitioner, etc.)
b) A local public health department clinic
c) A travel medicine specialty clinic
d) Other (please specify: __________________________________)
13. Did you receive any specific information on health risks or diseases present in the Dominican Republic
during this appointment?
□ Yes
□ No

Unique ID # (e.g., SJ-1-A-1):_____________________

14. Did you receive any specific information about how to avoid mosquito bites during this appointment?
□ Yes
□ No (skip to question 15)
14.1. If yes, what recommendations did the clinician give you to prevent mosquito bites? (Circle all that
apply)
a)
b)
c)
d)
e)

Wear long sleeves
Wear long pants
Wear a hat
Wear close-toed shoes (such as tennis shoes)
Applied insect repellent (bug spray or lotion) (Please specify brand name, color of bottle- for example
Deep Woods OFF has green bottle)
_____________________________________________________________
f) Bed nets
g) Mosquito coils
h) Insecticide aerosols (to spray in room and not on skin)
i) Insecticide treated clothing
j) None of these
k) Other (Please specify _____________________________________)
14.2 Did these recommendations influence you to use the following prevention measures?
a)
b)
c)
d)
e)
f)

Applied insect repellent
Wear protective clothing
Bed nets
Mosquito coils
Insecticide aerosols (to spray in room and not on skin)
Insecticide treated clothing

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□
□
□
□
□
□

No
No
No
No
No
No

15. Did you receive any specific information about dengue during this appointment?
□ Yes
□ No
16. Did you receive any specific information about chikungunya during this appointment?
□ Yes
□ No
17. From what additional source(s) did you seek health information about the Dominican Republic before your
travel?
a)
Online/website(s) (please specify:_____________________________)
b)
Primary care physician
c)
Friend(s)/Family
d)
Travel/Trip coordinator
e)
Television
f)
Periodicals/Newspapers (please specify: ________________________)
g)
Magazines (please specify: ___________________________________)
h)
Other(please specify: ________________________________________)
i)
None

Unique ID # (e.g., SJ-1-A-1):_____________________

**********************************************************************

Pre-departure training (Program Orientation)
**********************************************************************
18. Did you receive any specific information on health risks or diseases in the Dominican Republic during your
pre-departure training with your service organization?
□Yes
□ No
19. Did you receive any specific information about how to avoid mosquito bites during this pre-departure
training?
□Yes
□ No (skip to question 20)
19.1. If yes, did the information in this training influence you to use the following prevention measures?
a)
b)
c)
d)
e)
f)

Applied insect repellent
Wear protective clothing
Bed nets
Mosquito coils
Insecticide aerosols (to spray in room and not on skin)
Insecticide treated clothing

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□
□
□
□
□
□

No
No
No
No
No
No

20. Did you receive any specific information about dengue during this pre-departure training?
□Yes
□ No
21. Did you receive any specific information about chikungunya during this pre-departure training?
□Yes
□ No
**********************************************************************

In-country training/briefing (Program Orientation)
**********************************************************************
22. Did you receive any specific information on health risks or diseases in the Dominican Republic during this
in-country training?
□Yes
□ No
23. Did you receive any specific information about how to avoid mosquito bites during this in-country training?
□Yes
□ No (skip to question 24)
23.1. If yes, did the information in this training influence you to use the following prevention measures?
a)
b)
c)
d)
e)
f)

Applied insect repellent
Wear protective clothing
Bed nets
Mosquito coils
Insecticide aerosols (to spray in room and not on skin)
Insecticide treated clothing

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

24. Did you receive any specific information about dengue during in-country training?

□
□
□
□
□
□

No
No
No
No
No
No
□Yes

□ No

Unique ID # (e.g., SJ-1-A-1):_____________________

25. Did you receive any specific information about chikungunya during in-country training?
□Yes
□ No
**********************************************************************

Knowledge of health and safety before travel, pre-travel health visit, and program
training (both pre-departure and in-country)
**********************************************************************
26. Before signing up for this trip to the Dominican Republic and your training with your service organization,
how much did you know about dengue?
a) A lot
b) Some
c) A little
d) Nothing, never heard of it before going to the Dominican Republic (Skip to question #31)
27. Before this trip to the Dominican Republic and your training, did you know that dengue was transmitted by
mosquitoes?
□Yes
□ No
28. Before this trip to the Dominican Republic and your training, did you think that you could be exposed to
dengue while in the Dominican Republic?
□Yes
□ No
29. Before this trip to the Dominican Republic and your training, did you know that there was no vaccine for
dengue? □Yes
□ No
30. Before this trip to the Dominican Republic and your training, did you know that there was no treatment
specifically for dengue? □Yes
□ No
31. Before signing up for this trip to the Dominican Republic and your training with your service organization,
how much did you know about chikungunya?
a)
b)
c)
d)

A lot
Some
A little
Nothing, never heard of it before going to the Dominican Republic (Skip to question #36)

32. Before this trip to the Dominican Republic and your training, did you know that chikungunya was
transmitted by mosquitoes?
□Yes
□ No
33. Before this trip to the Dominican Republic and your training, did you think that you could be exposed to
chikungunya while in the Dominican Republic? □Yes □ No
34. Before this trip to the Dominican Republic and your training, did you know that there was no vaccine for
chikungunya?
□Yes
□ No
35. Before this trip to the Dominican Republic, did you know that there was no treatment specifically for
chikungunya?
□Yes
□ No

Unique ID # (e.g., SJ-1-A-1):_____________________

**********************************************************************

Comments
**********************************************************************
36. Please list any other comments you wish to share:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________
Thank you for completing this questionnaire and participating in the study. If you develop a fever within 2
weeks of returning home, please seek medical care with a health care provider immediately and inform your
service organization of this illness.

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Participant Identification Code

.

Ebola and Infection Control
Knowledge, Attitudes, and Practices (KAP)
To be administered in person
Script: “Hello my name is [NAME]. I am working with the [LOCAL AUTHORITY] and the US Centers for Disease Control and
Prevention. We would like you to take part in a brief survey. The purpose of this survey is to gather information that will help us
develop a program and training that help us respond to Ebola. We will keep the information you give us private and confidential. We
will not take down your name, so your responses cannot be linked to you. Only members of the survey team will be allowed to look
at the records. This survey is voluntary.

Demographics

Who I am….

1. Facility Name:
2. Facility Type
2. Age:
4. Sex:

□
□

Male
Female

5. Job Title:
6. How many years of experience do you have as a Health Care Worker?

□
□
□
□

Less than 1 year
2 to 5 years
6 to 10 years
More than 10 years

7. What is the highest level of professional education you have achieved?

□
□
□
□
□
□

Enrolled Nurse
Registered Nurse
Registered Nurse with Bachelor’s Degree (BSN)
Registered Nurse with Master’s Degree
Physician
Other ______

__

8. What is the number of hours you spend each week on the following activities?
Providing Direct Patient Care

________ hours

Supervising Health Care Workers

________ hours

Performing administrative tasks

________ hours

Training Health Care Workers

________ hours

1 of 5
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 Reports Clearance Officer;
1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

KNOWLEDGE

What I know ….

Please select your level of agreement or disagreement with each statement
below. Please check (ü) one for each statement.

Agree

Disagree

General Infection Control and Occupational Health Risks
9. A common way infections are spread in hospitals is from unclean hands of
health care workers.
10. Crowded conditions in hospitals increase the chance of spreading
infections from one person to another.
11. When I have an inquiry about infection control, I know whom to ask at this
hospital for help.
Hand Hygiene Concerns
12. Hand washing before and after every patient contact will reduce the
spread of infection among hospitalized patients.
13. Waterless hand gel is an acceptable substitute for hand washing with
soap and water, as long as hands are not visibly soiled.
14. Health care workers should always wear gloves when conducting patient
care activities.
Ebola Knowledge – Self protection
15. I can get Ebola from touching a healthy (asymptomatic) person’s skin
16. I can get Ebola from touching an Ebola patient’s skin
17. I can get Ebola from cleaning up vomit, pee, or poo from an Ebola patient
18. I can get Ebola from touching clothes or bedding of an Ebola patient
19. I can get Ebola from touching a dead body
20. I can protect myself from Ebola by washing my hands with soap and
water
21. I can protect myself from Ebola by cleaning my hands with alcohol-based
hand sanitizer, as long as my hands are not visibly soiled
22. I can protect myself from Ebola by wearing gloves
23. I can protect myself from Ebola by wearing other PPE (gown, face
mask/shield, shoe covers)
24. I can protect myself from Ebola by removing soiled gloves carefully
(without touching my skin)
Ebola Knowledge – Infection control
25. Ebola can spread in hospitals from unclean hands of healthcare workers
26. Ebola can spread in hospitals when healthcare workers reuse gloves with
more than one patient
27. Ebola can spread in hospitals when healthcare workers reuse other PPE
(gown, face mask/shield, shoe covers) with more than one patient
28. Crowded conditions in hospitals can increase the spread of Ebola among
patients
29. Any patient with a fever who has also had contact with an Ebola patient
(whether alive or dead) should be treated as if they have Ebola
30. Healthcare workers should contact the county health director about every
suspected Ebola patient
31. The same pair of gloves may be used on several patients without
increasing the risk of disease transmission, as long as the gloves are not
visibly soiled.

2 of 5

ATTITUDES

How I feel …

Please select your level of agreement or disagreement with each statement
below. Please check (ü) one for each statement.

Agree

Disagree

General Infection Control and Occupational Health Risks
32. I feel it is my personal responsibility to prevent infections among the
patients for whom I care.
33. Preventing the spread of infections in this hospital is important to our
hospital administrators.
34. My hospital has adequate resources to prevent the spread of infections
among patients.
35. During my educational training, I received adequate instruction on
infection control and the prevention of infections in hospitals.
36. When I have an inquiry about infection control, I feel confident there is
someone at this hospital I can go to for correct information.
Hand Hygiene Concerns
37. One important reason I wash my hands is to protect myself from
infections.
38. One important reason I wash my hands is to protect my patients from
infections.
39. Washing my hands before and after touching patients will make my hands
become dry and uncomfortable.
40. There is not enough time to wash my hands between every patient.
41. I would wash my hands before and after every direct patient contact if
soap and water were readily available.
42. I would use hand sanitizer gel before and after every direct patient contact
if it was readily available
43. Washing my hands before and after direct patient contact is a necessary
part of my job.
44. My supervisors at this facility expect me to wash my hands before and
after direct patient contact.
45. My coworkers at this hospital wash their hands before and after patient
contact.
46. I intend to wash my hands before and after every patient contact,
regardless of my clinical assignment.
Ebola-specific Concerns
47. I feel it is my personal responsibility to care for Ebola patients
48. I am able to adequately care for Ebola patients because I am confident I
can protect myself from getting Ebola.
49. Infection control practices for Ebola are nearly the same as infection
control practices for other diseases I have worked with.
50. During this epidemic, I am expected to treat Ebola patients whether or not
I feel prepared to treat them or to protect myself from Ebola.
Ebola Attitudes - Hospital
51. My hospital has enough gloves to change between every patient
52. My hospital has enough other PPE (gown, face mask/shield, shoe covers)
change between every patient
53. My hospital has enough staff to treat Ebola patients
54. My hospital has enough soap and water available for handwashing
55. My hospital has enough alcohol-based hand sanitizer
Ebola Attitudes - Capability
56. I received adequate training in Ebola prevention and treatment

3 of 5

Please select your level of agreement or disagreement with each statement
below. Please check (ü) one for each statement.
57. I have someone to ask for help if I need it

Agree

Disagree

58. I can wash my hands when I need to
59. I feel confident that I can protect myself from Ebola
Ebola Attitudes – Patient care
60. It is my responsibility to treat Ebola patients
61. It is my choice to treat Ebola patients
62. I feel pressure from my supervisors to treat Ebola patients
63. I feel pressure from my co-workers to treat Ebola patients
64. It is expected that I treat Ebola patients, whether or not I feel prepared
65. I feel scared treating Ebola patients
66. I feel comfortable treating Ebola patients

PRACTICES

What I do ...

Please select the frequency you perform each practice listed below. Please
check (ü) one for each statement.

Always

Most of
the time

Sometimes

Never

General Infection Control and Occupational Health Risks
67. I teach my patients ways they can prevent the spread of infections.
68. When I am ill with a respiratory infection, I stay home from work.
69. When I have an inquiry about infection control, I ask someone on the
infection control team for help.
Hand Hygiene Concerns
70. I wash my hands after removing gloves.
71. I wash my hands before touching a patient.
72. I wash my hands after touching a patient.

Ebola practices
70. I wear PPE (personal protective equipment) when caring for Ebola
patients
71. I change my PPE after seeing each Ebola patient
72. I wash my hands after touching each Ebola patient.
73. I complete a case report form for each Ebola patient.
74. I dispose of soiled items from Ebola patients (PPE, bedding, clothing,
etc.) in a special Ebola-specific waste container.

4 of 5

TRAINING
What I prefer....

Please answer the following questions about Ebola training:
75. Have you ever received training in Ebola patient care?

□
□

Yes
No

76. If you answered ‘Yes’ to question 75, do you feel you were adequately prepared by your training?

□
□

Yes
No

77. Have you ever received training in Ebola infection control practices (how to prevent transmission among patients)?

□
□

Yes
No

78. If you answered ‘Yes’ to question 77, do you feel you were adequately prepared by your training?

□
□

Yes
No
Thank you very much for completing this questionnaire.

5 of 5

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Structured Interview of County Health Director
1.
2.
3.
4.
5.
6.

Date of interview (dd/mm/yyyy) - ___/___/___
Name of interviewer ______________________________________________________________________
County ________________________________________________________________________________
Name of County Health Director_____________________________________________________________
Contact information of County Health Director___________________________________________________
Has there been a WHO gap analysis performed?
Y
N
a. If yes, then Is a copy of the analysis available?
Y
N
7. Do you have a county Ebola response plan?
Y
N
8. What percentage of their work hours are county health officials/workers currently spending on Ebola? ___
Healthcare Facilities
Hospital Name
9.
10.
11.
12.
13.

ETU?
9a.
10a.
11a.
12a.
13a.

Health Center Name
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

Y
Y
Y
Y
Y

N
N
N
N
N

Location
(Village name)
9b.
10b.
11b.
12b.
13b.

Location (Village name)

14a.
15a.
16a.
17a.
18a.
19a.
20a.
21a.
22a.
23a.
a. Use blank sheet to list additional health centers

Operating before
Ebola outbreak?
9c.
Y
N
10c.
Y
N
11c.
Y
N
12c.
Y
N
13c.
Y
N

Operating now?
9d.
10d.
11d.
12d.
13d.

Operating before
Ebola outbreak?
14b.
Y
N
15b.
Y
N
16b.
Y
N
17b.
Y
N
18b.
Y
N
19b.
Y
N
20b.
Y
N
21b.
Y
N
22b.
Y
N
23b.
Y
N

Y
Y
Y
Y
Y

# of
beds
9e.
10e.
11e.
12e.
13e.

N
N
N
N
N

Operating now?
14c.
15c.
16c.
17c.
18c.
19c.
20c.
21c.
22c.
23c.

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N

24. What are the major reasons that some hospitals/health centers are not open? (circle all that apply)
No healthcare workers
Fear of Ebola
Lack of medical supplies
Civil unrest
Other ________________________________________________________________________________
25. Are there plans to open an Ebola treatment unit (ETU)?
a. If yes, then Where ____________________________
b. When ______________________________________
c. # of beds ___
d. Have health workers been identified?
Y
N
26. Are there plans to open a holding center?
a. If yes, then Where____________________________
b. When _____________________________________
c. Will this center have isolation rooms or isolation wards?
Y
N
d. Will suspect and confirmed cases be separated?
Y
N
e. Will there be separate entrances for patients and staff?
Y
N
f. Will the toilets be individual or shared?
Y
N
g. # of beds ___
h. Have health workers been identified?
Y
N
Public reporting burden of this collection of information is estimated to average 60 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 (0920-1011).

i.
27. Are healthcare workers being paid?
Y
N
a. If no, then When was the last time they were paid? ________________________________________
28. Have healthcare workers received any training in Ebola treatment? Y
N
a. If yes, When? ________________
b. Performed by______________________________________
29. What services are currently provided by the healthcare system in this county?
a. EPI (Expanded Program on Immunization)
b. Malaria testing and treatment
c. HIV screening and treatment
d. Antenatal care
e. Obstetric care
f. Surgery
Infection Control
30. Have healthcare workers received training in infection control (including PPE)?
Y
N
a. If yes, then When? ________________
b. Performed by_____________________________________
31. Do you store and distribute PPE?
Y
N
32. Where do you get your PPE from? __________________________________________________________
33. Do you store and distribute body bags?
Y
N
34. Do you store and distribute disinfectant, such as chlorine and alcohol?
Y
N
35. What items or trainings are needed for infection control?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
d. ________________________________________________________________________________
Ambulances
36. Do you have a plan to safely transport suspected Ebola patients?
a. If yes, then What is the plan? _________________________________________________________
________________________________________________________________________________
37. Has ambulance staff been trained on safe transport of suspected Ebola patients?
Y
N
38. How many ambulances are available in this county? ___
39. If there are no ambulances, then how are patients transported to a healthcare facility? __________________
_______________________________________________________________________________________
40. What is the protocol if a patient is unable to be transported?
_______________________________________________________________________________________
_______________________________________________________________________________________
41. Is fuel available consistently for the ambulances?
Y
N
42. Are ambulances available 24 hours a day, 7 days week?
Y
N
43. Do you have adequate equipment for ambulance staff?
a. PPE
Y
N
b. Chlorine Sprayer
Y
N
c. Boots
Y
N
d. Disinfectant
Y
N
44. Does the ambulance team disinfect the home after removing the patient?
Y
N
45. What items or trainings are needed for ambulances?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
Specimen Collection
46. Are samples collected from patients in this county?
Y
N
a. Name of nearest lab facility
ELWA3
LIBR
Other____________________
b. How are samples shipped? _________________________________________________________
47. What is the turn-around time for Ebola specimens after collection? (i.e., from sample collection to result
reporting) ____________________________
48. Have lab technicians collecting specimens received training on infection control?
Y
N

a. If yes, When? _____________________________________
b. Performed by______________________________________
49. Are lab technicians being paid?
Y
N
a. If no, then When was the last time they were paid? ________________________________________
50. Are specimens being collected from dead bodies?
Y
N
a. If yes, then What type of specimen is being collected? _____________________________________
51. What items or trainings are needed for laboratories?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
Case Investigation
52. Please describe the protocol for case investigation
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
53. Is there an SOP in place for case investigation?
Y
N
54. How many members are on the case investigation team? _______
a. Role #1__________________________________________________________________________
b. Role #2__________________________________________________________________________
c. Role #3__________________________________________________________________________
d. Role #4_________________________________________________________________________
e. Role #5_________________________________________________________________________
55. How do case investigation teams travel?_____________________________________________________
56. How many case investigation teams are in the county? __
57. Is there a call center for Ebola? (a person or group who answers questions about Ebola)
Y
N
58. Who staffs the call center? _________________________________________________________________
59. Have the call center workers received training on Ebola?
Y
N
a. If yes, When? ________________ Performed by______________________________________
60. Is there a standardized call log for the call centers?
Y
N
61. What information is provided by the call centers? _______________________________________________
______________________________________________________________________________________
62. What information is collected by the call centers? _______________________________________________
______________________________________________________________________________________
63. What information is provided to suspect Ebola patients?
_______________________________________________________________________________________
_______________________________________________________________________________________
64. How many case-investigation forms do you have in the county? ___
65. Do you have case ID# stickers?
Y
N
66. Are case identification forms pre-labeled?
Y
N
67. What items or trainings are needed for case identification?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
Data Management
68. Describe data flow from county to central Ministry of Health database
______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
69. Is the county copying case investigation forms before sending to the Ministry of Health?
Y
N
70. Is the county maintaining a line list of suspect cases?
Y
N
71. Are there regular meetings of county health officials for Ebola?
Y
N
a. If yes, then How frequently? _______times per week / month (circle one)
72. Does the county have Epi Info?
Y
N
73. Have county staff been trained in Epi Info?
Y
N

74. Are county staff able to send Epi Info data to the Ministry of Health?
Y
N
75. What items or trainings are needed for data management?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
Contact Tracing
76. How many contact tracing teams are working in the county? _____
77. How many individuals work on each contact tracing team? ___
a. Role #1__________________________________________________________________________
b. Role #2__________________________________________________________________________
c. Role #3__________________________________________________________________________
78. Is there an SOP for contact tracing in place?
Y
N
79. What is the average time from completion of the contact tracing form to submission to the Ministry of Health
database? ___
80. Are contacts classified by high or low risk?
Y
N
a. If yes, then What is recommended for high risk contacts? (circle all that apply)
i. Home isolation
ii. Temp monitoring
iii. Daily visit
iv. Other ____________________________________________________________________
81. Is food being provided to contacts?
Y
N
82. What information is provided to contacts at the end of the 21 day tracing period?
_______________________________________________________________________________________
83. Have contact tracers received training on Ebola?
Y
N
a. If yes, When? _____________________________________________________________________
b. Performed by_____________________________________________________________________
84. Are contact tracers being paid?
Y
N
a. If no, When was the last time they were paid? __________________________________________
85. How do contact tracers travel? _____________________________________________________________
86. What items or trainings are needed for contact tracing?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
Burial Teams
87. Is there an SOP in place for safe burials of Ebola cases?
Y
N
88. Describe the SOP for safe burials ___________________________________________________________
______________________________________________________________________________________
89. How many burial teams are currently operating in this county? ___
90. Do burial teams have PPE?
Y
N
91. Does the burial team disinfect the home after removing the body?
Y
N
92. What items or trainings are needed for burial teams?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
d. ________________________________________________________________________________
Health Communication
93. How are messages regarding Ebola distributed in the community? (circle all that apply)
a. Fliers
b. Radio
c. SMS
d. Other ___________________________________________________________________________
94. What groups are performing health education? _________________________________________________
__________________________________________________________________________________________
95. What items or trainings are needed for health communication?
a. ________________________________________________________________________________

b. ________________________________________________________________________________
c. ________________________________________________________________________________
Community Engagement Strategy
96. Have health officials met with community leaders to develop a communication and messaging plan? Y

N

Home Hygiene Kits
97. Are home hygiene kits being distributed?
Y
N
98. Who is distributing them? __________________________________________________________________
99. Where are they being distributed? (circle all that apply)
a. Healthcare facilities
b. Homes
c. Other____________________________________________________________________________
100.
How many kits have been distributed to date? ___
101.
Were instructions included in the kits? Y
N
102.
What is included in the home hygiene kits?
_______________________________________________________________________________________
_______________________________________________________________________________________
103.
What items or trainings are needed for home hygiene kits?
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________
Psychosocial Support
104.
Is psychosocial support provided as part of the Ebola response?
Y
N
105.
What aspects of the response have a psychosocial member involved?
a. Case management
b. Contact tracing
c. Delivering lab results
d. Burial team
e. Survivor reintegration
f. Contacts who complete 21 day tracing
g. Other ___________________________________________________________________________
106.
How many people are trained in psychosocial support/mental health in the county? ___
Miscellaneous
107.
Are any communities currently under quarantine?
Y
N
a. If yes, then How are those communities getting food, medical supplies, etc.?____________________
_______________________________________________________________________________
108.
Are there any other health issues in the county that you are concerned about, such as measles?
a. _______________________________________________________________________________
b. _______________________________________________________________________________
c. _______________________________________________________________________________

Health Center Name

Location (Village name)

Operating before Ebola
outbreak?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N

Operating now?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Participant Identification Code

. Survey Date__________________________

Ebola
Knowledge, Attitudes, and Practices (KAP)
To be administered in person
Script: “Hello my name is [NAME]. I am working with the [LOCAL AUTHORITY] and the US Centers for Disease Control and Prevention. We
would like you to take part in a brief survey. The purpose of this survey is to gather information that will help us give you better information
about Ebola. We will keep the information you give us private and confidential. We will not take down your name, so your responses cannot be
linked to you. Only members of the survey team will be allowed to look at the records. This survey is voluntary.

Demographics

Who I am….

1. County
2. District or Community
2. Age:
4. Sex:

□
□

Male
Female

5. Job Title:
7. What is the highest level of education you have achieved?

□
□
□
□
□
□
□

Primary
Middle
Secondary
Vocational/Technical
Tertiary/University
Professional/Advanced degree
Other ______

__

Knowledge, Attitudes, and Practices
Please select your level of agreement or disagreement with each statement below. Please circle

Agree

Disagree

1) I can get Ebola from a healthy (asymptomatic) person

A

D

2) I can get Ebola from kissing a symptomatic person

A

D

3) I can get Ebola from sharing a spoon / fork with a symptomatic person

A

D

4) I can get Ebola from sleeping in the same bed as a symptomatic person

A

D

5) I can get Ebola from cleaning up vomit from a symptomatic person

A

D

6) I can get Ebola from having sex with a symptomatic person, even if I wear a condom

A

D

7) I can get Ebola from cleaning up pee or poop from a symptomatic person

A

D

one for each statement.
Ebola Knowledge

1 of 2
Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)

8) I can get Ebola from touching a dead person

A

D

9) I can get Ebola from washing a dead person

A

D

10) I can get Ebola from cleaning the sheets from a funeral of an Ebola patient

A

D

11) I can get Ebola from eating bush meat

A

D

12) I can get Ebola from attending a burial of an Ebola patient

A

D

Agree

Disagree

A

D

A

D

A

D

16) Ebola is a real disease

A

D

17) Ebola is a serious disease

A

D

18) Anyone can get Ebola (even healthy people)

A

D

19) I am worried about getting Ebola

A

D

20) I am at risk for getting Ebola

A

D

21) I can get Ebola if someone puts a curse / spell on me

A

D

22) I am afraid of people with Ebola

A

D

23) I am afraid of people who live with Ebola patients

A

D

24) I am afraid of treatment centers

A

D

25) I am afraid of people who have been cured of Ebola

A

D

26) I would know if I had Ebola symptoms

A

D

27) I know how to protect myself from getting Ebola

A

D

28) If I got Ebola symptoms, I would seek treatment

A

D

29) If I got Ebola symptoms, I know where to go for treatment

A

D

30) If I got Ebola symptoms, I would be afraid of going to a treatment center

A

D

31) If I got Ebola symptoms, I would go to a traditional healer

A

D

32) If I got Ebola symptoms, I would hide away in my house

A

D

33) If a friend or family member gets Ebola, I would take them to a treatment center

A

D

34) If a friend or family member gets Ebola, I would take them to a traditional healer

A

D

35) If a friend or family member gets Ebola, I would keep them in my house

A

D

36) If I go to a treatment center, I will die

A

D

37) If I go to a treatment center, I will not be allowed to see my family

A

D

38) White people brought Ebola here

A

D

Please select your level of agreement or disagreement with each statement below. Please circle
one for each statement.
13) A baby can get Ebola from breastfeeding from a symptomatic mother
14) Fever is a symptom of Ebola
15) Handwashing can prevent transmission of Ebola
Ebola Attitudes

Anticipated Practices

Ebola Treatment Center Fears

2 of 2
)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/17

Hospitalized Case Investigation Form
Respiratory Illness

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 Reports Clearance Officer; 1600 Clifton
Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number

I. Reporter Information
State/Territory
State/Territory Epi Case ID
State/Territory Lab ID
Date form completed:
/
/
CDC Case ID
Person completing form: First Name:_
Last Name:_
Phone:
What are the source(s) of data for this
¨ Medical chart
¨ Death certificate
¨ Case report form
report? (check all that apply)

Email:_
¨ Other_

II. Patient Information and Medical Care
1. Patient Date of birth:
/
/_
(mm/dd/yyyy)
2. Did the patient have an outpatient or ER
¨ Yes, date:
/_
/
medical care encounter during this illness?
(if multiple, list most recent)
3. Was the patient admitted to the hospital for this ¨ Yes, date:
/_
/
illness?
Time:
:
¨ AM ¨ PM
4. Was patient hospitalized previously at another facility during this illness?
Admission date:

/_

/

Discharge date:

/_

/

6. Height

8. Blood Pressure
11. O Sat
2

¨ Inches

/_
%

9. Respiratory Rate

¨ Unknown

¨ No

¨ Unknown

¨ Yes

¨ No

¨ Unknown

Was discharge from prior hospital a transfer?

Please note initial vital signs at hospital admission/ER presentation.
5. Body Mass

¨ No

Date taken:

¨ Height

/_

/_

7. Weight:

¨ Yes

(mm/dd/yyyy)
¨ Lbs.

¨ Weight Unknown

per min

12. Fraction of inspired oxygen

10. Heart Rate
beats/min Temperature:
13. Using: ¨ O2 mask ¨ room air ¨ ventilator
¨% ¨L
Specify O2 mask type:

¨°C ¨°F

III. Illness Signs and Symptoms
14. Please mark all signs and symptoms experienced or listed in the admission note.
Date of initial symptom onset:
/
/
¨ Fever (measured) highest temp.
¨°C ¨°F
Date of fever onset
/_
/_
(mm/dd/yyyy)
¨ Feverishness (temperature not measured)
¨ Wheezing
¨ Altered mental status
¨ Cough
¨ Chills
¨ Red or draining eyes (conjunctivitis)
¨ With sputum (i.e., productive)
¨ Headache
¨ Abdominal pain
¨ Hemoptysis or bloody sputum
¨ Excessive crying/fussiness (< 5 years old)
¨ Vomiting
¨ Sore throat
¨ Fatigue/weakness
¨ Diarrhea
¨ Runny nose (rhinorrhea)
¨ Muscle pain/myalgia
¨ Rash, location
¨ Dyspnea/difficulty breathing
Location
¨ Other_
¨ Chest pain
¨ Seizure

IV. Patient Medical History
15. Does the patient have any of the following pre-existing medical conditions? Check all that apply.

15a. ¨ Asthma/Reactive Airway Disease
15b. ¨ Chronic Lung Disease
¨ Emphysema/COPD
¨ Other:_
15c. ¨ Chronic Metabolic Disease
¨ Diabetes
Insulin dependent ¨ Yes ¨ No ¨ Unknown
¨ Other:_
15d. ¨ Blood disorders/Hemoglobinopathy
¨ Sickle cell disease
¨ Splenectomy/Asplenia
¨ Other:_

15h. ¨ Immunocompromising Condition
¨ HIV infection
¨ AIDS or CD4 count < 200
¨ Stem cell transplant (e.g., bone marrow transplant)
¨ Organ transplant
¨ Cancer diagnosis within last 12 months (excluding nonmelanoma skin cancer) Type:_
¨ Chemotherapy within last 12 months
¨ Primary immune deficiency
¨ Chronic steroid therapy (within 2 weeks of admission)
¨ Other:
15i. ¨ Renal Disease
¨ Chronic kidney disease/chronic renal insufficiency
¨ End stage renal disease
¨ Dialysis
¨ Nephrotic syndrome
¨ Other:_

2

¨ No

UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
15e. ¨ Cardiovascular Disease (excluding hypertension)
¨ Atherosclerotic cardiovascular disease
¨ Cerebral vascular incident/Stroke
With disability ¨ Yes ¨ No ¨ Unknown
¨ Congenital heart disease
¨ Coronary artery disease (CAD)
¨ Heart failure/Congestive heart failure
¨ Other:_
15f. ¨ Neuromuscular or Neurologic disorder
¨ Muscular dystrophy
¨ Multiple sclerosis
¨ Mitochondrial disorder
¨ Myasthenia gravis
¨ Cerebral palsy
¨ Dementia
¨ Severe developmental delay
¨ Plegias/Paralysis
¨ Epilepsy/Seizure disorder
¨ Other:_
15g. ¨ History of Guillain-Barré Syndrome

15j. ¨ Other
¨ Liver disease
¨ Scoliosis
¨ Obese or BMI ≥ 30
¨ Morbidly obese or BMI ≥ 40
¨ Down syndrome
¨ Pregnant, gestational age in weeks:
¨ Post-partum (≤ 6 weeks)
¨ Current smoker
¨ Drug abuse
¨ Alcohol abuse
¨ Other:_

PEDIATRIC CASES ONLY (<18 years old)
Abnormality of upper airway
¨ Yes
¨ No
History of febrile seizures
¨ Yes
¨ No
Premature
¨ Yes
¨ No
(gestational age < 37 weeks at birth for patients < 2yrs)
If yes, specify gestation age at birth in weeks:
¨ Unknown gestational age at birth

¨ Unknown

¨ Unknown
¨ Unknown
¨ Unknown

V. Hematology and Serum Chemistries
16. Were any hematology or serum chemistries performed at hospital
¨ Yes
¨ No (skip to Q. 35) ¨ Unknown (skip to Q. 35)
admission/presentation to care?
Please note initial values at admission/presentation to care. Date values were taken:
/_
/_
(mm/dd/yyyy)
17. White blood cell count (WBC)
cells/mm3 19. Hematocrit (Hct)
% 24. Serum creatinine
mg/dL
18. Differential: Neutrophils
% 20. Platelets (Plt)
103/mm3 25. Serum glucose
mg/dL
Bands
% 21. Sodium (Na)
U/L 26. SGPT/ALT
U/L
Lymphocytes
% 21. Potassium (K)
U/L 27. SGOT/AST
U/L
Eosinophils
% 22. Bicarbonate (HCO3)
mg/dL
U/L 28. Total bilirubin
23. Serum albumin
g/dL 29. C-reactive protein (CRP)
mg/dL
Please describe other significant lab findings (e.g., CSF, protein).
Type of test
Specimen type
Date (mm/dd/yyyy)
Result
31.
/
/
32.
/
/
33.
/
/
34.
/
/

VI. Bacterial Pathogens – Sterile or respiratory site only
35. Was a pneumococcal urinary antigen test performed?
¨ Yes
¨ No
¨ Unknown
If yes, result:
¨ Positive
¨ Negative
¨ Unknown
35. Was a Legionella urinary antigen test performed?
¨ Yes
¨ No
¨ Unknown
If yes, result:
¨ Positive
¨ Negative
¨ Unknown
35. Were any bacterial culture tests performed (regardless of result)? ¨ Yes
¨ No (skip to Q.41)
¨ Unknown (skip to Q.41)
36. . Indicate sites from which specimens
¨ Blood
¨ Cerebrospinal fluid (CSF)
¨ Bronchoalveolar lavage (BAL)
were collected (check all that apply):
¨ Sputum
¨ Pleural fluid
¨ Endotracheal aspirate ¨ Other:_
37. Was there culture confirmation of any bacterial infection?
¨ Yes
¨ No (skip to Q.41)
¨ Unknown (skip to Q.41)
38b. Specimen type: ¨ Blood ¨ Cerebrospinal fluid (CSF) ¨ Bronchoalveolar lavage (BAL)
¨ Sputum
¨ Pleural fluid
¨ Endotracheal aspirate
¨ Other:_
38c. Pathogen(s) identified:
¨ S. aureus
¨ S. pyogenes
¨ S. pneumoniae
¨ H. influenzae
¨ Other:
38d. If Staphylococcus aureus, specify:
¨ Methicillin resistant (MRSA)
¨ Methicillin sensitive (MSSA)
¨ Sensitivity unknown
38a. Positive Culture 1 collection date:
/
/
(mm/dd/yyyy)

39b. Specimen type: ¨ Blood ¨ Cerebrospinal fluid (CSF) ¨ Bronchoalveolar lavage (BAL)
¨ Sputum
¨ Pleural fluid
¨ Endotracheal aspirate
¨ Other:
39c. Pathogen(s) identified:
¨ S. aureus
¨ S. pyogenes
¨ S. pneumoniae
¨ H. influenzae
¨ Other:_
39d. If Staphylococcus aureus, specify:
¨ Methicillin resistant (MRSA)
¨ Methicillin sensitive (MSSA)
¨ Sensitivity unknown
39a. Positive Culture 2 collection date:
/
/
(mm/dd/yyyy)

3

UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
40b. Specimen type: ¨ Blood ¨ Cerebrospinal fluid (CSF) ¨ Bronchoalveolar lavage (BAL)
¨ Sputum
¨ Pleural fluid
¨ Endotracheal aspirate
¨ Other:_
40c. Pathogen(s) identified:
¨ S. aureus
¨ S. pyogenes
¨ S. pneumoniae
¨ H. influenzae
Other:_
40d. If Staphylococcus aureus, specify:
¨ Methicillin resistant (MRSA)
¨ Methicillin sensitive (MSSA)
¨ Sensitivity unknown
40a. Positive Culture 3 collection date:
/
/
(mm/dd/yyyy)

VII. Respiratory Viral Pathogens
41. Was the patient tested for any other viral pathogens? ¨ Yes
a. Respiratory syncytial virus/RSV
b. Adenovirus
c. Parainfluenza 1
d. Parainfluenza 2
e. Parainfluenza 3
f. Human metapneumovirus
g. Rhinovirus
h. Coronavirus
i. Other, specify:
j. Other, specify:

Positive
¨
¨
¨
¨
¨
¨
¨
¨
¨
¨

Negative
¨
¨
¨
¨
¨
¨
¨
¨
¨
¨

¨ No (skip to Q.42)

Not Tested/Unknown
¨
¨
¨
¨
¨
¨
¨
¨
¨
¨

¨ Unknown (skip to Q.42)
Collection Date
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/

Specimen Type

VIII. Medications
42. Did the patient receive influenza antiviral medications during illness?
¨ Yes
¨ No
¨ Unknown
Date started
Date stopped
Frequency
Dose
Oseltamivir (Tamiflu)
¨ PO ¨ IV ¨ Inhaled
/
/
/
/
¨ QD ¨ BID ¨ TID
Zanamivir (Relenza)
¨ PO ¨ IV ¨ Inhaled
/
/
/
/
¨ QD ¨ BID ¨ TID
Peramivir
¨ PO ¨ IV ¨ Inhaled
/
/
/
/
¨ QD ¨ BID ¨ TID
Other influenza antiviral:_
¨ PO ¨ IV ¨ Inhaled
/
/
/
/
¨ QD ¨ BID ¨ TID
Other influenza antiviral:_
¨ PO ¨ IV ¨ Inhaled
/
/
/
/
¨ QD ¨ BID ¨ TID
43. Did the patient receive antibiotics during the illness?
¨ Yes
¨ No
¨ Unknown
If yes, name
Date started
Date stopped
Dose
/
/
/
/
¨ PO ¨ IV ¨ IM
/
/
/
/
¨ PO ¨ IV ¨ IM
/
/
/
/
¨ PO ¨ IV ¨ IM
/
/
/
/
¨ PO ¨ IV ¨ IM
/
/
/
/
¨ PO ¨ IV ¨ IM
44. Did the patient receive steroids (excluding inhaled steroids or one time injections) or other
¨ Yes
¨ No
¨ Unknown
immune modulating treatment specifically for this illness?
If yes, name
Date started
Date stopped
Dose
/
/
/
/
¨ PO ¨ IV ¨ IM
/
/
/
/
¨ PO ¨ IV ¨ IM
/
/
/
/
¨ PO ¨ IV ¨ IM
45. Additional treatment comments:

IX. Chest Radiograph – Based on final impression/conclusion of the radiology report
Please include a copy of the radiology report with the form.
46. Did the patient have a chest x-ray within 3 days of
¨ Yes, date
/_
/_
¨ No (skip to Q.52)
admission?
¨ Yes, date
/_
/_
¨ No (skip to Q.52)
47. If yes, was the chest x-ray abnormal?
48. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
Final impression/conclusion:

4

¨ Unknown (skip to Q.52)
¨ Unknown (skip to Q.52)

UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number

¨ Multi-lobar infiltrate (unilateral)
¨ Multi-lobar infiltrate (bilateral)
¨ Single lobar infiltrate
¨ Lobar or segmental collapse
¨ Cavitation/Abscess/Necrosis
¨ Round pneumonia
¨
Alveolar
(air
space)
disease
¨
Interstitial
disease
¨ Mixed (airspace and interstitial) disease
¨ Other Infiltrate: à
¨ Unilateral
¨ Bilateral
¨ Pleural Effusion: à
¨ Uncomplicated
¨ Complicated
¨ Bronchiolitis: à
¨ Air leak/Pneumothorax
¨ Lymphadenopathy
¨ Chest wall invasion
¨ Other: à
¨ Specify:_
49. Did the patient have another chest x-ray within 3
¨ Yes, date
/_
/_
¨ No (skip to Q.52) ¨ Unknown (skip to Q.52)
days of admission?
50. If yes, was the chest x-ray abnormal?
¨ Yes, date
/_
/_
¨ No (skip to Q.52) ¨ Unknown (skip to Q.52)
51. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
¨ Consolidation: à

Final impression/conclusion:

¨ Consolidation: à
¨ Other Infiltrate: à
¨ Pleural Effusion: à
¨ Bronchiolitis: à
¨ Other: à

¨ Single lobar infiltrate
¨ Lobar or segmental collapse
¨ Alveolar (air space) disease
¨ Unilateral
¨ Complicated
¨ Air leak/Pneumothorax
¨ Specify:_

¨ Multi-lobar infiltrate (unilateral)
¨ Cavitation/Abscess/Necrosis
¨ Interstitial disease
¨ Bilateral
¨ Uncomplicated
¨ Lymphadenopathy

¨ Multi-lobar infiltrate (bilateral)
¨ Round pneumonia
¨ Mixed (airspace and interstitial) disease

¨ Chest wall invasion

X. Chest CT or MRI – Based on final impression/conclusion of the radiology report
please include a copy of the radiology report with the form.
52. Did the patient have a chest CT/MRI scan within
¨ Yes, date
/_
/_
¨ No (skip to Q.56) ¨ Unknown (skip to Q.56)
3 days of admission?
52. If yes, please select one:
¨ CT: contrast
¨ CT: non-contrast
¨ MRI
54. If yes, was the CT/MRI abnormal?
¨ Yes, date
/_
/_
¨ No (skip to Q.56) ¨ Unknown (skip to Q.56)
55. For abnormal chest CT/ MRI, please check all that apply and please transcribe the final impression/conclusion:
Final impression/conclusion:

¨ Consolidation: à
¨ Other Infiltrate: à
¨ Pleural Effusion: à
¨ Bronchiolitis: à
¨ Other: à

¨ Single lobar infiltrate
¨ Lobar or segmental collapse
¨ Alveolar (air space) disease
¨ Unilateral
¨ Complicated
¨ Air leak/Pneumothorax
¨ Specify:_

¨ Multi-lobar infiltrate (unilateral)
¨ Cavitation/Abscess/Necrosis
¨ Interstitial disease
¨ Bilateral
¨ Uncomplicated
¨ Lymphadenopathy

¨ Multi-lobar infiltrate (bilateral)
¨ Round pneumonia
¨ Mixed (airspace and interstitial) disease

¨ Chest wall invasion

XI. Clinical Course and Severity of Illness
56. At any time during the current illness, did the patient require or have the diagnosis of :
a. Admission to intensive care unit (ICU)
¨ Yes
Admission date:
/
/
Discharge date:
If multiple admissions, 2nd ICU admission date:
/
/
2nd ICU discharge date:
If more than 2 ICU admissions, please provide dates in the comments section (Q.66)
¨ Yes
b. Supplemental oxygen
/
Date started:
/
Date stopped
c. Ventilatory support
¨ Yes
Check all that apply:
Date started:
/
/
¨ Intubation
Date stopped:
Date started:
/
/
¨ ECMO
Date stopped:
Date started:
/
/
¨ CPAP
Date stopped:

5

¨ No
/
/
/
/

¨ Unknown

¨ No
/
/
¨ No
/
/
/
/
/
/

¨ Unknown
¨ Unknown

UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
¨ BiPAP

Date started:

/

d. Vasopressor medications (e.g. dopamine, epinephrine)
Date started:
/
/
e. Dialysis (Acute)
Date started:
/
/
f. Resuscitation, CPR
¨ Yes, date started:
g. Acute respiratory distress syndrome (ARDS)
¨ Yes, date started:
h. Disseminated intravascular coagulopathy (DIC)
¨ Yes, date started:
i. Hemophagocytic syndrome
¨ Yes, date started:
j. Bronchiolitis
¨ Yes, date started:
k. Pneumonia
¨ Yes, date started:
l. Stroke (Acute)
¨ Yes, date started:
m. Sepsis
¨ Yes, date started:
n. Shock
¨ Yes, date started:
Type: ¨ hypovolemic
¨ cardiogenic
¨ septic
¨ toxic
o. Acute myocarditis
¨ Yes, date started:
p. Acute myocardial dysfunction
¨ Yes, date started:
q. Acute myocardial infarction
¨ Yes, date started:
r. Seizures
¨ Yes, date started:
s. Reye’s syndrome
¨ Yes, date started:
t. Acute encephalitis / encephalopathy
¨ Yes, date started:
u. Guillain-Barre syndrome
¨ Yes, date started:
v. Rhabdomyolysis
¨ Yes, date started:
w. Acute liver impairment
¨ Yes, date started:
x. Acute renal failure
¨ Yes, date started:
y. Other, specify:
¨ Yes, date started:
z. Other, specify:
¨ Yes, date started:

/

Date stopped:

/

/
/
/
/
/
/
/
/
/

/
/
/
/
/
/
/
/
/

¨ Yes
Date stopped
¨ Yes
Date stopped
stopped:
/_
stopped:
/_
stopped:
/
stopped:
/_
stopped:
/_
stopped:
/_
stopped:
/_
stopped:
/_
stopped:
/_

/
/
/
/
/
/
/
/
/
/
/
/

/
/
/
/
/
/
/
/
/
/
/
/

stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:

/_
/_
/_
/_
/_
/_
/_
/_
/_
/_
/_
/_

/

¨ No
/
/
¨ No
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/

¨ Unknown
¨ Unknown
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No

¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No
¨ No

¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown
¨ Unknown

XII. Outcomes
¨ Yes, date

57. Did the patient die during this illness?

/_

¨ No (skip to Q.62)

/_

¨ Unknown (skip to Q.62)

58. What was the location of death?
¨ Home
¨ Hospital ¨ ER
¨ Hospice
¨ Other, specify
59. . Did the patient have a DNR (do not resuscitate) order?
¨ Yes
¨ No
¨ Unknown
60. Was an autopsy performed?
¨ Yes (please attach a copy of the autopsy form to this report if available)
¨ No
¨ Unknown
61. What were the causes of death (immediate and underlying) in order of appearance on the death certificate or medical record?
1.

4.

7.

2.

5.

8.

3.

6.

9.

62. Has the patient been discharged from the hospital?
¨ Yes, date
/_
/
¨ No
¨ Unknown
63. If yes, please indicate to where:
¨ Home
¨ Other hospital
¨ Hospice
¨ Rehabilitation Facility
¨ Other long-term care facility
¨ Other, specify:
63. If no, please indicate status:
¨ Hospitalized on ward
¨ Hospitalized in ICU ¨ Died
64. If patient was pregnant, please indicate pregnancy status at discharge or final update:
¨ Still
¨ Uncomplicated labor/delivery ¨ Complicated labor/delivery
pregnant
Describe
64. If pregnancy resulted in delivery, please indicate neonatal outcome: Birth date:
/_
¨ Healthy newborn

¨ Ill newborn, describe:

¨ Fetal loss
Date
/_

XIII. Additional Comments
66. Additional Comments:

6

/_

/

¨ Newborn died: Date

65. Additional notes regarding discharge:

¨ Unknown

/_

/_

¨ Unknown

UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number

7

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Verbal Assent for Pneumococcal Carriage Study
The following will be read to the potential study participant and responses will be recorded by the interviewer:
Hi, my name is _______________. I’m working with the U.S. Centers for Disease Control and Prevention (CDC), the
Office of Refugee Relocation, and this shelter to try to understand why some children in this shelter were sent to the
hospital or emergency room with fever and cough. We’d like to put a swab in your nose to test for some germs. This
test won’t cause you any harm, but may be uncomfortable and might cause light bleeding. You may not get any direct
benefit by doing this test, but by taking part you will help us to learn how to prevent more kids in the shelter from
getting sick. You don’t have to allow us to swab your nose; you can decide if you want to let us swab your nose. We
can answer any questions that you have about the work we are doing and procedures.
May I swab your nose now?

□ Yes

□ No

Alien Number:

Verbal consent obtained by:

________________________________ Date:

____________

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 (0920-1011).

UAC Respiratory Disease Cluster
Case Investigation Form

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

State: _____ Date reported to health department: ___/___/_____ (MM/DD/YYYY) Date interview completed: ___/___/_____ (MM/DD/YYYY)
Alien Number:_______________________________________________ CDC Lab ID: ________________________________________________
Demographic Information
1. Date of birth: _____/_____/_____ (MM/DD/YYYY)
2. Country of origin: ____________________________ Region: ____________________________ City/town: ___________________________
3. Estimated travel time from country of origin to US border: ___________ days weeks months
4. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
5. Sex:
Male
Female
Symptoms and Care Seeking
6. What date did symptoms associated with this illness start? _____/_____/_______ (MM/DD/YYYY)
7. Were symptoms present at the CBP Processing Center?
Yes
No
Unknown
8. Were symptoms present at a CBP facility before transfer to the processing center?
Yes, which facility? _______________ No Unknown
9. During this illness, did the patient experience any of the following?
Symptom
Symptom Present?
Symptom
Symptom Present?
Fever (highest temp _________ oF)
Yes
No
Unk Shortness of breath
Yes
No
Unk
If fever present, date of onset ___/___/____ (MM/DD/YYYY)
Vomiting
Yes
No
Unk
Felt feverish
Yes
No
Unk Diarrhea
Yes
No
Unk
If felt feverish, date of onset ___/___/____ (MM/DD/YYYY)
Eye infection/redness
Yes
No
Unk
Cough
Yes
No
Unk Rash
Yes
No
Unk
Sore Throat
Yes
No
Unk Fatigue
Yes
No
Unk
Muscle aches
Yes
No
Unk Seizures
Yes
No
Unk
Headache
Yes
No
Unk Back pain
Yes
No
Unk
Abdominal pain
Yes
No
Unk Other, specify
Yes
No
Unk
10. Does the patient still have symptoms?
Yes (skip to Q.12)
No
Unknown (skip to Q.12)
11. When did the patient feel back to normal? _____/_____/_____ (MM/DD/YYYY)
12. Did the patient receive any medical care for the illness?
Yes
No (skip to Q.14)
Unknown (skip to Q.14)
13. Where and on what date did the patient seek care (check all that apply)?
CBP Processing Center date:_____/_____/_____ (MM/DD/YYYY)
Shelter medical service date:_____/_____/_____ (MM/DD/YYYY)
Urgent care date:_____/_____/_____ (MM/DD/YYYY)
Emergency room date:_____/_____/_____ (MM/DD/YYYY)
Other _______________________________ date:_____/_____/_____ (MM/DD/YYYY)
Unknown
14. Did the patient experience any other complications as a result of this illness?
Yes (please describe below)
No
Unknown
____________________________________________________________________________________________________________________
15. Does the patient have any preexisting medical conditions (e.g. problems with heart, lung)?
Yes (please describe below)
No
Unknown
____________________________________________________________________________________________________________________
Risk Factors
16. In the 7 days prior to illness onset, please list the locations/CPB facilities the patient has been (including international).
Location 1: Dates: _____/_____/_____ to _____/_____/_____ Country _____________ State ______ City/CPB facility__________________
Location 2: Dates: _____/_____/_____ to _____/_____/_____ Country _____________ State ______ City/CPB facility__________________
Location 3: Dates: _____/_____/_____ to _____/_____/_____ Country _____________ State ______ City/CPB facility__________________
17. Which dormitory was the patient in when symptomatic? ________ (dormitory 101-110)
18. Which bed number was the patient in when symptomatic? ___________
19. Does the patient know anyone who had fever, respiratory symptoms like cough or sore throat, or another respiratory illness like pneumonia in
the 7 days BEFORE the case patient’s illness onset?
Yes (please list those ill before the case patient in the table below)
No
Unknown
Sex
Date of
Contact name
Age
Comments
(M/F)
illness onset

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 (0920-1011.

UAC Respiratory Disease Cluster
Case Investigation Form

20. Any additional comments or notes?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Please review the patient’s medical record, patient testing results, and facility records to obtain the answers for the remainder of the form.
Clinical Course, Treatment, and Outcome
21. Date of identification by CBP: _____/_____/_____ (MM/DD/YYYY)
22. Date of arrival to CBP Processing Center: _____/_____/_____ (MM/DD/YYYY)
Nogales, AZ or
McAllen, TX
Other: ____________
23. Date of arrival to Baytown Shelter: _____/_____/_____ (MM/DD/YYYY)
24. Approximately how many children were in the patient’s dormitory at the shelter on the date of symptom onset? ______________
25. Were other persons in the same dormitory symptomatic in the 7 days prior to the illness onset in this patient?
Yes
No (skip to Q.27)
Unknown (skip to Q.27)
26. How many persons were ill? ____________________
27. Was the patient hospitalized for the illness?
Yes
No (skip to Q.36)
Unknown (skip to Q.36)
28. Date(s) of hospital admission? First admission date:___/___/____ (MM/DD/YYYY) Second admission date:___/___/____ (MM/DD/YYYY)
29. Was the patient admitted to an intensive care unit (ICU)?
Yes
No (skip to Q.31)
Unknown (skip to Q.31)
30. Date of ICU admission: ______/_____/_______ (MM/DD/YYYY) Date of ICU discharge: ______/_____/_______ (MM/DD/YYYY)
31. Did the patient receive mechanical ventilation / have a breathing tube?
Yes
No (skip to Q.33)
Unknown (skip to Q.33)
32. For how many days did the patient receive mechanical ventilation or have a breathing tube? ___________________ days
33. Was the patient discharged?
Yes
No (skip to Q.36)
Unknown (skip to Q.36)
34. Date(s) of hospital discharge? First discharge date:___/___/____ (MM/DD/YYYY) Second discharge date:___/___/____ (MM/DD/YYYY)
35. Where was the patient discharged?
NBVC Shelter
Family member
Permanent shelter
Other _________________________
Unknown
36. Did the patient have a new abnormality on chest x-ray or CAT scan?
No, x-ray or scan was normal
Yes, x-ray or scan detected new abnormality
No, chest x-ray or CAT scan not performed
Unknown
37. Did the patient receive a diagnosis of pneumonia?
Yes
No
Unknown
38. Did the patient receive a diagnosis of ARDS?
Yes
No
Unknown
39. Did the patient receive antimicrobials prior to becoming ill (within 2 weeks) or after becoming ill?
Yes, (please complete table below)
No
Unknown
Start date
End date
Total number of days
Dosage
Drug
(MM/DD/YYYY) (MM/DD/YYYY)
receiving antivirals
(if known)
Oseltamivir (Tamiflu)
mg
Zanamivir (Relenza)
mg
Azithromycin
mg
Levofloxacin
mg
Augmentin
mg
Penicillin
mg
Other antimicrobial_____________________
mg
Other antimicrobial_____________________
mg
Other antimicrobial_____________________
mg
40. Did the patient die as a result of this illness?
Yes, Date of death:_____/_____/_____ (MM/DD/YYYY)
No
Unknown

Appendix A: Case Investigation Form

2

UAC Respiratory Disease Cluster
Case Investigation Form
Medical History -- Past Medical History and Vaccination Status
41. Were any of the following chronic medical conditions noted during patient interview or recorded on the patient’s medical record? Please specify
ALL conditions noted.

42.
43.
44.
45.
46.
47.
48.

a.

Asthma/reactive airway disease

Yes

No

Unknown

b.

Tuberculosis

Yes

No

Unknown (If YES, specify) _______________________________

c.

Other chronic lung disease

Yes

No

Unknown (If YES, specify) _______________________________

d.

Chronic heart or circulatory disease

Yes

No

Unknown (If YES, specify) _______________________________

e.

Diabetes mellitus

Yes

No

Unknown (If YES, specify) _______________________________

f.

Kidney or renal disease

Yes

No

Unknown (If YES, specify) _______________________________

g.

Non-cancer immunosuppressive condition

Yes

No

Unknown (If YES, specify) _______________________________

h.

Cancer chemotherapy in past 12 months

Yes

No

Unknown (If YES, specify) _______________________________

i.

Neurologic/neurodevelopmental disorder

Yes

No

Unknown (If YES, specify) _______________________________

j.

Cerebrospinal fluid leaks

Yes

No

Unknown (If YES, specify) _______________________________

k.

Chronic liver disease

Yes

No

Unknown (If YES, specify) _______________________________

l.

Sickle cell/other hemaglobinopathies

Yes

No

Unknown (If YES, specify) _______________________________

m. Congenital or acquired asplenia

Yes

No

Unknown (If YES, specify) _______________________________

n.

Yes

No

Unknown (If YES, specify weight/height) ___________________

Malnutrition

o. Other chronic diseases
Yes
No
Unknown (If YES, specify) _______________________________
Was patient pregnant or ≤6 weeks postpartum at illness onset?
Yes, pregnant (weeks pregnant at onset)________
Yes, postpartum (delivery date) ___/___/____ (MM/DD/YYYY)
No
Unknown
Does the patient currently smoke?
Yes
No
Unknown
Was the patient vaccinated against influenza in the past year?
Yes
No (skip to Q.47)
Unknown (skip to Q.47)
Month and year of influenza vaccination? Vaccination date 1:____/_____ (MM/YYYY) Vaccination date 2:____/_____ (MM/YYYY)
Type of influenza vaccine (check all that apply):
Inactivated (injection)
Live attenuated (nasal spray)
Unknown
Did the patient ever receive the pneumococcal vaccine?
Yes
No (skip to Q.49)
Unknown (skip to Q.49)
Month and year of pneumococcal vaccination? Vaccination date 1:____/_____ (MM/YYYY)

Specimen Testing Results
49. Was the patient tested for any pathogens?

 Yes (please complete table below)

 No

 Unknown

Positive Negative Not Tested/Unknown
Collection Date
CT Value
a. Influenza
____/____/______
___________________________



If influenza positive, specify subtype  H1N1pdm09  H3N2  A,subtype unknown  Influenza B  Other___________________  Unknown
b. Pneumococcus
____/____/______
___________________________



c. Respiratory syncytial virus/RSV
____/____/______
___________________________



d. Adenovirus
____/____/______
___________________________



e. Parainfluenza 1



____/____/______
___________________________
f. Parainfluenza 2



____/____/______
___________________________
g. Parainfluenza 3



____/____/______
___________________________
h. Human metapneumovirus



____/____/______
___________________________
i. Rhinovirus



____/____/______
___________________________
j. Coronavirus



____/____/______
___________________________
k. Other, specify: _________________
____/____/______
___________________________



l. Other, specify: __________________
____/____/______
___________________________



m. Other, specify: _________________
____/____/______
___________________________




Appendix A: Case Investigation Form

3

UAC Respiratory Disease Cluster
Case Investigation Form

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Estado: _TX_ Fecha de reporte al Departamento de Salud: ___/___/___ (MM/DD/AAAA) Fecha de la entrevista: ___/___/_____ (MM/DD/AAAA)
Número de extranjería:_______________________________________________ CDC Lab ID: __________________________________________
Información Demográfica
1. Fecha de nacimiento: _____/_____/_____ (MM/DD/AAAA)
2. País de origen: ___________________Region:____________________Ciudad/Pueblo:_______________________________________
3. Tiempo de viaje estimado de país de origen a la frontera con EEUU: ________ días semanas meses
4. Etnia:
Hispano ó Latino
No Hispano ó Latino
5. Sexo:
Masculino
Femenino
Síntomas, Curso Clínico de la enfermedad, Tratamiento, Análisis de las muestras y Resultados
6. En qué fecha comenzaron los síntomas asociados con la enfermedad? _____/_____/_______ (MM/DD/AAAA) (VER CALENDARIO)
7. Los síntomas estaban presentes al llegar a la Base de la Patrulla de Frontera de los EEUU?
Si
No
No sabe
8. Los síntomas estaban presentes antes de llegar a la Base de la Patrulla de Frontera de los EEUU?
Si
No
No sabe, si dijo si
Cual?___________
9. Durante el curso de la enfermedad, el paciente manifestó alguno de los siguientes síntomas?
Síntoma
Presentó?
Síntoma
Presentó?
Fiebre (Temperatura más alta __ oF)
Si
No
No sabe Dificultad para respirar
Si
No
No sabe
Si presentó fiebre, fecha de inicio __/__/___(MM/DD/AAAA)
Vómitos
Si
No
No sabe
Se sintió afiebrado
Si
No
No sabe Diarrea
Si
No
No sabe
Si se sintió afiebrado, fecha de inicio__/__/__(MM/DD/AAAA) Infección en los ojos/Ojos rojos
Si
No
No sabe
Tos
Si
No
No sabe Salpullido
Si
No
No sabe
Dolor de garganta
Si
No
No sabe Fatiga
Si
No
No sabe
Dolor muscular ó de cuerpo
Si
No
No sabe Convulsiones
Si
No
No sabe
Dolor de cabeza
Si
No
No sabe Dolor de espalda
Si
No
No sabe
Dolor abdominal
Si
No
No sabe Otro, especificar
Si
No
No sabe
10. El paciente todavía tiene síntomas?
Si (Pasar a la pregunta Q.12)
No
No sabe (Pasar a la pregunta Q.12)
11. En qué fecha es que el paciente se siente sano nuevamente? _____/_____/_____ (MM/DD/AAAA)
12. Recibió el paciente la atención médica adecuada para tratar la enfermedad?
Si
No (Pasar a la pregunta Q.14)
No sabe (Pasar a la pregunta Q.14)
13. Dónde y en qué fecha es que el paciente solicita atención médica (marcar todas las que apliquen)?
Base de la Patrulla de Frontera de los EEUU fecha:_____/_____/_____ (MM/DD/AAAA)
Clínica de CASA HOGAR fecha:_____/_____/_____ (MM/DD/AAAA)
Clínica de urgencia fecha:_____/_____/_____ (MM/DD/AAAA)
Sala de emergencia fecha:_____/_____/_____ (MM/DD/AAAA)
Otro, especificar _______________________________ fecha:_____/_____/_____ (MM/DD/AAAA)
No sabe
14. El paciente desarrolló alguna complicación como resultado de la enfermedad?
Si (por favor describir/especificar)
No
No
sabe
____________________________________________________________________________________________________________________
15. El paciente tenía alguna condición médica preexistente (por ejemplo condición crónica pulmonar)
Si (por favor describir/especificar)
No
No sabe
____________________________________________________________________________________________________________________
Factores de Riesgo
16. En los 7 días previos al inicio de síntomas, liste la ubicación del paciente (incluyendo zona internacional)
Ubicación 1: Fecha: De_____/____/_____a _____/_____/____ País ____________Estado ______Ciudad/Base Patrulla Fronteriza_________
Ubicación 2: Fecha: De_____/____/____ a _____/_____/____ País ___________ Estado ______ Ciudad/Base Patrulla Fronteriza_________
Ubicación 3: Fecha: De_____/____/____ a _____/_____/____ País ____________ Estado ______ Ciudad/Base Patrulla Fronteriza_________
Ubicación 4: Fecha: De_____/____/_____a _____/_____/____ País ____________Estado ______ Ciudad/Base Patrulla Fronteriza_________
17. En qué numero de dormitorio se encontraba el paciente cuando tuvo los síntomas? ________ (dormitorio 101-110)
18. En qué numero de cama se encontraba el paciente cuando tuvo los síntomas? ___________

Appendix A: Case Investigation Form

4

UAC Respiratory Disease Cluster
Case Investigation Form

19. El paciente conoció a alguien que tuvo fiebre, síntomas respiratorio como tos o dolor de garganta u otro síntoma respiratorio como
neumonía 7 días ANTES del inicio de síntomas en el paciente?
Si (liste todos los que estuvieron enfermos antes que el paciente)
No
No sabe
Fecha de
Sexo
Nombre
Edad
inicio de
Comentarios
(M/F)
síntomas

20. Algún comentario o nota adicional?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Appendix A: Case Investigation Form

5

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

ASSESSMENT OF INFECTION CONTROL POLICIES AND PRACTICES.

Site/Shelter Name
_______________________________________________________________________________________________________________
Medical Facility Point of Contact____________________________________________________________________________________
Phone __ __ __ - __ __ __ - __ __ __ __

Email or Other Contact___________________________________________________

Shelter POC_____________________________________________________________________________________________________
Department of Health POC_________________________________________________________________________________________

Section 1. Administrative Policies ,Shelter Practices and Education
Practice performed

If answer is No, document plan

(Yes, No)

for remediation

Facility policies( Ask HCW manager/staff)
a)

Written infection prevention policies and procedures are available,
current, and based on evidence-based guidelines (e.g., CDC/
HICPAC), regulations, or standards.
Note: Policies and procedures should be appropriate for the
services provided by the facility and should extend beyond OSHA
blood borne pathogen training

b)

Infection prevention policies and procedures are re-assessed at
least annually or according to state or federal requirements

c)

At least one individual trained in infection is employed by or
regularly available to the facility

d)

Shelter has adequate supplies necessary for adherence to standard
precautions readily available e.g. hand hygiene products, protective
equipment.
Note: This includes hand hygiene products, personal
protective equipment, and injection equipment.

Public reporting burden of this collection of information is estimated to average 8 hours 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 (0920-1011)

General Infection Prevention Education and Training (Ask HCW manager/staff)
a) Shelter staff and Health care workers(HCW) have received jobspecific training on infection prevention policies and procedures e.g.
proper selection and use of PPE
Note: This includes those employed by outside agencies and
available by contract or on a volunteer basis to the facility.
b) Competency and compliance with job-specific infection prevention
policies and procedures are documented both upon hire and
through annual evaluations/assessments
Occupational Health (Ask HCW manager/staff)
a) HCP are trained on the OSHA blood borne pathogen standard upon
hire and at least annually
b) The facility maintains a log of needle sticks, sharps injuries, and
other employee exposure events
c) Following an exposure event, post-exposure evaluation and followup, including prophylaxis as appropriate, are available at no cost to
employee and are supervised by a licensed healthcare professional
d) Hepatitis B vaccination is available at no cost to all employees who
are at risk of occupational exposure
e) Post-vaccination screening for protective levels of hepatitis B
surface antibody is conducted after third vaccine dose is
administered
f)

All shelter staff and volunteers are offered annual influenza
vaccination at no cost

g) All shelter staff who have potential for exposure to tuberculosis (TB)
are screened for TB upon hire and annually (if negative)
h) Shelter staff are assessed for current immunization status upon
admittance to the shelter and encouraged to receive vaccinations
( MMR,DPT, Varicella, HepB)
i)

Shelter has a respiratory protection program that details required
worksite-specific procedures and elements for required respirator
use

j)

Respiratory fit testing is provided at least annually to appropriate
HCP

k) Facility has written protocols for managing/preventing job-related
and community-acquired infections or important exposures in HCP,
including notification of appropriate Infection Prevention and
Occupational Health personnel when applicable
l)

Shelter staffs are excluded from work when ill with certain illnesses
e.g. ILI till resolution of symptoms

m) Shelter has protocols or guidance for prevention and response of
conditions of outbreak potential among UC and shelter staff.
Surveillance and Disease reporting ( Ask HCW manager/staff)
a) An updated list of diseases reportable to the public health authority
is readily available to all personnel
b) The facility can demonstrate compliance with mandatory reporting
requirements for notifiable diseases, healthcare associated
infections, and for potential outbreaks.
c) Is there an assessment plan to triage and screen UC and staff upon
initial admission/registration?
If Yes, describe step by step processes
Is there documentation of triage process?
( need to ask this of two other people who work at intake)
d) Are assessment periodically done?
How often?
Daily during infectious disease disasters?
By whom?
Healthcare professional on-site
Designated, trained shelter worker
e)

Is there a system in place to assess and monitor illness among UC,
staff, and volunteers?
-Passive surveillance ( e.g. self- report of symptoms)
-Active surveillance for symptoms among well UC and staff
(Get more description of this and how is this is done)

f)

Are UC and shelter workers encouraged to report symptoms of
infectious diseases?

g) Are there posters of reportable signs and symptoms/syndromes of
potentially infectious diseases strategically located around the

shelter?
h) Shelter clinic keeps a daily log of conditions diagnosed onsite
i)

Are Increases in rates of illness identified through syndromic
surveillance investigated by the ICP/ICP designee on-site and the
local health department?

j)

Is there set “trigger points” in which shelter operations and/or
changes in staffing must be considered prior to hitting a critical
nature.
Hand hygiene ( Ask HCW manager/staff)

a) The shelter provides supplies necessary for adherence to hand
hygiene (e.g., soap, water, paper towels, alcohol-based hand rub)
and ensures they are readily accessible to HCP in patient care
areas
b) HCP are educated regarding appropriate indications for hand
washing with soap and water versus hand rubbing with alcoholbased hand rub
Note: Soap and water should be used when bare hands are
visibly soiled (e.g., blood, body fluids) or after caring for a
patient with known or suspected infectious diarrhea (e.g.,
Clostridium difficile or norovirus). In all other situations,
alcohol-based hand rub may be used.
c) The facility periodically monitors and records adherence to hand
hygiene and provides feedback to personnel regarding their
performance
Personal Protective Equipment (Ask HCW manager/staff)
a) The facility has sufficient and appropriate PPE available and readily
accessible to HCW
b) HCP receive training on proper selection and use of PPE
Injection Safety
a) Medication purchasing decisions at the facility reflect selection of
vial sizes that most appropriately fit the procedure needs of the
facility and limit need for sharing of multi-dose vials
b) Injections are required to be prepared using aseptic technique in a
clean area free from contamination or contact with blood, body

fluids or contaminated equipment
c) Facility has policies and procedures to track HCP access to
controlled substances to prevent narcotics theft/diversion
Respiratory Hygiene/Cough Etiquette (Ask HCW manager/staff, but also observe)
a) The facility has policies and procedures to contain respiratory
secretions in persons who have signs and symptoms of a
respiratory infection, beginning at point of entry to the facility and
continuing through the duration of the visit.
Measures include:
i.

Posting signs at entrances (with instructions to patients
with symptoms of respiratory infection to cover their
mouths/ noses when coughing or sneezing, use and
dispose of tissues, and perform hand hygiene after hands
have been in contact with respiratory secretions.)

ii.

Providing tissues and no-touch receptacles for disposal of
tissues

iii.

Providing resources for performing hand hygiene in or
near waiting areas

iv.

Offering facemasks to coughing patients and other
symptomatic persons upon entry to the medical
facility/shelter

v.

Providing space and encouraging persons with symptoms
of respiratory infections to sit as far away from others as
possible.

vi.

If available, facilities may wish to place these patients in a
separate area while waiting for care

b) Shelter clinic educates healthcare providers on the importance of
infection prevention measures to contain respiratory secretions to
prevent the spread of respiratory pathogens when examining and

caring for patients with signs and symptoms of a respiratory
infection
Environmental Cleaning (Ask HCW manager/staff)
a) Facility has written policies and procedures for routine cleaning and
disinfection of environmental services, including identification of
responsible personnel
b) Environmental services staff receive job-specific training and
competency validation at hire and when procedures/policies change
c) Training and equipment are available to ensure that HCP wear
appropriate PPE to preclude exposure to infectious agents or
chemicals (PPE can include gloves, gowns, masks, and eye
protection)
d) Cleaning procedures are periodically monitored and assessed to
ensure that they are consistently and correctly performed
e) The facility has a policy/procedure for decontamination of spills of
blood or other body fluids
Reprocessing of Reusable Medical Devices
a) Facility has policies and procedures to ensure that reusable medical
devices are cleaned and reprocessed appropriately prior to use on
another patient
b) Policies, procedures, and manufacturer reprocessing instructions for
reusable medical devices used in the facility are available in the
reprocessing area(s)
c) HCP responsible for reprocessing reusable medical devices are
appropriately trained and competencies are regularly documented
(at least annually and when new equipment is introduced).
d) Training and equipment are available to ensure that HCP wear
appropriate PPE to prevent exposures to infectious agents or
chemicals (PPE can include gloves, gowns, masks, and eye
protection).
Note: the exact type of PPE depends on infectious or chemical
agent and anticipated type of exposure
Sterilization of Reusable Instruments and Devices
a) All reusable critical instruments and devices are sterilized prior to

reuse
b) Routine maintenance for sterilization equipment is performed
according to manufacturer instructions (confirm maintenance
records are available)
c) Policies and procedures are in place outlining facility response (i.e.,
recall of device and risk assessment) in the event of a reprocessing
error/failure.
High-Level Disinfection of Reusable Instruments and Devices
d) All reusable semi-critical items receive at least high-level
disinfection prior to reuse
e) The facility has a system in place to identify which instrument (e.g.,
endoscope) was used on a patient via a log for each procedure
f)

Routine maintenance for high-level disinfection equipment is
performed according to manufacturer instructions; confirm
maintenance records are available
Management of sick UC (Ask HCW manager/staff)

a) Shelter clinic has guidelines for referral and management of ill UC
with specific conditions e.g. Influenza
b) Facility has adequate designated isolation areas for ill UC
c) An Isolation area is available for ill UC
-

Easily-cleanable?

-

Have separate toilets?

-

Separate hand-washing facilities?

d) There is adequate spatial separation at least 3 feet of space
between sick individuals and adequate bed configuration( head to
toe arrangement)
e) ILL UC are spatially separated from well UC until they are
fever/symptom free for 24 hours?
f)

Facility has guidelines for discharge of sick UC from Isolation back
into dormitories?

g) There are postage to indicate that individuals should not enter
isolation area without appropriate personal protective equipment
(PPE)?

h) Are there dedicated shelter staff (e.g., healthcare workers when
available, housekeeping, custodial) to provide care for ill UC in
isolation area?
i)

Are isolation staff restricted from working with non-infectious
individuals in the shelter

j)

Are ill UC in isolation cohorted by disease/syndrome?

k) Are the Isolation area doors or barriers kept closed?
l)

Does the isolation room have any specific air handling mechanism?

e.g. airborne infection isolation room, negative pressure rooms/areas

Section II: Personnel and Patient-care Observations
Hand hygiene: Is Hand hygiene performed correctly
a) Before contact with the patient or their immediate care environment
(even if gloves are worn)
b) Before exiting the patient’s care area after touching the patient or
the patient’s immediate environment (even if gloves are worn)
c) Before performing an aseptic task (e.g., insertion of IV or preparing
an injection) (even if gloves are worn)
d) After contact with blood, body fluids or contaminated surfaces (even
if gloves are worn)
e) When hands move from a contaminated-body site to a clean-body
site during patient care (even if gloves are worn)
Personal protective equipment is correctly used
a) PPE is removed and discarded prior to leaving the patient’s room or
care area
b) Hand hygiene is performed immediately after removal of PPE
c) Gloves
i) HCW wear gloves for potential contact with blood, body fluids,
mucous membranes, non-intact skin, or contaminated equipment
ii) HCW do not wear the same pair of gloves for the care of more
than one patient
iii) HCW do not wash gloves for the purpose of reuse
d) Gowns:
i. HCP wear gowns to protect skin and clothing during procedures or

activities where contact with blood or body fluids is anticipated
ii. HCP do not wear the same gown for the care of more than one
patient
e) Facial protection
i) HCP wear mouth, nose, and eye protection during procedures
that are likely to generate splashes or sprays of blood or other body
fluids
ii. HCP wear a facemask (e.g., surgical mask) when placing a
catheter or injecting material into the epidural or subdural space
(e.g., during myelogram, epidural or spinal anesthesia)
iii) Are facemasks offered to coughing UC and shelter staff upon
entry into the shelter?
iv) Are sick UC provided appropriate PPE e.g. face masks outside
of isolation areas?
Injection Safety
a) Needles and syringes are used for only one patient (this includes
manufactured prefilled syringes and cartridge devices such as
insulin pens)
b) The rubber septum on a medication vial is disinfected with alcohol
prior to piercing
c) Medication vials are entered with a new needle and a new syringe,
even when obtaining additional doses for the same patient
d) Single dose (single-use) medication vials, ampules, and bags or
bottles of intravenous solution are used for only one patient
e) Medication administration tubing and connectors are used for only
one patient
f)

Multi-dose vials are dated by HCP when they are first opened and
discarded within 28 days unless the manufacturer specifies a
different (shorter or longer) date for that opened vial Note: This is
different from the expiration date printed on the vial.

g) Multi-dose vials are dedicated to individual patients whenever
possible.
h) Multi-dose vials to be used for more than one patient are kept in a
centralized medication area and do not enter the immediate patient

treatment area (e.g.,. operating room, patient room/cubicle)
Note: If multi-dose vials enter the immediate patient treatment
area they should be dedicated for single-patient use and
discarded immediately after use.
i)

All sharps are disposed of in a puncture-resistant sharps container

j)

Filled sharps containers are disposed of in accordance with state
regulated medical waste rules

k) All controlled substances (e.g., Schedule II, III, IV, V drugs) are kept
locked within a secure area
Point of Care Testing
a) New single-use, auto-disabling lancing device is used for each
patient
Note: Lancet holder devices are not suitable for multi-patient
use.
b) If used for more than one patient, the point-of-care testing meter is
cleaned and disinfected after every use according to manufacturer
instructions
Note: If the manufacturer does not provide instructions for
cleaning and disinfection, then the testing meter should not be
used for >1 patient.
Environmental Cleaning
a) Environmental surfaces, with an emphasis on surfaces in proximity
to the patient and those that are frequently touched, are cleaned
and then disinfected with an EPA-registered disinfectant
b) Cleaners and disinfectants are used in accordance with
manufacturer instructions (e.g., dilution, storage, shelf-life, contact
time)
Reprocessing of Reusable Instruments and Devices
a) Reusable medical devices are cleaned, reprocessed (disinfection or
sterilization) and maintained according to the manufacturer
instructions.
Note: If the manufacturer does not provide such instructions,
the device may not be suitable for multi-patient use.

b) Single-use devices are discarded after use and not used for more
than one patient.
Note: If the facility elects to reuse single-use devices, these
devices must be reprocessed prior to reuse by a third-party
reprocessor that it is registered with the FDA as a third-party
reprocessor and cleared by the FDA to reprocess the specific
device in question. The facility should have documentation
from the third party reprocessor confirming this is the case.
c) Reprocessing area has a workflow pattern such that devices clearly
flow from high contamination areas to clean/sterile areas (i.e., there
is clear separation between soiled and clean workspaces)
d) Medical devices are stored in a manner to protect from damage and
contamination
Sterilization of Reusable Instruments and Devices
a) Items are thoroughly pre-cleaned according to manufacturer
instructions and visually inspected for residual soil prior to
sterilization
Note: For lumened instruments, device channels and lumens
must be cleaned using appropriately sized cleaning brushes.
b) Enzymatic cleaner or detergent is used for pre-cleaning and
discarded according to manufacturer instructions (typically after
each use)
c) Cleaning brushes are disposable or cleaned and high-level
disinfected or sterilized (per manufacturer instructions) after each
use
d) After pre-cleaning, instruments are appropriately wrapped/packaged
for sterilization (e.g., package system selected is compatible with
the sterilization process being performed, hinged instruments are
open, instruments are disassembled if indicated by the
manufacturer)
e) A chemical indicator (process indicator) is placed correctly in the
instrument packs in every load
f)

A biological indicator is used at least weekly for each sterilizer and
with every load containing implantable items

g) For dynamic air removal-type sterilizers, a Bowie-Dick test is
performed each day the sterilizer is used to verify efficacy of air
removal
h) Sterile packs are labeled with the sterilizer used, the cycle or load
number, and the date of sterilization
i)

Logs for each sterilizer cycle are current and include results from
each load

j)

After sterilization, medical devices and instruments are stored so
that sterility is not compromised

k) Sterile packages are inspected for integrity and compromised
packages are reprocessed prior to use
l)

Immediate-use steam sterilization (flash sterilization), if performed,
is only done in circumstances in which routine sterilization
procedures cannot be performed

m) Instruments that are flash-sterilized are used immediately and not
stored
High-Level Disinfection of Reusable Instruments and Devices
a) Flexible endoscopes are inspected for damage and leak tested as
part of each reprocessing cycle
b) Items are thoroughly pre-cleaned according to manufacturer
instructions and visually inspected for residual soil prior to high-level
disinfection
Note: For lumened instruments, device channels and lumens
must be cleaned using appropriately sized cleaning brushes.
c) Enzymatic cleaner or detergent is used and discarded according to
manufacturer instructions (typically after each use)
d) Cleaning brushes are disposable or cleaned and high-level
disinfected or sterilized (per manufacturer instructions) after each
use.
e) For chemicals used in high-level disinfection, manufacturer
instructions are followed for:
i. preparation
ii. testing for appropriate concentration
iii. replacement (i.e., prior to expiration or loss of efficacy)

f)

If automated reprocessing equipment is used, proper connectors
are used to assure that channels and lumens are appropriately
disinfected

g) Devices are disinfected for the appropriate length of time as
specified by manufacturer instructions
h) Devices are disinfected at the appropriate temperature as specified
by manufacturer instructions
i)

After high-level disinfection, devices are rinsed with sterile water,
filtered water, or tap water followed by a rinse with 70% - 90% ethyl
or isopropyl alcohol

j)

Devices are dried thoroughly prior to reuse
Note: Lumened instruments (e.g., endoscopes) require flushing
channels with alcohol and forcing air through channels.

k) After high-level disinfection, devices are stored in a manner to
protect from damage or contamination
Note: Endoscopes should be hung in a vertical position

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Verbal Consent / Assent Script
Hi, my name is _______________. I’m working with the health department and this shelter to find out
what has been making some children here sick with fever and cough. We’d like to ask you some
questions about the symptoms you’ve had in the last week. We will swab your nose and throat to test
for any germs that might be making you sick. You don’t have to answer our questions or allow us to
swab your nose and throat; you can decide if you want to talk to us and let us swab you. We can answer
any questions that you have about the study and procedures. Do you have any questions?
May I ask you some questions now?

□ Yes

□ No

□ Yes

□ No

(Complete questionnaire)
May I swab your nose and throat now?

Place sticker with Alien number here,
DO NOT PUT CHILD’s NAME ON THIS FORM

Verbal consent obtained by: ___________________________________ Date: ____________

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Consentimiento Verbal
El párrafo a continuación se leerá al entrevistado y las respuestas serán registradas por el
entrevistador:
Hola, me llamo_______________, estoy trabajando con el departamento de salud y este
refugio para tratar de entender por qué algunos niños de éste refugio se están enfermando con
fiebre y con tos. Nos gustaría hacerte algunas preguntas sobre los síntomas que has tenido la
semana pasada. Vamos a pasarte un hisopo por la nariz y por la garganta para detectar
algunos gérmenes que podrían estar enfermándote. No tienes que responder a nuestras
preguntas o dejarte pasar el hisopo si no quieres; o si quieres podemos hacerte las preguntas y
pasar un hisopo por la nariz y garganta. Podemos responder a cualquier pregunta que tengas
sobre este estudio y los procedimientos. Tienes alguna pregunta?
¿Puedo hacerte algunas preguntas ahora? □ Sí □ No
(Cuestionario completo)
¿Puedo pasar el hisopo por la nariz y garganta ahora? □ Sí □ No

Place sticker with Alien number here,
DO NOT PUT CHILD’s NAME ON THIS FORM

El consentimiento verbal fue obtenido por: ________________________Fecha: ________

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)

Form approved
OMB No. 0920-1011
Exp. Date 03/31/2017

RAPID ENVIRONMENTAL HEALTH ASSESSMENT FOR UAC FACILITIES
I. ASSESSING AGENCY DATA
87Immediate Needs Identified:
¹Agency /Organization Name ___________________________________________________________________
ÿ Yes ÿ No
2Assessor Name/Title ___________________________________________________________________________________________________________________
3Phone __ __ __ - __ __ __ - __ __ __ __
4Email or Other Contact ____________________________________________________________________
II. FACILITY TYPE, NAME AND CENSUS DATA
5Shelter Type
7CBP Sector __________________
ÿ DOD ÿ Other ORR ÿ Other _______________________ 6CBP Facility? ÿ Yes ÿ No ÿ Unk/NA
8Date Shelter Opened __ __ /__ __/__ __ (mm/dd/yr)
9Date Assessed __ __ /__ __/__ __ (mm/dd/yr)
10Time Assessed __ __ : __ __ ÿ am ÿ pm
11Reason for Assessment
ÿ Preoperational
ÿ Initial
ÿ Routine ÿ Other __________________________________________________________________
12Location Name and Description ________________________________________________________________________________________ ___________________
13Street Address ________________________________________________________________________________________________________________________
14City / County ____________________________________ 15State __ __ 16Zip Code __ __ __ __ __ 17Latitude/Longitude ________________/_______________
18Facility Contact / Title ____________________________ 19Facility Type
ÿ Barrack ÿ Open Area Structure ÿ Modular Temporary ÿ Other________________
20Phone __ __ __ - __ __ __ - __ __ __ __
21Fax __ __ __ - __ __ __ - __ __ __ __
22E-mail or Other Contact _______________________________
23Current Census _____________
24Estimated Capacity ______________
25Size of Facility ____________
26Number of Staff / Volunteers __________
III. FACILITY
VIII. SOLID WASTE GENERATED
27Structural damage
66Adequate num. receptacles (1/30-gx10 persons)
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
28Security / law enforcement available
67Appropriate separation
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
29Water system operational
68
Appropriate
disposal
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
30Hot water available
69Appropriate storage
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
31HVAC system operational
70Timely removal
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
32Adequate ventilation
71Types
ÿ Yes ÿ No ÿ Unk/NA
ÿ Solid ÿ Hazardous ÿ Medical ÿ Unk/NA
33Adequate space per person (20-40ft2)
IX. CHILDCARE AREA
ÿ Yes ÿ No ÿ Unk/NA
34Free of injury /occupational hazards
72Clean diaper-changing facilities
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
35Free of pest / vector issues
73Hand-washing facilities available
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
36Acceptable level of cleanliness
74Adequate toy hygiene
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
37Electrical grid system operational
75Safe toys
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
38Generator in use, 39 If yes, Type__________
76
Clean food/bottle preparation area
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
40Indoor temperature _________ oF
77Adequate child/caregiver ratio
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
78Acceptable level of cleanliness
IV. FOOD
ÿ Yes ÿ No ÿ Unk/NA
41Preparation on site
X. SLEEPING AREA
ÿ Yes ÿ No ÿ Unk/NA
42Served on site
79Adequate number of cots/beds/mats
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
43Safe food source
80Adequate supply of bedding
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
44Adequate supply
81Bedding changed regularly
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
45Appropriate storage
82Adequate spacing (2.5 - 3 ft between cots)
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
46Appropriate temperatures
83
Acceptable
level
of
cleanliness
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
47Hand-washing facilities available
XI. OTHER CONSIDERATIONS
ÿ Yes ÿ No ÿ Unk/NA
48Safe food handling
84Handicap accessibility
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
49Dishwashing facilities available
85 UACs with functional needs present
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA
50Clean kitchen area
86 Pregnant UAC present
ÿ Yes ÿ No ÿ Unk/NA
ÿ Yes ÿ No ÿ Unk/NA

Public reporting burden of this collection of information is estimated to average 8 hours 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 (0920-1011)

V. DRINKING WATER AND ICE
51Adequate water supply
52Adequate ice supply
53Safe water source
54Safe ice source
VI. HEALTH / MEDICAL
55Reported outbreaks
56Medical care services on site
57Mental health services available

ÿ Yes
ÿ Yes
ÿ Yes
ÿ Yes

ÿ No
ÿ No
ÿ No
ÿ No

ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA

ÿ Yes
ÿ Yes
ÿ Yes

ÿ No ÿ Unk/NA
ÿ No ÿ Unk/NA
ÿ No ÿ Unk/NA

VII. SANITATION
58Adequate

laundry services
ÿ Yes ÿ No
number of toilets (1/20 persons)
ÿ Yes ÿ No
60Adequate number of showers (1/15)
ÿ Yes ÿ No
61Adequate num. of hand-washing stations (1/15)
ÿ Yes ÿ No
62Hand-washing supplies available
ÿ Yes ÿ No
63Toilet supplies available
ÿ Yes ÿ No
64Acceptable level of cleanliness
ÿ Yes ÿ No
65Sewage system type
ÿ Community ÿ On site ÿ Portable
59Adequate

XII. COMMENTS (List Critical Needs on Immediate Needs Sheet)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA
ÿ Unk/NA

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Public reporting burden of this collection of information is estimated to average 8 hours 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 (0920-1011)

SECTION B

1. Administrative Policies ,Shelter Practices and Education

a) Are there written infection environmental health/infection control
policies and procedures are available, current, and based on
evidence-based guidelines (e.g., CDC/ HICPAC), regulations, or
standards for: e.g.
-Waste disposal including medical waste
-Pest control
-Sanitation
b) Is there at least one individual trained in infection prevention or
environmental health is employed by or regularly available to the
facility?
c) Does shelter have adequate supplies necessary for adherence to
standard precautions readily available e.g. hand hygiene products,
protective equipment, cleaning and disinfectant supplies?
d) Do shelter staff and volunteers have received job-specific training
on environmental health policies and procedures e.g. proper
selection and use of PPE?
Respiratory Hygiene/Cough Etiquette:
e) Does the facility have policies and procedures to contain respiratory
secretions in persons who have signs and symptoms of a
respiratory infection, beginning at point of entry into the shelter?
Measures include :
-Posting signs at entrances (with instruction to patients with
symptoms of respiratory infections to cover their mouths/noses
when coughing or sneezing, use and dispose of tissues, and
perform hand hygiene after hands have been in contact with
respiratory secretions?

Practice performed
(Yes, No)

If answer is No, document plan
for remediation

-Provide tissues and no-touch receptacles for disposal of tissues
-Provide resources for performing hand hygiene
Personal protective equipment
f) Are facemasks offered to coughing UC and shelter staff upon entry
into the shelter?
g) Are shelter staff provided appropriate PPE when performing tasks :
- Laundry collection and processing,
- Food preparation and handling,
-Waste collection and disposal
h) Are PPEs stored appropriately?
i) Are PPE e.g. masks worn appropriately/correctly?
Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for

j) Is there a means of disposal of used PPE?
5. Hand hygiene
a) Are UC and staff are educated on hand washing with soap and
water and use of alcohol hand gels?
_ Educated on indications of alcohol based gels and use of water
and soap?
b) Do shelter staff monitor UC adherence/compliance to hand hygiene
c) Is there hand hygiene signage at
- shelter entrances,
-washrooms,
- isolation area
-meal tents
And hand hygiene stations?
d) Are there hand hygiene facilities ;
-In or just outside every isolation room/area
-Near the restrooms
- Near the food preparation and/or kitchen area
- Near the eating area
- At the entrance/exit of any common play
areas/classroom/dormitories
- As needed throughout the shelter
6. Environmental Controls
e) Are staffs trained in the management of spill involving potentially
hazardous substance such as body fluids, and medical waste?
f) Are staffs trained regarding PPE use and disposal to decrease skin
exposure to harsh chemicals during cleaning and disinfection
activities?
g) Are environmental surfaces, (with an emphasis on surfaces in
isolation spaces and medical facility and those that are frequently
touched) cleaned and then disinfected with an EPA-registered
disinfectant?
h) How often does cleaning occur?
-Bathroom areas should be cleaned daily and as necessary
-Food preparation areas should be cleaned after each meal and as
needed between food preparation tasks
-Dining areas should be cleaned after each meal
-Living and sleeping areas should be cleaned at least weekly and
more often if necessary
-Traffic flow patterns and use will determine the frequency these
areas should be cleaned
-Cots and assorted bedding should be cleaned and laundered
between occupants and as needed when contaminated with body
fluids

Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for

-Medical/First aid or triage areas should be cleaned daily and as
necessary
-Isolation area should be cleaned daily, upon individual transfer to a
medical facility or move to another part of the shelter, and as
necessary
i) Are cleaners and disinfectants are used in accordance with
manufacturer instructions (e.g., dilution, storage, shelf-life, contact
time)
j) Are shelter employees are using appropriate PPE when cleaning or
doing laundry

Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for

SECTION C: List of Infection Prevention and Control Equipment/Supplies Needed for Shelters

Equipment
-Red bags or containers for regulated medical waste disposal
-Biohazard stickers or labels for regulated medical waste disposal
-Sharps containers
-Personal Protective Equipment (PPE)
Respirators (N-95 or equivalent)
Masks (surgical/procedure masks)
Gowns (patient care gowns)
Gloves (non-sterile procedure gloves)
Eye protection (goggles or face shields)
Hand hygiene products
Alcohol Based Hand Rubs (ABHR) and dispensing system
Soap (non-antimicrobial or anti-microbial)
Paper towels
Disinfectants
Towelettes (antimicrobial wipes)
Disinfectant (EPA-registered chemical germicide)
Water Decontamination Products
Chlorine or iodine tablets
Non-scented household bleach (sodium hypochlorite)
Wound Management Supplies
Dressing materials (gauze, absorbent pads, tape, etc)
Syndromic Surveillance Supplies
Thermometers (disposable or supplies for disinfection between
individuals)
Sexually Transmitted Disease Prevention Supplies
Barrier methods (condoms, dental dams, etc)
Body Fluid Management Supplies
Absorbent pads (blue pads) for incontinent individuals
Diapers
Impermeable sheets or pads for cots/sleeping area, when
needed (based on ICP/ICP
designee’s recommendation)
Facial tissues
Environmental Controls
Fans for creating negative pressure
Plastic, drywall, or plywood for barrier creation
Food Safety
Thermometer for monitoring refrigerator/freezer and food

Present

Comments

Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for

temperature
Vaccination Supplies
Syringes
Alcohol swabs

Public reporting burden of this collection of information is estimated to average 8 hours per response, including the time for

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Appendix 1:

VIRAL HEMORHAGIC FEVER
CASE INVESTIGATION FORM

Public reporting burden of this collection of information is estimated to average 25 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 (0920-1011)

VIRAL HEMORHAGIC FEVER
CASE INVESTIGATION FORM

Outbreak
Case ID:
Health
Facility
Case ID:

Date of Case Report: ____/____/_____ (D, M, Yr)

Section 1.

Patient Information

Patient’s Surname: ______________________ Other Names:____________________________
Age: _______
Years
Months
Gender:
Male
Female
Phone Number of Patient/Family Member:_____________________ Owner of Phone: ________________
Alive

Status of Patient at Time of This Case Report:

Dead

If dead, Date of Death: ___/___/____ (D, M, Yr)

Permanent Residence:
Head of Household: __________________________ Village/Town: _______________________ Parish: __________________________
Country of Residence: _________________ District: ____________________________ Sub-County: ____________________________
Occupation:
Farmer
Butcher
Hunter/trader of game meat
Miner
Religious leader
Housewife
Pupil/student
Child
Businessman/woman; type of business: _____________________
Transporter; type of transport: ___________________________
Healthcare worker; position: _________________ healthcare facility: ___________________
Traditional/spiritual healer
Other; please specify occupation: _____________________________________________________
Location Where Patient Became Ill:
Village/Town: _________________________ District: _________________________ Sub-County: _________________________
GPS Coordinates at House: latitude: __________________ longitude: ________________________
If different from permanent residence, Dates residing at this location: ___/___/____ - ___/___/____ (D, M, Yr)

Section 2.

Clinical Signs and Symptoms

Date of Initial Symptom Onset:

____/____/______ (D, M, Yr)

Please tick an answer for ALL symptoms indicating if they occurred during this illness between symptom onset and case detection:

Fever

If yes, Temp: ____º C Source:

Axillary

Vomiting/nausea
Diarrhea
Intense fatigue/general weakness
Anorexia/loss of appetite
Abdominal pain
Chest pain
Muscle pain
Joint pain
Headache
Cough
Difficulty breathing
Difficulty swallowing
Sore throat
Jaundice (yellow eyes/gums/skin)
Conjunctivitis (red eyes)
Skin rash
Hiccups
Pain behind eyes/sensitive to light
Coma/unconscious
Confused or disoriented

Section 3.

Yes

No

Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Oral

Rectal

Unexplained bleeding from any site
If Yes:
Bleeding of the gums
Bleeding from injection site
Nose bleed (epistaxis)
Bloody or black stools (melena)
Fresh/red blood in vomit (hematemesis)
Digested blood/“coffee grounds” in vomit
Coughing up blood (hemoptysis)
Bleeding from vagina,
other than menstruation
Bruising of the skin
(petechiae/ecchymosis)
Blood in urine (hematuria)

Yes

No

Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Yes

No

Unk

Yes

No

Unk

Other hemorrhagic symptoms
Yes
No
Unk
If yes, please specify: ___________________________
Other non-hemorrhagic clinical symptoms:
Yes
No
If yes, please specifiy: ___________________________

Unk

Hospitalization Information
Yes

At the time of this case report, is the patient hospitalized or currently being admitted to the hospital?
If yes, Date of Hospital Admission: ____/____/_____ (D, M, Yr)

No

Health Facility Name: ________________________________________

Village/Town: __________________________ District: _______________________ Sub-County: _________________________
Is the patient in isolation or currently being placed there?
Yes
No
If yes, date of isolation: ____/____/_____ (D, M, Yr)
Was the patient hospitalized or did he/she visit a health clinic previously for this illness?

Yes

No

Unk

If yes, please complete a line of information for each previous hospitalization:
Dates of Hospitalization

Health Facility Name

Village

District

Was the patient isolated?

___/___/____ - ___/___/____ (D, M, Yr)

Yes
No

___/___/____ - ___/___/____ (D, M, Yr)

Yes
No

Outbreak
Case ID:

Section 4.

Epidemiological Risk Factors and Exposures

IN THE PAST ONE(1) MONTH PRIOR TO SYMPTOM ONSET:
1. Did the patient have contact with a known or suspect case, or with any sick person before becoming ill?
If yes, please complete one line of information for each sick source case:
Name of Source
Case

Relation to
Patient

Dates of Exposure
(D, M, Yr)

Village

District

No

Was the person dead or alive ?

Unk
Contact
Types**

Alive
Dead, date of death: ___/___/____ (D, M, Y)
Alive
Dead, date of death: ___/___/____ (D, M, Y)
Alive
Dead, date of death: ___/___/____ (D, M, Y)

___/___/___ - ___/___/___
___/___/___ - ___/___/___
___/___/___ - ___/___/___

**Contact Types:
(list all that apply)

Yes

1 – Touched the body fluids of the case (blood, vomit, saliva, urine, feces)
2 – Had direct physical contact with the body of the case (alive or dead)
3 – Touched or shared the linens, clothes, or dishes/eating utensils of the case
4 – Slept, ate, or spent time in the same household or room as the case

2. Did the patient attend a funeral before becoming ill?
Yes
No
Unk
If yes, please complete one line of information for each funeral attended:
Name of Deceased Person Relation to Patient

Dates of Funeral
Attendance (D, M, Yr)

Village

District

Did the patient participate
(carry or touch the body)?

___/___/____ - ___/___/____

Yes

No

___/___/____ - ___/___/____

Yes

No

3. Did the patient travel outside their home or village/town before becoming ill?
Yes
No
Unk
If yes, Village: __________________________ District: ______________________ Date(s): ___/___/____ - ___/___/____
4. Was the patient hospitalized or did he/she go to a clinic or visit anyone in the hospital before this illness?
If yes, Patient Visited: ____________________ Date(s): ___/___/____ - ___/___/____ (D, M, Yr)

Yes

(D, M, Yr)

No

Unk

Health Facility Name: _________________________ Village: _____________________ District: _______________________
Yes

5. Did the patient consult a traditional/spiritual healer before becoming ill?

No

Unk

If yes, Name of Healer: _____________________Village: _______________ District: _____________ Date: ___/___/____ (D, M, Yr)
6. Did the patient have direct contact (hunt, touch, eat) with animals or uncooked meat before becoming ill?
If yes, please tick all that apply:
Animal:
Status (check one only):
Bats or bat feces/urine
Healthy
Sick/Dead
Primates (monkeys)
Healthy
Sick/Dead
Rodents or rodent feces/urine
Healthy
Sick/Dead
Pigs
Healthy
Sick/Dead
Chickens or wild birds
Healthy
Sick/Dead
Cows, goats, or sheep
Healthy
Sick/Dead
Other; specify______________
Healthy
Sick/Dead
Yes

7. Did the patient get bitten by a tick in the past 2 weeks?

Section 5.

No

Yes

No

Unk

Unk

Clinical Specimens and Laboratory Testing

Specimen/shipping instructions:  Label sample with patient name, date of collection, and case ID

 Send sample cold with a cold/ice pack, and packaged appropriately.
 Collect whole blood in a purple top (EDTA) tube – green or red top tubes
acceptable if purple not available
 Preferred sample volume = 4ml (minimum sample volume = 2ml)

Has this patient had a sample submitted previously?
Sample 1:

Yes

Do not complete
UVRI Only

Sample 2:

Sample Collection Date: ____/____/______

(D, M, Yr)

Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Other specimen type, specify: ________________

Section 6.

No
Do not complete
UVRI Only

Sample Collection Date: ____/____/______ (D, M, Yr)
Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Other specimen type, specify: ________________

Case Report Form Completed by:

Name: ______________________________ Phone: _________________________ E-mail: _______________________________
Position: _____________________________ District: _____________________ Health Facility: ____________________________
Information provided by:
Patient
Proxy; If proxy, Name:______________________ Relation to Patient: ___________________

Outbreak
Case ID:

Case
Name:

**If the patient is deceased or has already recovered from illness, please fill out the next section.
**If the patient is currently admitted to the hospital, leave the next section blank (it will be completed upon discharge)

Section 7.

Patient Outcome Information

Please fill out this section at the time of patient recovery and discharge from the hospital OR at the time of patient death.
Date Outcome Information Completed: ____/____/_____ (D, M, Yr)
Final Status of the Patient:

Alive

Dead

Did the patient have signs of unexplained bleeding at any time during their illness?
Yes
No
Unk
If yes, please specify: _______________________________________________________________________________
If the patient has recovered and been discharged from the hospital:
Name of hospital discharged from: _______________________________ District: _________________________________
If the patient was isolated, Date of discharge from the isolation ward: ____/____/______ (D, M, Yr)
Date of discharge from the hospital: ____/____/______

(D, M, Yr)

If the patient is dead:
Date of Death: ____/____/______ (D, M, Yr)
Place of Death:
Community
Hospital: _______________________
Other: ________________________________
Village: _______________________ District: _________________________ Sub-County: _______________________
Date of Funeral/Burial: ____/____/______ (D, M, Yr)
Funeral conducted by:
Family/community
Outbreak burial team
Place of Funeral/Burial:
Village: _______________________ District: _________________________ Sub-County: _______________________
Please tick an answer for ALL symptoms indicating if they occurred at any time during this illness including during hospitalization:

Fever

If yes, Temp: ____º C Source:

Axillary

Vomiting/nausea
Diarrhea
Intense fatigue/general weakness
Anorexia/loss of appetite
Abdominal pain
Chest pain
Muscle pain
Joint pain
Headache
Cough
Difficulty breathing
Difficulty swallowing
Sore throat
Jaundice (yellow eyes/gums/skin)
Conjunctivitis (red eyes)
Skin rash
Hiccups
Pain behind eyes/sensitive to light
Coma/unconscious
Confused or disoriented

Yes

No

Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Oral

Rectal

Other non-hemorrhagic clinical symptoms:
Yes
No
If yes, please specifiy: ____________________________

Unk

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Appendix 2:

CONTACT TRACING FORM

Public reporting burden of this collection of information is estimated to average 3 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 (0920-1011)

*8,1($ VIRAL HEMORRHAGIC FEVER CONTACT LISTING FORM
Case Information
UVRI/MoH
Case ID

Surname

Other Names

Head of Household

Village

Sub-County

District

Date of
Symptom
Onset

Date of
Admission to
Isolation

Date of Death

**For all information on location, please list information on where the contact will be residing for the next month.

Contact Information
Surname

Other
Names

Sex Age Relation
(M/F) (yrs) to Case

Date of
Last
Contact
with Case

Type of
Contact
(1,2,3,4)*
list all

Head of
Household

Village

District

SubCounty

LC1
Chairman

Phone Number

Healthcare
Worker (Y/N)
If yes, what
facility?

*Types of Contact:
1 = Touched the body fluids of the case (blood, vomit, saliva, urine, feces)
2 = Had direct physical contact with the body of the case (alive or dead)
3 = Touched or shared the linens, clothes, or dishes/eating utensils of the case
4 = Slept, ate, or spent time in the same household or room as the case

Contact Sheet Filled by:

Name: ___________________________________ Position: ___________________________ Phone: ________________________

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Human Parechovirus 3 (HPeV3) Investigation
Family Interview Questionnaire

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333;
ATTN: PRA (0920-1011)

Please note that this questionnaire has 17 pages and contains 8 parts:
Part A: Demographic information about the infant who was ill with HPeV3
Part B: Summary of mother’s peripartum period
Part C: Summary of infant’s illness with HPeV3
Part D: Review of infant’s general health
Part E: Infant’s surroundings and household contacts in the week before illness
Part F: Family and friend visits in the week before illness
Part G: Childcare or healthcare worker visits in the week before illness
Part H: Other information

Interview form for ___________________________________________ (please insert infant’s name)
Date of interview: ________________ (MM/DD/YYYY)
Name of interviewer: _________________________________________________________
Interviewer’s institution: ______________________________________________________
Primary interviewee (eg mother): ________________________________________________
Phone number to call: ________________________________________ Home
________________________________________ Cell
________________________________________ Work
________________________________________ Other

Secondary interviewee (eg father): _______________________________________________
Phone number to call: ________________________________________ Home
________________________________________ Cell
________________________________________ Work
________________________________________ Other

1

When initiating the interview, please use the following paragraph:

As we have previously discussed over the telephone, we are here today because we are investigating
recent cases of infants diagnosed with parechovirus. We are working on this together with colleagues
at Children’s Mercy hospital, the CDC and the Kansas and Missouri state health departments. We are
hoping to understand more about what happened around the time of the illness, and we hope that
this will help us to understand parechovirus infections better and prevent future transmission.
Just to confirm, are you willing to speak with me today about this?

¨Yes ¨No

Final interview was conducted with: _____________________________________________
Relationship to infant (case patient): ____________________________________________

2

Part A: HPeV3 case-patient information
Infant’s First Name: _______________________ ____
Infant’s Last (Family) Name: __________________________
Date of Birth: __________________ (MM/DD/YYYY)

Sex:

¨Female ¨Male ¨Unknown

First name of first parent/guardian: _____________________________________
Last (Family) name of first parent/guardian: ______________________________
Email address: ___________________________________________________
Residence address: __________________________________________________________________
__________________________________________________________________________________

First name of second parent/guardian: _____________________________________
Last (Family) name of second parent/guardian: ______________________________
Email address: ___________________________________________________
Residence address: __________________________________________________________________
__________________________________________________________________________________

3

Part B: Summary of mother’s peripartum period
The questions below are directed towards the mother of the infant
Please adjust phrasing of questions according to who is being interviewed
I would first like to ask you a few questions about yourself and about the period of time from the week
before birth up to when your son/daughter became ill.
What is your date of birth? ___________________ (MM/DD/YYYY)

OR Age (years): ________

What is your occupation? _____________________________________________________________
Did you have any non-pregnancy-related illnesses during this period? Anything from a mild cold to
hospitalization is important here. (Cold, fevers, rashes, abdominal pain, diarrhea or vomitting). And
can you remember when that occurred?
(if rash is mentioned, please ask for a detailed description – location, duration and general descriptors
e.g. flat, raised, red, bumpy, scaly, blistering, fluid-filled blisters etc)

Did you seek medical care for any of these symptoms or illnesses at a doctor’s office, clinic, urgent
care center or hospital?
¨Yes ¨No
If yes, please describe:
(dates, hospital name, symptoms, admitted)

4

After the birth of your son/daughter, did you breastfeed him/her?

¨Yes ¨No

Has the baby been exclusively breast fed since birth?

¨Yes ¨No

If no, did you also use formula?

¨Yes ¨No

How often was formula used?

_______________________________________________________

Are you currently still breastfeeding him/her?

¨Yes ¨No

If no, for how long did you breastfeed him/her? __________________________________________
Is there a family history of neurologic disorders, including seizures?

¨Yes ¨No ¨Unknown

If yes, please describe:

Part C: Summary of infant’s illness
I will now ask a few questions about your son’s/daughter’s illness.
Date of first symptoms: ______________________ (MM/DD/YYYY)
What symptoms did your son/daughter first show?

5

Please describe any other symptoms that followed and when they occurred:

Was he/she at home when the illness began?

¨Yes ¨No ¨Unknown

If no, where was he/she? ____________________________________________________________
Did you seek medical care for any of these symptoms at a doctor’s office, clinic or urgent care center
before your son/daughter was admitted to hospital?
¨Yes ¨No
If yes, please give details (where, when, name of physician etc): _____________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

When did you take him/her to hospital? _____________________ (MM/DD/YYYY)
Hospital name: _____________________________________________________________________
Hospital floor and room number: ________________________________________________________
Admitting physician’s name: ____________________________________________________________
Were they transferred to another hospital?

¨Yes ¨No ¨Unknown

If yes, transfer date: _____________________ (MM/DD/YYYY)
If yes, receiving hospital name: ________________________________________________________
If yes, doctor’s name: ________________________________________________________________

6

Part D: Review of infant’s general health
Before your son/daughter became ill and required admission, was he/she on any medications?
Medication

For what reason?

Date Started
(MM/DD/YYYY)

Date stopped
(MM/DD/YYYY)

Before this illness, did you take your son/daughter to the hospital for any reason?

¨Yes ¨No

Before this illness, did you take your son/daughter to an outpatient clinic?

¨Yes ¨No

If yes to either, please describe (dates/hospitals/symptoms/providers):

7

Part E: Infant’s surroundings and household contacts in the week before illness
I would now like to ask you some questions about who your son/daughter might have had close contact
with in the week before their illness.
Does your infant (who was ill) attend day care?

¨Yes ¨No

¨Unknown

If yes, please describe the frequency of attendance, location/setting, the approximate number of other
children at the setting and the age of the other children at the setting:

If speaking to the mother, please skip to Person 2, under household contacts
Now I would like to ask you about the people who may have had contact with your child, starting with
yourself:
Person 1
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Occupation: ________________________________________________________________________
Were you ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did you have? _____________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
If yes, did you receive any treatment? ___________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
8

Household contacts
Could you now please describe the other members of your household, including both adults
and children:

Person 2
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ___________________________________

Occupation or school/preschool: ________________________________________________________
Were they ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did they have? _____________________________________________
__________________________________________________________________________________
If yes, did they seek medical care and where? _____________________________________________
__________________________________________________________________________________
If yes, did they receive any treatment? __________________________________________________
__________________________________________________________________________________

Person 3
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Occupation or school/preschool: ________________________________________________________
Were they ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did they have? _____________________________________________
__________________________________________________________________________________
If yes, did they seek medical care and where? _____________________________________________
__________________________________________________________________________________
If yes, did they receive any treatment? __________________________________________________
__________________________________________________________________________________
9

Person 4
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Occupation or school/preschool/day care: _______________________________________________
Were they ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did they have? _____________________________________________
__________________________________________________________________________________
If yes, did they seek medical care and where? _____________________________________________
__________________________________________________________________________________
If yes, did they receive any treatment? __________________________________________________
__________________________________________________________________________________

Person 5
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Occupation or school/preschool/day care: _______________________________________________
Were they ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did they have? _____________________________________________
__________________________________________________________________________________
If yes, did they seek medical care and where? _____________________________________________
__________________________________________________________________________________
If yes, did they receive any treatment? __________________________________________________
__________________________________________________________________________________

10

Person 6
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Occupation or school/preschool/day care: _______________________________________________
Were they ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did they have? _____________________________________________
__________________________________________________________________________________
If yes, did they seek medical care and where? _____________________________________________
__________________________________________________________________________________
If yes, did they receive any treatment? __________________________________________________
__________________________________________________________________________________

Person 7
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Occupation or school/preschool/day care: _______________________________________________
Were they ill in the week before your son/daughter became ill?
¨Yes ¨No
(please ask specifically about respiratory and diarrheal symptoms)

¨Unknown

If yes, what kind of symptoms did they have? _____________________________________________
__________________________________________________________________________________
If yes, did they seek medical care and where? _____________________________________________
__________________________________________________________________________________
If yes, did they receive any treatment? __________________________________________________
__________________________________________________________________________________

11

Part F: Family and friend visits in the week before illness
Were there any other family members or close friends who appeared unwell and who visited the infant
in the week prior to onset of illness? Or that you went to visit? Please include children too.
Person 8
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Occupation or school/preschool/day care: _______________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

Person 9
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Occupation or school/preschool/day care: _______________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

12

Person 10
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Occupation or school/preschool/day care: _______________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

Person 11
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Occupation or school/preschool/day care: _______________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

13

Person 12
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Occupation or school/preschool/day care: _______________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

Person 13
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Occupation or school/preschool/day care: _______________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please continue overleaf

¨Yes ¨No

¨Unknown

14

Part G: Childcare or healthcare worker visits in the week before illness
Were there any childcare or healthcare worker contacts who appeared unwell,in the week before
illness? (e.g. babysitter, pediatric provider, lactation specialist)
Person 14
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Reason for visit:_____________________________________________________________________
What kind of symptoms did the visitor have? _____________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

Person 15
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Reason for visit:_____________________________________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

15

Person 16
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Reason for visit:_____________________________________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please include details in the next person below

¨Yes ¨No

¨Unknown

Person 17
Name: ____________________________________________________________________________
Age: ________________

Relationship to infant: ____________________________________

Where did you see them? _____________________________________________________________
Reason for visit:_____________________________________________________________________
What kind of symptoms did they have? _________________________________________________
__________________________________________________________________________________
Did they seek medical care and where? __________________________________________________
__________________________________________________________________________________
Did they receive any treatment? _______________________________________________________
__________________________________________________________________________________
Do you know if they had any ill family members or friends?
If yes, please continue overleaf

¨Yes ¨No

¨Unknown

16

Part H: Other information
Is there any other information that you feel may be important or unusual, with regard to your
son’s/daughter’s illness or stay in hospital:

Thank you very much for taking the time to speak with me today. Your interview has been
extremely useful and we hope it will help us to better understand the current situation.
We might need to contact you again in the future to ask some more questions about this.
Would it be OK if I (or my colleagues) contacted you?
¨Yes ¨No

Collect diaper(s) if agreed.
Thank you very much for your help today.

End of interview form

17

`

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Human Parechovirus 3 (HPeV3) Investigation
Medical Chart Abstraction Form

Public reporting burden of this collection of information is estimated to average 65 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 (0920-1011)

Please note that this medical chart review form has 19 pages and contains four parts:
Part A: demographic information about the infant who was ill with HPeV3
Part B: information from the medical chart of the mother for labor, delivery and follow up
Part C: information from the medical chart of the infant during delivery and neonatal care
Part D: information from the medical chart of the infant following admission for HPeV3 illness
(most likely at Facility A)
Date of chart abstraction: ________________ (MM/DD/YYYY)
Name of person completing form: _________________________________________________________
Name and address of institution where this form was completed:
_____________________________________________________________________________________
_____________________________________________________________________________________

Part A: HPeV3 case-patient information
First Name: ____________________________

Last (Family) Name: _________________________

Date of Birth: __________________ (MM/DD/YYYY)
Race:

Ethnicity:

Sex:

¨Female ¨Male ¨Unknown

¨Asian
¨Black or African American ¨Native Hawaiian or Other Pacific Islander
¨American Indian or Alaska Native
¨White
(More than one box can be checked)
¨Hispanic ¨Non-Hispanic

First name of parent/guardian: _____________________________________
Last (Family) name of parent/guardian: ______________________________
Contact telephone number: ________________________________________
Email address: ___________________________________________________
Residence address: __________________________________________________________________
__________________________________________________________________________________

1

Part B: Mother’s medical record for labor, delivery and follow up
Medical record number: _____________________________
Hospital name: _____________________________________________________________________
Hospital floor: ____________________

Hospital room number ______________________

Date mother was admitted to hospital: ______________________ (MM/DD/YYYY)
Date of discharge: _____________________ (MM/DD/YYYY)

Mother’s First Name: ______________________________________
Mother’s Last (Family) Name: _______________________________
Mother’s date of birth: __________________ (MM/DD/YYYY)
Mother’s race:

Mother’s ethnicity:

OR

Mother’s age (yrs) ________

¨Asian
¨Black
¨Hawaiian/Pacific Islander
¨Native American/Alaskan
¨White
¨Other
(More than one box can be checked)
¨Hispanic ¨Non-Hispanic

Mother’s telephone number (if different to Part 1): _______________________________________
Mother’s residence address (if different to Part 1): _________________________________________
__________________________________________________________________________________
Mother’s type of health insurance ______________________________________________________
Does the mother have any pre-existing medical conditions?

¨Yes ¨No ¨Unknown

If yes, please describe:

2

Date of delivery: _____________________ (MM/DD/YYYY)

Time of delivery: _______________

Delivery ward: ______________________________________________________________________
Mode of delivery: ¨Vaginal delivery

¨Caesarean Section

¨Unknown

If vaginal, duration of membrane rupture prior to delivery (hours) ___________
Was a scalp monitor used during delivery? ¨Yes ¨No ¨Unknown
If yes, was there evidence of its use upon physical examination? ¨Yes ¨No ¨Unknown
(e.g. bruising, laceration)

Was the mother febrile (>38 °C) during delivery?

¨Yes ¨No ¨Unknown

Was the mother febrile (>38 °C) in the week before delivery?

¨Yes ¨No ¨Unknown

Did the mother have a rash during delivery?

¨Yes ¨No ¨Unknown

Did the mother have a rash in the week before delivery?

¨Yes ¨No ¨Unknown

If yes to any of the above, please include a description of the rash (eg location, type {maculopapular,
vesicular} etc):

Please list any medications prescribed to the mother in hospital (e.g. PRN medications, oxytocin,
antibiotics, anesthetics):
Medication

Dose and route

Date Started
(MM/DD/YYYY)

Date Stopped
(MM/DD/YYYY)

3

Medication

Dose and route

Date Started
(MM/DD/YYYY)

Date Stopped
(MM/DD/YYYY)

Please list staff present before and during labor or the delivery, and also post-partum care:
Name

Job Title

4

Any other comments regarding labor, delivery or post-partum care:

5

Part C: Infant’s chart for delivery and neonatal follow up
Medical record number: _______________________
Hospital name: ______________________________________________________________________
Infant’s First Name: _______________________ ____
Infant’s Last (Family) Name: __________________________
Date of delivery: _________________ (MM/DD/YYYY)

Time of delivery: ___________________

Length of gestation (weeks): _________
Infant’s Birth Weight (lbs): __________

¨Estimated

¨Measured

¨Unknown

Was resuscitation required at birth? ¨Yes ¨No ¨Unknown
If yes: ¨Suction

¨Oxygen

¨Positive pressure ventilation (PPV)

¨Intubation

Which nursery was the infant in after birth? _______________________________________________
How long was the infant in the nursery? ________ hours/days (please circle)

¨Unknown

Please list any staff who cared for the infant in the nursery:
Name

Job Title

6

Please list any medications prescribed to the infant during neonatal care:
Medication

Dose and route

Date Started
(MM/DD/YYYY)

Date Stopped
(MM/DD/YYYY)

Please describe any treatment regimens or interventions provided to the infant during neonatal care
(e.g. supplemental oxygen, respiratory therapy, supplemental feeding, circumcision, PRN meds etc):
Do not include intravenous fluids

7

Any other comments regarding the infant’s delivery or neonatal care:

Discharge date: __________________ (MM/DD/YYYY)
Status upon discharge: ________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

8

Part D: Medical chart of infant’s hospitalization for HPeV3 illness
Medical record number: __________________________________
Infant’s First Name: ______________________________________
Infant’s Last (Family) Name: _______________________________
Infant’s date of birth: __________________ (MM/DD/YYYY)
Date of testing for HPeV: __________________(MM/DD/YYYY)
Test type: ___________________________

Results: ________________________________

Admission date to hospital of initial presentation: ______________________ (MM/DD/YYYY)
Transfer date from hospital of initial presentation: ______________________ (MM/DD/YYYY)
Admission date to secondary facility: ______________________ (MM/DD/YYYY)
Transferred from:
Hospital name and nursery: ____________________________________________________________
Transferred to:
Hospital name and nursery: ____________________________________________________________
Please describe any patient information available from a referring facility, if applicable:

Did the infant have any underlying medical conditions?
If yes, please describe:

¨Yes ¨No ¨Unknown

9

Are outpatient visits prior to becoming ill noted in the chart?

¨Yes ¨No ¨Unknown

If yes, please describe:

Is family history of neurologic illness, including seizures, noted in the chart? ¨Yes ¨No ¨Unknown
If yes, please describe:

10

Please list any medications prescribed to the infant before hospitalisation (e.g. OTC meds used by
parents, medications discontinued prior to hospitalisation):
Medication

Dose and route

Date Started
(MM/DD/YYYY)

Place of
administration

Signs and Symptoms
Date of first clinical symptoms: ___________________ (MM/DD/YYYY)
As part of this illness, does the infant have or has the infant had any of the following:
Fever
Fever (>38 °C)………………………………………………………….. ¨Yes ¨No ¨Unknown
If yes, what was the highest temperature? _______ °C
Temperature <35 °C…….………………………………………….. ¨Yes ¨No ¨Unknown
If yes, what was the lowest temperature? _______ °C
Rash
Skin rash……..………………………………………………………….. ¨Yes ¨No ¨Unknown
If yes, please describe (eg. Location, type {maculopapular, vesicular} etc):_______________________
___________________________________________________________________________________
___________________________________________________________________________________
Redness on feet or hands ………………………………………… ¨Yes ¨No ¨Unknown
Ulcers or lesions in mouth……………………………………….. ¨Yes ¨No ¨Unknown
11

Neurologic
Focal seizures/convulsions…….……………………………. ¨Yes ¨No ¨Unknown
Generalized seizures/convulsions…….…………………….. ¨Yes ¨No ¨Unknown
Intractable seizures/convulsions…….…………………..….. ¨Yes ¨No ¨Unknown
Myoclonic jerk..………………………………………………………. ¨Yes ¨No ¨Unknown
Tremors.…………………………………………………………………. ¨Yes ¨No ¨Unknown
Limb weakness/monoparesis………………………………….. ¨Yes ¨No ¨Unknown
Stiff neck..……………………………………………………………….. ¨Yes ¨No ¨Unknown
Bulging fontanelle.………………………………………………….. ¨Yes ¨No ¨Unknown
Lethargy………………………………………………………………….. ¨Yes ¨No ¨Unknown
Irritability.……………………………………………………………….. ¨Yes ¨No ¨Unknown
Inconsolable crying…………………………………………………. ¨Yes ¨No ¨Unknown
Cranial nerve palsy………………………………………………….. ¨Yes ¨No ¨Unknown

Respiratory
Cough (dry, productive).….…………..………………………….. ¨Yes ¨No ¨Unknown
Secretions……………………………………………………………….. ¨Yes ¨No ¨Unknown
Runny nose.…………………………………………………………….. ¨Yes ¨No ¨Unknown
Sneezing………………………………………………………………….. ¨Yes ¨No ¨Unknown
Difficulty breathing………………………………………………….. ¨Yes ¨No ¨Unknown
Wheezing.……………………………………………………………….. ¨Yes ¨No ¨Unknown
Rales/crackles/crepitations.…………………………………….. ¨Yes ¨No ¨Unknown
Tachypnea (as assessed and recorded by provider)… ¨Yes ¨No ¨Unknown
If yes, please indicate rate ___________ (RR/min)
Frothy secretions from mouth..……………………………….. ¨Yes ¨No ¨Unknown
Hemoptysis.…………………………………………………………….. ¨Yes ¨No ¨Unknown
Respiratory failure.………………………………………………….. ¨Yes ¨No ¨Unknown
Oxygen given.………………………………………………………….. ¨Yes ¨No ¨Unknown
If yes, how was it administered? _______________________________________________________
Intubation……………………………………………………………….. ¨Yes ¨No ¨Unknown
Retractions, nasal flaring..……………………………………….. ¨Yes ¨No ¨Unknown

12

Cardiovascular
Bradycardia (as assessed and recorded by provider).. ¨Yes ¨No ¨Unknown
If yes, please indicate rate ___________ (HR/min)
Tachycardia (as assessed and recorded by provider).. ¨Yes ¨No ¨Unknown
If yes, please indicate rate ___________ (HR/min)
Variable heart rate (tachy/brady)……………………………. ¨Yes ¨No ¨Unknown
Cyanosis………………………………………………………………….. ¨Yes ¨No ¨Unknown
Mottled skin……………………………………………………………. ¨Yes ¨No ¨Unknown
Arrhythmia.…………………………………………………….……….. ¨Yes ¨No ¨Unknown
Abnormal heart sounds.………………………………………….. ¨Yes ¨No ¨Unknown
If yes, please describe ________________________________________________________________
Hypotension/shock………………………………………………….. ¨Yes ¨No ¨Unknown

Gastrointestinal
Vomiting………………………………………………………………….. ¨Yes ¨No ¨Unknown
Watery stools………………………………………………………….. ¨Yes ¨No ¨Unknown
Constipation..………………………………………………………….. ¨Yes ¨No ¨Unknown
Abdominal distention.…………………………………………….. ¨Yes ¨No ¨Unknown
Abdominal pain……………………………………………………….. ¨Yes ¨No ¨Unknown
Jaundice………………………………………………………………….. ¨Yes ¨No ¨Unknown
Poor feeding………………………………………………………… .. ¨Yes ¨No ¨Unknown

Others
Conjunctivitis.………………………………………………………….. ¨Yes ¨No ¨Unknown
Bleeding.………………………………………………………………….. ¨Yes ¨No ¨Unknown
Persistent crying………………………………………………………. ¨Yes ¨No ¨Unknown
Lymphadenopathy.………………………………………………….. ¨Yes ¨No ¨Unknown

13

Please describe any other symptoms not listed above, or any of note:

Laboratory Exams
Please list here all laboratory findings from admission:
Specimen
Collection Date

Specimen
type

Test type

Serum

AST(SGOT), ALT(SGPT),
GGT

Serum

T. BILI, direct bili

Serum

BUN, creatinine

Serum

Glucose

Serum

Creatinine Kinase

Serum

Sodium

Blood

HB/HCT

Blood

WBC

Blood

Neutros

Results (include reference range)

(MM/DD/YYYY)

14

Specimen
Collection Date

Specimen
type

Test type

Blood

Bands

Blood

Lymphs

Blood

Monos

Blood

EOS

Blood

PLTS

Blood

Culture

Blood

ANC

Blood

LDH

Blood

CRP

Blood

ESR

Results (include reference range)

(MM/DD/YYYY)

NP/OP/Throat Culture
Rectal/stool

Culture

Eye

Culture

Vesicle

Culture

Urine

Culture

Urine

UA

CSF

Opening pressure

CSF

RBC

CSF

WBC

CSF

Neutro

CSF

Lympho

CSF

EOS

15

Specimen
Collection Date

Specimen
type

Test type

CSF

Protein

CSF

Glucose

CSF

Gram stain

CSF

Culture

Results (include reference range)

(MM/DD/YYYY)

HPeV3-specific PCR
Enterovirus-specific PCR
HSV-specific PCR
Other virus PCR

Please describe below any other unusual laboratory results at admission

16

Radiologic Exams
Please describe here all radiological exams requested:
Exam date

Test type

Results

(MM/DD/YYYY)
CXR

CT

MRI

Echocardiography

Ultrasound

EEG

Plain abdominal
radiographs

17

Medication and Treatment
Was the infant placed in the neonatal intensive care unit (NICU)?
If yes, admission date: ________________

Discharge date: ________________ (MM/DD/YYYY)

Was the infant placed in the pediatric intensive care unit (PICU)?
If yes, admission date: ________________

¨Yes ¨No ¨Unknown

¨Yes ¨No ¨Unknown

Discharge date: ________________ (MM/DD/YYYY)

Please list any medications prescribed to the infant in hospital:
Medication

Dose and route

Date Started
(MM/DD/YYY)

Date Stopped
(MM/DD/YYY)

Please describe any other treatment regimens or interventions provided to the infant in hospital
(e.g. supplemental oxygen, respiratory therapy, supplemental feedings, PRN meds etc):
Do not include intravenous fluids

18

Discharge
Is infant still in hospital? ¨Yes ¨No

If no, discharge date: __________________(MM/DD/YYYY)

Status upon discharge: ________________________________________________________________
Died: ¨Yes ¨No ¨Unknown

If yes, date of death ___________________ (MM/DD/YYYY)

Discharge diagnosis: __________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Other information
Please describe here any other information that you feel may be important or unusual, with regard to
the infant’s stay in hospital:

End of medical chart abstraction form
19

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Human Parechovirus 3 (HPeV3) Investigation
Patient and Sibling Diaper Collection Instrument

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 (0920-1011)

Variables Collected in Database:
MO/KS:
Specimen ID:
Name:
DOB:
Diagnosis Date:
Collection Date:
Comments:
HPeV result:
MS2 result:
Repeat Result:
Final Result:
Time between collection/diagnosis:
30 day collection:
60 day collection:
Call 1
Call 2
Call 3
Call 4
Call 5

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 (0920-1011)

Form Approved; OMB No. 0920-1011; Exp Date: 03/31/2017

Formulaire d’évaluation des Formations de Santé
Nom de l’évaluateur _____________________________

Date de visite de la formation ____/_____/2014

Village/Ville __________________________________ Zone de Santé _________________________________________
Informations Générales:
1. Type de Formation Sanitaire: ____Hôpital de Référence

____Centre de Santé

____Poste de Santé

2. Nombre approximatif de Villages/Villes desservis ______________
Staff

Nombre de
chaque staff

Date de la dernière
formation? (Donner l’année)

Durée de la
dernière formation
(ex. 30mins)

Médecin
Infirmier
Sage-femme
Relais communautaires
Technicien de Labo
Hygiéniste
Educateur des masses
Autre (s)

3. Combien de fois la formation sanitaire est disponible/semaine? 1-2 fois
4. Nombre de patients desservis en moyenne/jour __________________
5. Ebola contrôle de l’Infection : Enumérer les éléments disponibles.
Il y a :
Une équipe designée pour prendre en charge les cas d’Ebola
Un livre sur Ebola est disponible
Un contact d’information avec le Médecin Chef de Zone (MCZ)
Comment entre en contact avec le MCZ ?

Oui Non
Oui Non
Oui Non
NA

Information sur l’Ebola disponible sur papier/poster, etc.
Vestiaire avec vêtements professionnels appropriés pour Ebola
Aire d’isolement du patient

Oui Non
Oui Non
Oui Non

Restriction des visiteurs pour les patients d’Ebola
Séparation du matériel médical des patients Ebola
Masques chirurgicaux pour patients Ebola
Des toilettes séparées pour patients Ebola
Un protocole de désinfection pour le matériel médical de
réemploi
Personnel choisi pour le nettoyage des pièces d’isolement

Oui
Oui
Oui
Oui
Oui

Non
Non
Non
Non
Non

3-4 fois

5-6 fois

Toujours

Information complementaire

__Radiophonie __Téléphonee
__Messenger
_Autre
__________

Si utilisée? ____Pièces séparées
____Bâtiments séparés
Citer les restrictions:

Oui Non

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)

Matériel de nettoyage séparé pour les patients Ebola (ex seau)
Accès facile pour se laver (Mains)
Capacité de transporter le patient à l’hôpital
Ravitaillement/Equipement pour la surveillance d’Ebola

Oui
Oui
Oui
Oui

Non
Non
Non
Non

Kit de prélèvement
Matériel de cargaison pour les échantillons
Formulaire de Surveillance
Frigo fonctionnel
Glaciaire/Boîtes pour transport des échantillons

Oui
Oui
Oui
Oui
Oui

Non
Non
Non
Non
Non

6.Equipement de protection personnelle

Nombre
d’équipement
disponible lors
de la visite

Nombre de ravitaillement au
moment de la visite

Source d’approvisionnement
(cocher ce qui convient)
Gouverne
ment

Gants (# de gants/cartons)
Blouse jettable (usage unique)
Masque à nez
Lunettes
Masques chirurgicaux
Bottes en caoutchouc
Savons
Désinfectant (énumérer ci-bas)
7. Disponibilté ou accès aux équipements énumérés ci-bas
Téléphone
¨
Radiophonie
¨
Générateur d’électricité
¨
Panneau solaire avec batterie
¨
Ordinateur
¨

2

NGO

Autre

A quand remonte le
dernier
approvisionnement des
articles

No. ______________

Form Approved; OMB No. 0920-1011; Exp Date: 03/31/2017

RECO Interview
1. Aire de Santé: __________________________ Village: __________________________
a. Nombre de population dans le village: _____________ habitants
b. Nombre des RECOs dans le village: __________________
c. Sexe: M F
d. Age:__________ ans
e. Niveau d’étude:_______________________________________
2. Depuis combien de temps etes-vous RECO? _____________________Mois/Annees
3. Comment vous etiez choisis comme RECO? ___________________________________
4. Quand aviez-vous appris de l’épidémie d’ebola?________________________________
5. Avez vous été formé sur ebola? ___________________________________________
a. Si oui, quand? _________________ b. Par qui? ___________________________
Si non, c’est interessant? OUI
NON
6. Avez-vous été appelés a aider pour un cas suspect Ebola?
OUI
NON
7. Si oui, où aviez-vous procuré les kits de protection?
OUI
NON
a. Si oui, quels étaient les materiels compris? _______________________________
b. Avez-vous besoin d’utiliser ceux-là?
OUI
NON
i. Si oui, dans quelle circonstance pourriez-vous les utiliser? _____________
_____________________________________________________________________
c. Avez-vous été formé pour l’utilisation des kits de protection? OUI
NON
d. Pouvez-vous expliquer comment les utiliser ? ____________________________
_______________________________________________________________________
8. Avez vous fait le suivi des contacts?
OUI
NON
a. Est-ce que vous etiez formé pour le suivi des contacts? OUI
NON
i. Si oui, par qui? ________________________________________________
b. Pouvez-vous m’expliquer pourquoi on suit les contacts? ____________________
_____________________________________________________________________
c. Que faites-vous si vous constatez que le contact a fait la fièvre? ______________
______________________________________________________________________

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)

9. Que pourriez-vous faire si vous decouvrez une personne malade dans la communauté,
et vous pensez que ce peut etre Ebola? _______________________________________
______________________________________________________________________
a. Qui pourriez-vous informer? _________________________________________
b. Comment le contacter? _______________________________________________
10. Est-ce-que vous etes informee des lieux ou communautes ou il y a Ebola? OUI NON
a. Qui vous donne ces informations?
_______________________________________________
b. Quand avez-vous recu les dernières informations? _________________________
11. Est-ce-que la population a peur ou s’inquiete d’ebola?
OUI
NON
a. Si oui, que pensez-vous etre à la base des inquietudes de la communauté? (Etre
malade, Etre dans le centre de santé en cas de maladie, Une famille qui tombe malade,
Soutien financier familial, souffrance, autre à preciser)

__________________________________________________________________
__________________________________________________________________
12. Votre communauté a recu des messages en provenance d’une organisation pour se
proteger elle meme contre Ebola? OUI
NON
a. Si oui, souviens-tu de cette organisation? ________________________________
b. Si non, est-ce-que c’est interressant pour la communauté? OUI
NON
13. Que comprends-tu d’Ebola? ________________________________________________
_______________________________________________________________________
_______________________________________________________________________
14. Comment quelqu’un peut-il attraper Ebola? ___________________________________
_______________________________________________________________________
15. Où recevez-vous la rémunération pour votre travail?
OUI
NON
a. Si oui, la quelle ou les quelles? _________________________________________
b. C’est suffisant pour vous?
OUI
NON
i. Pouquoi/Pourquoi pas?________________________________________
C’est tout! Merci beaucoup!

CDC Patient ID: _________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Chart Abstraction Form

Unique CDC Patient ID:____________________________________________

Patient Medical Record Number: _____________________________________

Patient Name : ___________________________________________________
DOB : ________________
Facility:__________________________
Case Collection date (for cases) : __________________________

Public reporting burden of this collection of information is estimated to average 12 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 (0920-1011)

1

CDC Patient ID: __________________

1. Is this patient a case or control?

□ Case □ Control

2. Dialysis Facility:
3. Chart abstractor:

□ CE □ ML □ KR □ PA □ SH □ Other:______

4. Information abstracted from (check all that apply):

□ Company EMR
□ Other Company records
□ Hospital records
□ Reprocessing records
□ Other: ______________________

Demographics
5. Age: _____________
6. Sex:

□M □ F

7. Race (Select all that apply):

□ American Indian/Alaska Native
□ Asian
□ Black or African American
□ Native Hawaiian or Other Pacific Islander
□ White
□ Unknown

8. Ethnicity:

□ Hispanic or Latino
□ Non-Hispanic
□ Unknown

Medical History
1. Date patient started ESRD __/___/___

□Y □N

2. Has patient had a kidney transplant?

3. Date that patient started at Company A: _________________

2

CDC Patient ID: __________________

4. Is the patient still attending Company A Clinics for dialysis (check for end date)?

□Y □N

5. Active dialysis access type(s) (check all that apply)

□ Fistula date inserted: ______________
□ Graft date inserted: ______________
□ Catheter date inserted: ______________
□ Other (specify) _____________________________

6. Comorbid Conditions:

□ Diabetes, DM □ Hypertension, HTN □ Congestive Heart Failure
□ Coronary artery disease, CABG, ASHD □ HIV / AIDS
□ Peripheral vascular disease, PVD or PAD □ Anemia
□ Cerebrovascular disease, TIA, stroke
□ Malnutrition, wasting
□ Cirrhosis, End-stage liver disease
□ Hepatitis C, HCV
□ Hepatitis B, HBV
□ Immunocompromised
□ Other, specify: _______________________________________________

7. Has this patient had a BSIs occurring after Sept1, 2012?

□ Yes □ No

8. Has this patient had an access site infections occurring after Sept1, 2012?

□

□

Yes
No
9. Has this patient had other relevant infections since Sept1, 2012?

□ Yes □ No

3

CDC Patient ID: __________________

10. If “Yes” to either 10, 11, or 12, list organisms and dates below (since Sept 1,
2012)

Type/source

Organism

date

antibiotics given?

___________________________________________________

□ Yes □ No

___________________________________________________

□ Yes □ No

___________________________________________________

□ Yes □ No

___________________________________________________

□ Yes □ No

Systemic Medications:

□ Coumadin/Warfarin □ Low Molecular Weight Heparin (Lovenox)
12. □ Aspirin
□ Other anticoagulant, specify

11.

(Dabigatran/Paradaxa) (Rivaroxaban/Xarelto) (Apixaban/Eliquis) (Plavix/Clopidogrel)

13.

□ Immunosuppressant medication, specify

Pre-dialysis, Dialysis and Post-Care
14. Access preparation, select one:

□ Alcohol
□ Antimicrobial Soap and Water Wash
□ ChloraScrub
□ ExSept Plus
□ Other
□ Shur-Clens

15. Anesthetic used:

□ Procaine

□ EMLA Cream

4

□ Betadine
□ ChloraPrep
□ Chlorhexidine
□ Hibiclens
□ Phisohex

CDC Patient ID: __________________

□ None
□ Other
□ Xylocaine
□ Lidocaine
□ Ethyl Chloride Spray
16. Dialysis access type used for this dialysis session (check only one):

□ Fistula □ Graft □ Catheter
□ Other (specify) ______________________________

17. Date of session: ________________________________
18. Dialysis session number:
19. Day of Session: ______________________
20. Dialysis station: ______________________________________________
21. Dialysis machine number: _____________________________________
22. Shift of session: _____________________________________________
23. Unit\Room: _________________________________________________

24. Dialyzer type/Brand:

□ Exeltra 150
□ Optiflux F160NR
□ Optiflux F180A
□ Exeltra NR 150
□ Exeltra Plus 210
□ Optiflux F180NR
□ Gambro Polyflux 24R 1240 □ Optiflux F200A

□ Optiflux 200NR
□ Optiflux 250NR
□ Revaclear Max
□ Rexeed 25R

25. Dialyzer confirmed:

□ Yes

□ No

26. Manufacturer label intact/legible:

□ Yes

□ No

27. Integrity/appearance intact:

□ Yes

□ No

28. Sterliant present:

□ Yes

□ No

5

CDC Patient ID: __________________

29. Reusable label legible/intact/complete:

□ Yes

□ No

30. Dry pack:

□ Yes

□ No

31. Did the patient show signs/symptoms of infection during dialysis sessions in the

□ Yes □ No

last week prior to this session?

□ Yes

32. Was this a reusable dialyzer?
If YES to reuse dialyzer,

a. Was this the first time the dialyzer was used?
b. Was dialyzer reprocessed prior to this use?
If YES,
i. Date last reprocessed: Date:
/

□ No
□ Y □ N □ Unknown
□ Y □ N □ Unknown
/

Time: ________

33. Usage count:
34. Has the patient received antibiotics in the week prior to session?

□ Yes □ No

35. Has the patient missed any sessions in week prior to session?

□ Yes □ No

If yes, select reasons (on following page):

□ Out of town
□ Hospitalization
□ personal reason

□ Illness, not requiring hospitalization
□ Unknown
□ Access problem
□ Other

36. Has the patient been hospitalized in the week prior to session?
a. If Yes, was the reason for hospitalization due to infection?

□ Yes □ No
□ Yes □ No

37. Any symptoms before dialysis started?:

□ Yes □ No □ Unknown

a. If Yes, check all that apply:

□ Fever (>100F then Tmax: _______)
6

□ nausea/vomiting

CDC Patient ID: __________________

□ Chills/cold
□ Low blood pressure (<100/60)
□ Other: ___________________
b. If Yes, date symptoms started__________________
38. Start time of dialysis:____________
39. End time of dialysis:_____________
40. Did any events occur during dialysis?:

□Y□N

a. If Yes, check all that apply:

□ Fever(>100F, Tmax: _______)
□ nausea/vomiting
□ Chills/cold
□ Low blood pressure (<100/60)
□ Equipment Malfunction(s):
□ Other:

41. If Yes, was dialysis discontinued prematurely?

□ Y □ N □ Unknown

□Y□N

42. Did any events occur post-dialysis?:
a. If Yes, check all that apply:

□ Fever (>100F, Tmax: _______)
□ nausea/vomiting
□ Chills/cold
□ Low blood pressure (<100/60)
□ Other:

b. If Yes, date symptoms started__________________
43. Describe post-dialysis access care (Dressing type or ointment used, etc.)
a. Was a new dressing applied:

□ Y □ N □ Unknown

44. Was patient sent to a hospital directly after this dialysis session?
(check patient status under patient log post-dialysis)

□Y□N

7

CDC Patient ID: __________________

Hospital Name/Location:
a. Was the reason for hospitalization related to infection?

□ Y □ N □ Unknown

45. Were blood cultures ordered (orders on left menu)?

□ Yes □ No

a. If Yes, why were the blood cultures ordered

□ clinical symptoms of infection
□ follow-up from prior infection/hospitalization
□ other, specify

46. Parenteral Medications/infusates given during dialysis: (visit log, orders)

□ Yes □ No
Zemplar
□ Yes □ No
□ Yes □ No
Heparin
Saline Flush □ Yes □ No

Aranesp

Epogen

Antibiotics (list):

Ferrlecit
Hecterol
Calcium

□ Yes
□ Yes
□ Yes
□ Yes

□ No
□ No
□ No
□ No

□ Yes □ No

Other IV/IM medications (list):

47. Was antimicrobial ointment applied:

□ Y □ N □ Unknown

a. If yes, describe: ___________________________________________

Reprocessing Information
48. Was the header removable?

□Y □N

8

CDC Patient ID: __________________

49. Who was the person who reprocessed it (NOT in SPIN): ________________
50. Renatron machine number: _______
51. Was reprocessing done on-site (NOT in SPIN)?

□ Y □ N □ Unknown

a. If No, List location __________________________
52. Regarding the following questions:

□ Y □ N □ Unknown
Did the patient give consent for dialyzer reuse? □ Y □ N □ Unknown

a. Was the dialyzer preprocessed?
b.

c. Was dialyzer refrigerated before most recent reprocessing?

□ Y □ N □ Unknown

a.

Was dialyzer stored after reprocessing?

□ Y □ N □ Unknown

b.

Was a germicide check documented?

□ Y □ N □ Unknown

9

CDC Patient ID: __________________

Outcome Information
53. Collection date of first positive culture meeting case
definition:_________________________________
a. Culture results:

□ B. cepacia
□ P. aeruginosa
□ R. pickettii
□ S. maltophilia
□ Other organism (list): _______________________________

54. Was patient started on antibiotics within 1 week after blood draw or immediately
upon display of signs and symptoms?

□ Y □ N □ Unknown

If Yes,
a. List additional antibiotics
(Name
/

Start Date/Time)

i. _____________________________________________________
ii. _____________________________________________________

55. Was the patient admitted to the hospital within 1 week of culture results/draw?

□Y □N

If YES, answer the following questions related to that hospitalization:
a. Name of hospital: _________________
b. If yes, to what kind of ward?

□ ICU □ non-ICU ward □ Unknown

c. Admission date: ________________ to Discharge date:_______________

d. Was the reason for admission related to infection?

□Y □N

e. Did the patient develop sepsis / hypotension requiring pressors:

□

□

56. Deceased:
Yes
No
a. If Yes, date of death: ________________

10

□Y □N

CDC Patient ID: __________________

57. Other outcomes:

□ Catheter infected
□ Graft infected
□ Catheter removed
□ Graft removed
□ Others: _________________________________________

11

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Reuse and Reprocessing Checklist

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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Reuse and Reprocessing Checklist
Note with a G when a glove change occurs
Note with an H when hand hygiene happens

Initial Steps
1. Put on PPE
2. Perform hand hygiene and put on gloves
3. Cut the venous line 1 to 2 inches above the venous drip chamber and discard the arterial blood
line
4. Place the dialyzer in the holder above the reuse sink with a blood line secured and free of kinks
5. Remove port caps
a. Are caps placed immediately into disinfectant for later reuse?
b. Was a weight insert used to ensure the caps are totally immersed?
6. Connect the dialysate RO water line to the lower dialysate port
7. Connect the tubing segment to the upper dialysate port, near the venous header
8. Turn the dialysate RO water switch on

Next steps (note the order of operations, which is done first, header cleaning or reverse
ultrafiltration?: ______________________________________________
1. Put on PPE
2. Perform hand hygiene and put on gloves
3. Stop the flow of water going through the venous dialysate port to begin reverse ultrafiltration
(attach a plug to the Hansen connector)
4. Leave the dialyzer under reverse ultrafiltration until the water exiting the dialyzer is clear
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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
5. Turn the dialysate RO water switch OFF and release the pressure from the dialysate
compartment
6. Remove lower dialysate RO line and return to panel
7. Remove the header cap using only AAMI standard RO water to facilitate the removal of blood
clots or rinse header areas
a. Are they manually cleaning the header with wipes or a cloth?
b. Are they manually cleaning the o ring with wipes or a cloth?
c. Did they perform this process for both headers?
d. Was the uncapped dialyzer end dipped into the disinfectant solution (Fresenius best
practices)?
8. Once the header caps have been cleaned, the cap and o-ring must be separate and immersed
in a 1% peracidin solution
a. Were headers or o-rings from multiple dialyzers placed into the same disinfectant
solution simultaneously?
b. Did the tech ensure the entire header cap and o-ring was submerged? (no floating
pieces)
9. While insuring proper o ring alignment, reassemble the header caps
a. Did they rinse off either the header or O-rings prior to re-assembly?
b. Were the headers and O-rings placed back on their respective dialyzers?
c. Are they using a wrench to tighten the header cap?
d. What is the orientation of the dialyzer during recapping (uncapped end facing up or
down, Fresenius best practices)?

Remaining Cleaning
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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
10. Using a disinfected segment, connect the RO water line to the arterial blood port and turn the
water ON.
11. Stop the flow of water going into the blood compartment and clamp the tubing from the venous
blood port
12. Re-attach the venous blood tubing to the top of the dialyzer venous blood port
13. Remove the RO line from the arterial blood port and allow fluid to drain from the arterial blood
port
14. Was the dialyzer wiped with bleach wipe thoroughly before being placed in the holding station?

Post-Renatron Storage
1. Was the dialyzer capped using caps cleaned in disinfectant?
2. Was the dialyzer stored in the cubby hole with the dialysate ports facing up?

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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

2014 CNS COLORADO CLUSTER
BRAIN MRI FINDINGS
MRN Number
Click here to enter text.
What date did the neurologic symptoms onset?
Click here to enter a date.
Was this patient a case?
Choose an item.
Was a brain MRI performed?
Choose an item.
Did the brain MRI show a supratentorial lesion?
Choose an item.
Did the brain MRI show a brainstem lesion(s)?
Choose an item.
Did the brain MRI show a midbrain lesion(s)?
Choose an item.
Did the brain MRI show a pons lesion(s)?
Choose an item.
Did the brain MRI show a dorsal pons lesion(s)?
Choose an item.
Did the brain MRI show a medulla lesion
Choose an item.
Did the brain MRI show any other cerebellar lesion(s)? Choose an item.
Did the brain MRI show a cranial nerve lesion(s)?
Choose an item.
Please describe any additional comments regarding the MRI of the brain:
Click here to enter text.

NEURORADIOLOGICAL FINDINGS
CERVICAL-THORACIC MRI FINDINGS
Was a CT spine MRI performed?
Choose an item.
What date as the CT spine MRI performed?
Choose an item.
Did the CT spine MRI show multilevel
Choose an item.
poliomyelitis?
Did the CT spine MRI show a conus lesion(s)?
Choose an item.
Please describe any additional comments regarding the MRI of the CT spine:

LUMB AR MRI FINDINGS
Was a L spine MRI performed?
Choose an item.
What date was the L spine MRI performed?
Choose an item.
Did the L spine MRI show a ventral nerve root enhancement?
Choose an item.
Please describe any additional comments regarding the MRI of the L spine:
Click here to enter text.

Public reporting burden of this collection of information is estimated to average 180 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 (0920-1011).

Last Modified: 1/12/2015 3:54 PM

1

2014 CNS COLORADO CLUSTER
DEMOGRAPHIC INFORMATION
MRN
Date of Neurologic Symptom Onset
Patient’s Age
Age Units
Patient’s Sex
Patient’s Race
Patient’s Ethnicity
Patient’s residential zip code

Last Modified: 1/12/2015 3:54 PM

Click here to enter text.
Click here to enter a date.
Click here to enter text.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Click here to enter text.

2

2014 CNS COLORADO CLUSTER
CLINICAL SYMPTOMS (PRE-NEUROLOGIC ONSET)MRN
Date of onset of neurologic symptoms
What was the patient’s past medical history?
Did the patient take any chronic medications?
Did the patient have chronic immunocompromised medications?
If the patient took chronic medications, please describe:
Click here to enter text.
Did the patient have any pets in their home?
Did the patient travel outside of their state in the last month?
Did the patient have a wilderness exposure in the last month?
If the patient travelled outside their state in the last month, what was their travel destination?
(city, state, country)
Was the patient vaccinated for polio?
Did the patient receive any vaccinations in the last month?
Please specify, if the patient received any vaccinations in the last month:
Click here to enter text.
Did the patient have a previous acute illness in the past month?
If patient had a previous acute illness, what was the date did the illness onset?

Last Modified: 1/12/2015 3:54 PM

Click here to enter text.
Click here to enter a date.
Choose an item.
Choose an item.
Choose an item.

Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.

Choose an item.
Choose an item.

3

2014 CNS COLORADO CLUSTER
CLINICAL SYMPTOMS CONTINUED
Did the patient have a fever (>38.0)?
What was the patient’s highest temperature?
Describe acute illness: Fatigue?
Describe acute illness: Headache?
Describe acute illness: Photphobia?
Describe acute illness: Red eyes?
Describe acute illness: Ear pain?
Describe acute illness: Runny nose?
Describe acute illness: Cough?
Describe acute illness: Shortness of breath?
Describe acute illness: Sores around the pharynx?
Describe acute illness: Sores Throat?
Describe acute illness: Abdominal pain?
Describe acute illness: Nausea/Vomitting?
Describe acute illness: Anorexia?
Describe acute illness: diarrhea?
Describe acute illness: Rash?
Describe acute illness: Generalized muscle pain?
Describe acute illness: joint pain?
Describe acute illness: neck pain?
Describe acute illness: back pain?
Describe acute illness: arm pain?
Describe acute illness: leg pain?
Medication for acute illness: acetaminophen
Medication for acute illness: NSAIDS
Medication for acute illness: albuterol
Medication for acute illness: corticosteroids
Medication for acute illness: please specify
corticosteroids
Medication for acute illness: antibiotics
Medication for acute illness: please specify
antibiotics
Time between acute illness and neurologic onset
(days)

Last Modified: 1/12/2015 3:54 PM

Choose an item.
Click here to enter text.
Choose an item.
Choose an item.
Choose an item.
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Choose an item.
Choose an item.

4

2014 CNS COLORADO CLUSTER
NEUROLOGIC SYMPTOMS
Medical Record Number:
Date of neurologic symptom onset :

Click here to enter text.
Click here to enter a date.

Please describe initial neurologic symptoms:
Click here to enter text.
Did the patient experience any of the following at onset of neurologic symptoms?
Altered mental status: Unknown
Diplopia:
Choose an
item.
Abnormal nystagmus: No
Increased reflexes:
Choose an
item.
Facial weakness: Choose an
Neck pain:
Choose an
item.
item.
Palatal weakness: Choose an
Back pain:
Choose an
item.
item.
Tongue weakness: Choose an
Arm pain:
Choose an
item.
item.
Neck weakness: Choose an
Leg pain:
Choose an
item.
item.
Respiratory weakness: Choose an
General numbness:
Choose an
item.
item.
Arm weakness: Choose an
Face numbness:
Choose an
item.
item.
Leg weakness: Choose an
Arm numbness:
Choose an
item.
item.
Bowel incontinence: Choose an
Leg numbness:
Choose an
item.
item.
Bladder incontinence: Choose an
Sensory level
Choose an
item.
numbness:
item.
Date of Nadir:
Click here to enter a date.
Please describe neurologic symptoms at nadir:
Click here to enter text.
Did the patient experience any of the following neurologic symptoms at nadir?
Altered mental status: Choose an item. Diplopia:
Choose an
item.
Abnormal nystagmus: Choose an item. Increased
Choose an
reflexes:
item.
Facial weakness: Choose an item. Neck pain:
Choose an
item.
Palatal weakness: Choose an item. Back pain:
Choose an
item.
Tongue weakness: Choose an item. Arm pain:
Choose an
item.
Neck weakness: Choose an item. Leg pain:
Choose an
Last Modified: 1/12/2015 3:54 PM

Spasticity: Choose an
item.
Upgoing Choose an
toes: item.
Ataxia: Choose an
item.
Myoclonus: Choose an
item.
Difficulty Choose an
walking: item.

Spasticity:
Upgoing toes:
Ataxia:
Myoclonus:
Difficulty

Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
5

2014 CNS COLORADO CLUSTER
Respiratory weakness: Choose an item.
Arm weakness: Choose an item.

General
numbness:
Face numbness:

Leg weakness: Choose an item.

Arm numbness:

Bowel incontinence: Choose an item.
Bladder incontinence: Choose an item.

Leg numbness:
Sensory level
numbness:

item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.

walking:

item.

PERSISTENT NEUROLOGIC SYMPTOMS
Have upper motor neuron symptoms resolved?
Choose an item.
Date first noticed upper motor neuron symptoms resolved:
Choose an item.
Was the patient hospitalized? Choose an item.
Date of hospital admission: Click here to enter a
Date of discharge: Click here to enter a date.
date.
Was the patient admitted to the ICU? Choose an item.
Date of ICU admission Click here to enter
Date of ICU discharge: Click here to enter a date.
a date.
Was the patient intubated?
Choose an item.
Date patient was intubated: Click here to enter Date patient was extubated: Click here to enter a
a date.
date.
Did patient receive corticosteroids for neurologic symptoms?
Plasma exchange for neurologic symptoms:

Choose an
item.

Did the patient receive IVIG for neurologic symptoms?

Choo Date received steroids:
se an
item.
Start date of plasma exchange:

Click here to
enter a date.

Click here
to enter a
date.
Click here to
enter a date.

Choose
Start date of IVIG:
an item.
Did the patient receive an experimental drug for neurologic symptoms?:
Choose an item.
State date of Experimental drug: Click here to enter a date.
Please specify which experimental drugs were given:
Choose an item.
EMG Done:
Choose an item.
EMG Date: Click here to enter a date.
Specify results of EMG:
Click here to enter text.
Latest/Current status:
Click here to enter text.
Date of status Update:
Click here to enter a date.

Last Modified: 1/12/2015 3:54 PM

6

Appendix 1: Chart Abstraction Form

CDC ID: ___________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Patient Name: ________________________________________________________
CDC ID#:___________________________________________________________

Public reporting burden of this collection of information is estimated to average 60 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 (0920-1011)

Appendix 1: Chart Abstraction Form

CDC ID: ___________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Chart Abstraction Form
Name of Person Completing Form _____________________________

Date: ____/_____/____

Case
Control: Matched to case (CDC ID): _______
Date of specimen collection with first positive Pseudomonas aeruginosa culture (“onset date”) (for case
or matched control): __________________
30 day window period: ________ to _________ (onset date)
7 day window period: _________ to _________ (onset date)
Surveillance culture; Source ________________
Clinical culture; Source ________________
Pseudomonas Specimen Susceptibility
Antibiotic
Aztreonam

Sensitivity (Susceptible=S, Resistant=R)

Cefepime
Ceftazidime
Ciprofloxacin
Gentamicin
Imipenem
Meropenem
Pipercillin+Tazobactam

A. Demographic Information
Sex:
Male
Female
Race:
White
Black

Day of life at onset date:________________
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other____________
Ethnicity:
Hispanic/Latino
Non-Hispanic/Latino

B. Birth History
Gestational age: ____ wks ____ days
Birth:
C-section
Vaginal delivery
APGAR: 1min____ 5 min____

Birth weight: ______ grams or _____lbs.____oz.
Multiple birth
Assisted delivery: Forceps/vacuum

Appendix 1: Chart Abstraction Form
C. Maternal/ Obstetric History:

Chorioamnionitis
Cigarette smoking

Drug use:_____________

Fetal distress

CDC ID: _________

G____P____

Maternal infection
(within 3 days prior to
delivery)
Preeclampsia
Premature ROM

Gestational diabetes

IUGR

No prenatal care
Unknown
Other______________

Prolonged ROM

D. Medical History
1. Comorbidities within 7 days prior to onset date:
Unknown
Aspiration
Patent ductus arteriosis
Gastric residual >30%
Perinatal asphyxia
Intracran. hemorrhage
Reflux/ Regurgitation
Cardiac abnormalities (e.g., congenital heart disease): _________________________________
Pulmonary disease (e.g., BPD, HMD/RDS, meconium aspiration): ______________________
Gastointestinal disease (e.g., NEC, gastroschisis, omphalocele): _______________________
Other: _________________________________________________________________________

2. Did infant have any of the following within 7 days prior to onset date?

Unknown

GI surgery
Non GI surgery (specify: ________________________________)
Retinopathy of prematurity (ROP) treatment
Eye exam
Oro/nasogastric tube
G-tube
Jejunal tube
Supplemental O2
CPAP or BiPAP (non-invasive)
Other devices (not captured in Tables 4 or 5 below; specify): _______________________________
E. Medication/Device History

1. Was infant treated with any systemic antimicrobials within 30 days prior to onset date?
Yes
No
Antimicrobial

Unk

Route

Start Date(s)

Stop Date(s)

Appendix 1: Chart Abstraction Form

CDC ID: _________

2. Other medications received within 7 days prior to onset date?
Medication
Route
Mixed with water?*
Start Date(s)
Yes
No
Unk
*Source: ___________

Stop Date(s)

Yes
No
Unk
*Source: ___________
Yes
No
Unk
*Source: ___________
Yes
No
Unk
*Source: ___________
Yes
No
Unk
*Source: ___________
Yes
No
Unk
*Source: ___________
Yes
No
Unk
*Source: ___________

3. Other injectables received within 7 days prior to onset date?
Product

TPN

Receipt
Yes No Unk

Lipids

Yes

No

Unk

Maintenance Fluids

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Start Date(s)

Stop Date(s)

Appendix 1: Chart Abstraction Form

CDC ID: _________

4. Catheter within 7 days prior to onset date?
Catheter type
Umbilical catheter

Presence
Yes No Unk

PICC line

Yes

No

Unk

Other central venous
catheter (specify:

Yes

No

Unk

Peripheral venous
catheter
Arterial catheter
Urinary catheter
Other (specify:

Yes

No

Unk

Yes
Yes
Yes

No
No
No

Unk
Unk
Unk

Other (specify:

Yes

No

Unk

Other (specify:

Yes

No

Unk

Start Date(s)

5. Ventilation/Intubation within 7 days prior to onset date?
Start Date(s)

Yes

Stop Date(s)

No

Unk

Stop Date(s)

6. Blood products received (PRBCs, Platelets, FFP, other) within 7 days prior to onset date?
Yes No Unk
Product

Date(s)

Appendix 1: Chart Abstraction Form

CDC ID: _________

F. Nutrition History:
1. Did infant receive breast milk:
a. Within 7 days prior to onset date?
Yes No Unk
b. Ever?
Yes No Unk
2. Did infant receive formula milk?
a. Within 7 days prior to onset date?
Yes No Unk
b. Ever?
Yes No Unk
3. Did infant ever receive thickeners?
a. In breast milk?
Yes No Unk
b. In formula?
Yes No Unk
c. Strength used? (e.g., 1/2-strength, ¾ strength, honey-thick):_______________________________
4. Did infant receive any supplements?
a. Within 7 days prior to onset date?
Yes No Unk Describe: _______________
b. Ever?
Yes No Unk Describe: _______________
G. Clinical Information: Please fill out for case-patients only
1. Signs and Symptoms within 48 hours prior to or after onset date:
Symptom

Fever (T>37.5oC)
Low temp (T<36.5)
Diagnosis of sepsis (Clin Dx)
Feeding intolerance (Note)
Lethargy (Note)
Tachycardia (>180 bpm)
Tachypnea (>60 rpm)
Bradycardia (<80 bpm)
Increase frequency of apnea
Other:
_____________________
Other:
_____________________
Other:
_____________________
Other:
_____________________

Presence

Date of initial
finding

Different from
“baseline”
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk
Yes No Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

2. Laboratory findings within 48 hours prior to or after onset date:
Abnormal laboratory finding
Leukocytosis: WBC______
Leukopenia: WBC _______

Presence
Yes
Yes

No
No

Unk
Unk

Date of Initial
finding

Different from
“baseline”
Yes No Unk
Yes No Unk

Appendix 1: Chart Abstraction Form
Neutropenia: ANC______
Other (specify:
Other (specify:

)
)

CDC ID: _________

Yes
Yes
Yes

No
No
No

Unk
Unk
Unk

Yes
Yes
Yes

No
No
No

Unk
Unk
Unk

3. Microbiology findings: List all positive cultures (clinical and surveillance)
(Date range: Within 7 days prior to onset date until resolution of illness)
No cultures drawn
Source
Date of
specimen
collection

4. Outcomes:
Outcome
Ongoing illness
Colonization only
Death
If Yes, attributed to Pseudomonas?
If Yes, autopsy performed?

All cultures negative
Unknown
Surveillance culture?
Organism(s)
# Positive
Bottles/Bottles sent
(x/y)
Yes No Unk

Yes
Yes
Yes
Yes
Yes

Presence
No Unk
No Unk
No Unk
No Unk
No Unk

5. Pathology samples from surgery or autopsy available?
Description of pathology results from surgery or autopsy:

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Yes

No

Unk

Date (if applicable)

Yes

No

Unknown

______________________________________________________________________________

Appendix 1: Chart Abstraction Form

CDC ID: _________

______________________________________________________________________________
______________________________________________________________________________
H.

Bathing/skin care products used within 7 days prior to onset date
Bathing/skin care
Brand/Manufacturer
products used

I. Oral care products used within 7 days prior to onset date
Oral care products
Brand/Manufacturer
used

J. Healthcare personnel exposures within 3 days prior to onset date
Staff
Role

Date(s) of use if known

Dates

Date(s) of direct patient care
if known

K.Location/Environment
1. Location(s) of infant within 7 days prior to onset date (in this hospital)
Unit
Room #
Entrance Date

2. Bed type(s) of infant within 7 days prior to onset date (in this hospital)

Exit Date

Appendix 1: Chart Abstraction Form
Bed Type
Giraffe bed/incubator
Radiant warmer
Open crib or bassinette
Other
(specify:____________)
Other
(specify:____________)

CDC ID: _________

Yes
Yes
Yes
Yes

Use
No
No
No
No

Unk
Unk
Unk
Unk

Yes

No

Unk

Start Date

Stop Date

3. Humidification used within 7 days prior to onset date (in this hospital)?
Humidity level (max) ________
Source ____________________

Yes

L. POU filter in place for all 7 days prior to positive culture?

Unk

Yes

No

No

Unk

M. Notes/Remarks (Anything potentially relevant about hospital course not included above, including
patterns of medication/thickener use, patient course at home, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

N. Medical Chart Abstraction Form Complete?

Yes---- date of completion _____/_____/_____
No

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Health Care Practices Audit Forms

Public reporting burden of this collection of information is estimated to average 90 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 (0920-1011)

Checklist for Prevention of Central Line 
Associated Blood Stream Infections  
Based on 2011 CDC guideline for prevention of intravascular catheter-associated bloodstream infections:
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

For Clinicians: 
Promptly remove unnecessary central lines 

□

Perform daily audits to assess whether each central line is still needed 

Follow proper insertion practices 

□
□
□
□
□
□

Perform hand hygiene before insertion 
Adhere to aseptic technique  
Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile full­body drape) 
Perform skin antisepsis with >0.5% chlorhexidine with alcohol 
Choose the best site to minimize infections and mechanical complications 
o Avoid femoral site in adult patients 
Cover the site with sterile gauze or sterile, transparent, semipermeable dressings 

Handle and maintain central lines appropriately 

□
□
□
□
□

Comply with hand hygiene requirements 
Scrub the access port or hub immediately prior to each use with an appropriate antiseptic (e.g., chlorhexidine, povidone 
iodine, an iodophor, or 70% alcohol) 
Access catheters only with sterile devices 
Replace dressings that are wet, soiled, or dislodged  
Perform dressing changes under aseptic technique using clean or sterile gloves 

For Facilities: 
□
□
□
□
□
□

Empower staff to stop non­emergent insertion if proper procedures are not followed 
“Bundle” supplies (e.g., in a kit) to ensure items are readily available for use 
Provide the checklist above to clinicians, to ensure all insertion practices are followed 
Ensure efficient access to hand hygiene 
Monitor and provide prompt feedback for adherence to hand hygiene 
http://www.cdc.gov/handhygiene/Measurement.html 
Provide recurring education sessions on central line insertion, handling and maintenance 

Supplemental strategies for consideration: 
●
●
●

2% Chlorhexidine bathing 
Antimicrobial/Antiseptic­impregnated catheters 
Chlorhexidine­impregnated dressings 

National Center for Emerging and Zoonotic Infectious Diseases 
Division of Healthcare Quality Promotion  

HAND HYGIENE AUDIT TOOL
HAND HYGIENE ADHERENCE DURING HIGH RISK PATIENT CONTACTS
Monitor each clinical area for approximately 30 MINUTES
Hospital

Date

Start time

AM / PM (circle)

Section of Hospital (e.g. ER, adult inpatient, pediatric)
If Inpatient Ward, Ward ID

and number of patients in ward

Observer name

Location of observer within ward

Hand Hygiene Opportunities
Use tick marks to indicate what behavior was observed for each hand hygiene opportunity

Discipline
(see below)

No
Attempted
attempt without success

Attempted
with success

Comments

Discipline: MD=doctor or resident, RN=registered nurse, T=technician or allied health specialist, S=student
(medical or nursing)

Duration of observation period:

minutes

Total number of patients observed during audit:

GUIDE TO HAND HYGIENE OPPORTUNITIES
HIGH RISK FOR TRANSMISSION
Perform hand hygiene before and after each of the following tasks
DIRECT PATIENT CONTACT
•
Bathing and mouth care
•
Wound care or dressing changes
•
Repositioning patient
•
Direct patient assessment or care
•
Specimen collection (blood, urine, stool, sputum)
•
Toileting activities
•
Physiotherapy activities
•
Invasive procedures (including, but not limited to, insertion of central
or peripheral intravascular devices, lumbar puncture, intubation/
extubation, bladder catheterization, etc)
MODERATE RISK FOR TRANSMISSION *
Perform hand hygiene between patients
INDIRECT PATIENT CONTACT
•
Preparing and administering medications
•
Touching patient equipment at the bedside (eg. Blood pressure cuffs,
thermometers) but no patient contact
•
Transporting patient in a wheelchair or stretcher
•
After handling patient soiled linens
•
Before handling food
LOW RISK FOR TRANSMISSION *
Perform hand hygiene periodically
ENVIRONMENTAL CONTACT
•
Charting or log book entry
•
Attendance at rounds
•
Handling stock linens or supplies
•
After personal toileting

*These contacts/activities are not priority activities to monitor during your audits
Please make note of the following during this session.
Yes No
Posters promoting hand hygiene are visible
Clinical staff nails are short and clean
Hand washing areas are clean, operational,
and free from clutter
There is visible and easy access to hand
washing sinks or hand sanitizer
Soap dispensers are available at all hand
washing areas
Paper towels are available at all hand
washing stations

ADDITIONAL COMMENTS / OBSERVATIONS

Not applicable

Comments

FORM #:____________

USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE) FOR CONTACT PRECAUTIONS
Infection Prevention and Control Audit
Facility:

Date: DD_______ MM_______ YYYY________

Patient Unit:

Day of Week: S

Auditor (print):

Start time: ____:____ End time: _____:_____

M

T

W Th

F

S

Healthcare Worker Category (Circle #):
1 = Physician

7 = Physiotherapy

13 = Dietary

2 = Nurse

8 = Occupational Therapy

14 = Speech Language/ Audiology

3 = Healthcare Aide
4 = Social Worker

9 = Housekeeping

15 = Rec. Therapy

10 = Patient Transport

16 = Pharmacy

5 = Spiritual Care

11 = Radiology/DI Technician

17 = Other

6 = IV Team/ DSM

12 = Respiratory Therapy

Instructions: Select “Y” if activity was observed and completed appropriately; select “N” if activity was observed
and not completed appropriately. Select “Not observed” if you were not able to observe the activity.
Bed/Bed Space Location or Number ► ____________
Item

Compliance

Setup
1. Precaution signage visible before entering the room or bedspace

Y

N

Not observed

2. PPE supplies available immediately outside room or bedspace

Y

N

Not observed

3. Hand hygiene is performed immediately prior to putting on PPE

Y

N

Not observed

4. New single use PPE applied prior to entering room/space

Y

N

Not observed

5. PPE applied in appropriate sequence:
A. Gown
B. Gloves

Y

N

Not observed

6. Gown worn as indicated by Contact Precautions

Y

N

Not observed

7. Appropriate type of gown is worn (i.e., yellow isolation gown)

Y

N

Not observed

8. Gown securely tied at the neck and then waist

Y

N

Not observed

9. Gloves worn as indicated by Contact Precautions

Y

N

Not observed

Y

N

Not observed

11. PPE is removed within the isolation room

Y

N

Not observed

12. PPE is removed in a manner to prevent contamination

Y

N

Not observed

13. PPE is removed in appropriate sequence:
A. Gloves and gown removed
B. Hand hygiene performed immediately after removal of PPE

Y

N

Not observed

Y

N

Not observed

Putting On PPE

Use of PPE
10. PPE is only worn inside the isolation room/space
Taking Off PPE

Form Approved
0920-1011
Exp. Date 03/31/2017

Risk Reduction Approach on Burial Practices
Focus Group Guide

Question 1: Tell me about how people feel about Ebola.
[Probe - Are people concerned about Ebola? What is the concern around Ebola? How do you
think people are getting Ebola? Probe around burial practices. Are you concerned for Ebola in
your family, why or why not?]
Question 2: Before Ebola, when someone died, what happened? Please tell us about the
common burial practices.
[Probe – how is the body prepared, what do they wear, color of clothing, how many days, who
prayed, different steps regarding tradition and religion (get perspective from both Christians and
Muslims), who comes to the house, what is the most important]
Question 3: Ebola is here in Sierra Leone, what have you heard that we should be doing when
someone dies? [Probe around 117, safe medical burial]
Question 4: How do you feel about this?
[Probe: Are you worried that someone will hide the body because they do not want safe medical
burial.]
Question 5: There have also been messages asking people to stop the burial and attending
funerals during this Ebola problem. Why do you think that some people may not follow this
advice?
[Probe if reason is due to religious reasons, would it be disrespectful to your community if you
did not go to the funeral of someone important?]
Question 6: What would people do to the body after they called 117 and while they wait for the
burial team to come?
Question 7: Do you know what happens at the house as part of the safe medical burial? Do
you know what happens at the cemetery as part of the safe medical burial? [Probe – Are family
members allowed to participate in the safe medical burial. What are some rumors in reference
to the medical burial. Probe on their perception.]

Public reporting burden of this collection of information is estimated to average 75 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 (0920-1011)

Form Approved
0920-1011
Exp. Date 03/31/2017

Question 8: What will encourage people in this community to stop touch, wash, clean, kiss,
wrap the dead body? [Probe around why do you think people are still doing those behaviors.]
Question 9: What can we do to make the safe medical burial processes better?
[Probe: make sure body bags are white, having a religious rep present either at the home or at
the cemetery.]
Question 10: Do you have any recommendations for us on making safe medical burial process
more acceptable?
[Probe: who can be the people that can help explain the process or ease the process. Probe:
Religious leaders blessing? Village chief’s blessing? Marking at the grave. Having family
members present at the cemetery]
Questions 11: Do you know what happens to the house after the body is removed from the
house and buried at the cemetery? Do you know what happens to the other members of the
household?
[Probe around quarantine, contact tracing]
[Time permitting, consider ranking exercise]
I.

List out various burial practices.
a. Must Do according to custom
b. Should Do according to custom
c. Don’t have to do according to custom
II. Whiteboard that list out making burial process more acceptable came up from ranking
exercise.
III. Have participants place stickers next to the ones that are acceptable.

Public reporting burden of this collection of information is estimated to average 75 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 (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Health-care workers (HCWs) and Ebola Virus Disease (EVD) exposure risk:
Reporting form to be completed for EVD cases in HCWs in West Africa
Case ID Number..........................................

1. PATIENT (HCW) IDENTITY
Last name:........................................... First Name:........................................... Second Name:...........................................
Nickname:.............................................
Date of birth:.........../.........../...........(dd/mm/yy)
Age (years):...............
Sex:
M
F
Village/neighbourhood of residence:...................................../........................................ District:........................................
GPS coordinates of domicile: Latitude:........................................................ Longitude:.......................................................
Ordinary residence: Head of household (last and first name):................................................................................................
Full address (if known):.......................................................................................................................................................
Nationality:........................................................................ Ethnic group:...........................................................................
Case classification
Suspected
Confirmed

2. PATIENT’S OCCUPATION (tick the appropriate box and provide details if/when necessary)
Doctor
Nurse
Office staff
Laboratory staff
Cleaner
Morgue/burial staff
Midwife
Ambulance driver
Traditional healer
Community health worker
Other (specify):
.........................................................................................................................................................................................
Health-care facility (HCF) name:.....................................................................................
Primary work place at the time of infection:
Ebola Treatment Center
Outpatient setting
Service:

Ebola Care Unit
Laboratory

Public hospital

Other (specify):.............................................................................................

EVD Suspected Cases Unit
Maternity

“Transit”/“Holding” center

Laboratory

Blood Transfusion

EVD Confirmed Cases Unit
Medicine

Administration

General Care Unit

Paediatric
Morgue

Surgery

Emergencies

Other (specify):..................................

Additional work place (paid or voluntary) at the time of infection:
Ebola Treatment Center
Outpatient setting
Service:

Ebola Care Unit
Laboratory

Public hospital

Other (specify):.............................................................

EVD Suspected Cases Unit
Maternity

“Transit”/“Holding” center

Laboratory

Blood Transfusion

EVD Confirmed Cases Unit
Medicine

Administration

General Care Unit

Paediatric
Morgue

Surgery

Emergencies

Other (specify):..................................

None
Activities that may have led to exposure (tick all that apply):
Provided general patient care (took vital signs, examined patients, moved patients)
Fed patients or administered oral medications
Bathed or cleaned patients
Gave injections

Drew blood

Discarded sharps
Put in IV

Moved/transported patients
Performed fingerprick

Cleaned needle for re-use

Handled IV line (e.g., gave IV medications)

Cleaned blood spill
Handled lab specimens

Recapped needle

Cleaned patient room or ward
Controlled bleeding

Handled urinary catheter
Handled waste

Had contact with contaminated surfaces

page 1 of 3

Delivered babies
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).

Case ID Number..........................................
Performed invasive procedure
Performed minor surgery
Performed major surgery
Moved dead bodies
Performed autopsy
Cleaned or disinfected latrines
Handled linen or clothes or mattresses (cleaners)
Provided care to sick relatives or significant others
Other: (specify)............................................................................................................................................................

3. CONTACT WITH EVD PATIENT(S):
Has the HCW been in contact* with anyone who had suspected or confirmed EVD in the 3 weeks preceding
onset of symptoms?
Yes
No
Don’t know
If Yes, was the contact a (if multiple contacts, indicate ‘confirmed’ if at least one contact was a confirmed EVD case):
Suspected EVD case
Confirmed EVD case
If Yes, where (tick all that apply):
in an Ebola Treatment Center
in a private clinic/cabinet

Ebola Care Unit
in another HCF
at home
in the community

If Yes, specify relationship with HCW (tick all that apply):
Patient
Other HCW
Household member
Other friend or relative
None
If other HCW included in previous response, did the contact occur:
At work, in a patient care area
At work, in a non-patient care area (break room, office, nursing station, etc)
Outside work
Did the HCW attend the funeral of someone who might have died of Ebola in the 3 weeks preceding
the onset of symptoms?
Yes
No
If Yes, did the HCW participate in the preparation of burials involving touching the dead body,
with no adequate personal protective equipment (PPE)**?
Yes
No
If Yes, did the HCW provide care to any suspected Ebola patients in a private home (not in a HCF)?
Yes
No

4. MOST LIKELY EXPOSURE TO EVD
Did the HCW describe any single exposure situation that most likely led to infection?
If Yes, skip the next three questions and go to section 5
If No, specify the date:.........../.........../...........(dd/mm/yy)

Yes

No

Don’t know

Setting where suspected exposure occurred:
Ebola Treatment Center
Outpatient setting
Home

Ebola Care Unit
Laboratory

“Transit”/“Holding” center

Public hospital

Other type of HCF (specify):...............................................

Other community setting (specify):......................................................................................

Mode of exposure:
Needle stick

Scalpel cut

Blood/body fluid splash on eye

Blood/body fluid splash on intact skin

Blood/body fluid splash on non-intact skin

Blood/body fluid splash on mouth/lips

Other (specify)....................................

Contaminant:
Blood

Any body fluid with visible blood

Vomit or saliva

Faeces

Urine

Internal body fluids (circle which one [s]): cerebrospinal, synovial, pleural, amniotic, pericardial, peritoneal
Vaginal secretions

Seminal fluid

Other (specify):...................................................................

page 2 of 3

Case ID Number..........................................

5. INFECTION PREVENTION AND CONTROL ASPECTS OF PRIMARY WORK PLACE
Use of PPE and Standard Precautions:
At time of exposure, was any PPE used?
If Yes, which ones (tick all that apply):
Coverall (Tyvek-like)
Goggles
Cap

Yes

No
Single gloves

Face shield

Face mask

Waterproof apron
Hood

Don’t know
Double gloves

N-95 respirator or above

Closed resistant shoes

Leg covers

Yes

No

Gum boots

Don’t know

Were hand hygiene products available at the time of exposure
Yes
If Yes, which ones (tick all that apply):
Running (tap) water
Disposable towels

Shoe covers

Other (specify):......................................

Did the HCW apply duct tape to secure your PPE

Soap

Disposable gown

No
Don’t know
Chlorinated water from reservoir

Alcohol antiseptic

Was hand hygiene performed appropriately***?

Yes

At time of exposure, were safety boxes available?

No

Yes

Don’t know

No

Don’t know

On average, how many hours did you work while wearing PPE** in the isolation area?.....................................................
Have you been trained on infection prevention and control in the context of the Ebola outbreak?

Yes

No

Which organization led this training?
National Government

WHO

CDC

MSF

Other (specify):...................................................................................

UNMEER
Don’t know

*

Contact defined as the HCW touching, without proper personal protective equipment (PPE), a suspect or confirmed EVD
patient or their bodily fluids.
** PPE= gloves, impermeable gown or coverall, impermeable head cover with neck protection, rubber boots, face mask and
face shield or goggles.
*** Appropriate hand hygiene indications: before donning gloves and wearing PPE; before any clean/aseptic procedures; after
any exposure risk or actual exposure to the patient’s blood and body fluids; after touching (even potentially) contaminated
surfaces/items/equipment; after removal of PPE, upon leaving the care area.

Additional details of exposure or comments:....................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................
.........................................................................................................................................................................................

page 3 of 3
© The World Health Organization, 2014. All rights reserved.
WHO/EVD/caserep/14

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Rapid Anthropological Assessment
Topic Guide for Community Leader Focus Group Discussion

Public reporting burden of this collection of information is estimated to average 90 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 (0920-1011)

RAPID ANTHROPOLOGICAL ASSESSMENT
TOPIC GUIDE FOR COMMUNITY LEADER FGD
Community Knowledge about Ebola and Care-Seeking Behaviors
1. What are people in this community saying about Ebola? What are some of their concerns?
2. What do people do to prevent themselves or family members from getting Ebola?
3. What do people usually do if they think they or a family member has Ebola?
4. If a family member becomes sick with Ebola, what happens to people who live in the same
house?
4.1 What happens to the friends and neighbours they know?
5. What are some of the reasons people might not want to seek treatment if they think they
or a family member has Ebola?
6. Does this community have an Ebola Task Force? If yes, what is its role?
6.1 Which groups of people are on the Task Force?
Ebola-Related Services in the Community
7. What is the government doing to help people who get sick from Ebola?
8. What are other organizations doing to help?
9. What are the names of the ETUs that you know? What are people saying about the
different ETUs?
Community-Based Deaths
10. What happens if someone in the community dies at home? What do family members do?
10.1 What do community members do?
11. What do family members do if a child dies from Ebola at home? An adult? An elderly
person?
11.1 Do family members use a funeral home for the death of a child? For an adult?
12. If someone dies at home, how long do people usually keep the body at home?
12.1 Is there any stigma to keeping the body at home?

CDC and MOHSW_Rapid Assessment of Community-Based Deaths_Community Leader FGD Topic Guide_ 2014

3
13. Since this Ebola business started, has anyone died in this community? If yes, did they die at
home or somewhere else?
13.1 What happened to the body?
14. Have you ever heard that sometimes people bury the body secretly? If yes, ask:
14.1 Why do they do bury secretly and who conducts the secret burial?
14.2 How much do secret burials cost?
14.3 Have there been any secret burials in this community?
15. Which bodies are people more likely to bury in secret? Why?
16. What does the government say people should do if someone dies at home? Are people
supposed to call anyone? If so, who?
16.1 Do people follow the government’s advice? Why or why not? [If not mentioned, probe
about cremation policy]
FINAL COMMENTS OR SUGGESTIONS
17. What do you think the government should do about Ebola?
18. What do you think the government should do when people die at home?
19. Is there anything else about Ebola in this community or in Liberia that you would like to
mention or think we should know? Is there anything you think the government should
know?
COMMUNITY DEMOGRAPHICS
20. How many people live in this community?
21. How is this community organized in terms of leadership? What are the different leadership

positions and responsibilities? (E.g. Community chairperson, governor, other community
group leader, community members, etc.)
22. How are community leaders selected?
23. What different types of social groups or organizations are there in the community (e.g.
women’s groups, youth groups, etc.)?

CDC and MOHSW Rapid Assessment of Community-Based Deaths_Community Leader FGD Topic Guide_Dec 2014

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Rapid Anthropological Assessment
Topic Guide for Community Member Focus Group Discussion

Public reporting burden of this collection of information is estimated to average 90 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 (0920-1011)

RAPID ANTHROPOLOGICAL ASSESSMENT
TOPIC GUIDE FOR COMMUNITY LEADER FGD
Community Knowledge about Ebola and Care-Seeking Behaviors
1. What are people in this community saying about Ebola? What are some of their concerns?
2. What do people do to prevent themselves or family members from getting Ebola?
3. What do people usually do if they think they or a family member has Ebola?
4. If a family member becomes sick with Ebola, what happens to people who live in the same
house?
4.1 What happens to the friends and neighbours they know?
5. What are some of the reasons people might not want to seek treatment if they think they
or a family member has Ebola?
6. Does this community have an Ebola Task Force? If yes, what is its role?
6.1 Which groups of people are on the Task Force?
Ebola-Related Services in the Community
7. What is the government doing to help people who get sick from Ebola?
8. What are other organizations doing to help?
9. What are the names of the ETUs that you know? What are people saying about the
different ETUs?
Community-Based Deaths
10. What happens if someone in the community dies at home? What do family members do?
10.1 What do community members do?
11. What do family members do if a child dies from Ebola at home? An adult? An elderly
person?
11.1 Do family members use a funeral home for the death of a child? For an adult?
12. If someone dies at home, how long do people usually keep the body at home?
12.1 Is there any stigma to keeping the body at home?

CDC and MOHSW_Rapid Assessment of Community-Based Deaths_Community Member FGD Topic Guide_Dec 2014

3
13. Since this Ebola business started, has anyone died in this community? If yes, did they die at
home or somewhere else?
13.1 What happened to the body?
14. Have you ever heard that sometimes people bury the body secretly? If yes, ask:
14.1 Why do they do bury secretly and who conducts the secret burial?
14.2 How much do secret burials cost?
14.3 Have there been any secret burials in this community?
15. Which bodies are people more likely to bury in secret? Why?
16. What does the government say people should do if someone dies at home? Are people
supposed to call anyone? If so, who?
16.1 Do people follow the government’s advice? Why or why not? [If not mentioned, probe
about cremation policy]
Final Comments or Suggestions
17. What do you think the government should do about Ebola?
18. What do you think the government should do when people die at home?
19. Is there anything else about Ebola in this community or in Liberia that you would like to
mention or think we should know? Is there anything you think the government should
know?

CDC and MOHSW Rapid Assessment of Community-Based Deaths_Community Member FGD Topic Guide_Dec 2014

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Rapid Anthropological Assessment
Topic Guide for Contact Tracer Focus Group Discussion

Public reporting burden of this collection of information is estimated to average 60 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 (0920-1011)

RAPID ANTHROPOLOGICAL ASSESSMENT
TOPIC GUIDE FOR CONTACT TRACER FGD
1. What are people in the communities you visit saying about Ebola? What are some of their
concerns?
2. What are the job responsibilities of a contact tracer?
3. How do you know which people are contacts?
4. How do you know which homes to visit?
5. What do you do once you arrive at a home?
6. What kind of information do you collect?
7. Which forms do you fill out?
8. What do you do if the people refuse to provide the information?
9. What do you do if the contacts you are supposed to see are not at home?
10. What happens with the information you collect from the contacts you visit?
11. What Ebola safety precautions do you take while you are working?

Challenges of the Job

12. What are the biggest challenges of your job?
13. What was the reason you decided to work as a contact tracer?
14. How were you recruited?
15. How long have you had this job?
16. What type of training have you received for this job?
17. Who provided the training and how long did the training last?
18. What kinds of things did you learn?

CDC and MOHSW_Rapid Assessment of Community-Based Deaths_Contact Tracer FGD Topic Guide_Dec 2014

3
19. Have you received any refresher training? If so, how many times?
20. What kinds of things did you learn at the refresher training?

Final Comments or Suggestions

21. What do you think the government should do about Ebola?
22. What do you think the government should do when people die at home?
23. Is there anything else about your job or Ebola that you would like to mention or think we should
know? Is there anything you think the government should know?

CDC and MOHSW Rapid Assessment of Community-Based Deaths_Contact Tracer FGD Topic Guide_Dec 2014

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Rapid Anthropological Assessment
Topic Guide for Contact Tracer Supervisor Key Informant Interview

Public reporting burden of this collection of information is estimated to average 40 minute 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 (0920-1011)

RAPID ANTHROPOLOGICAL ASSESSMENT
TOPIC GUIDE FOR CONTACT TRACER SUPERVISOR KII
Community Knowledge about Ebola and Care-Seeking Behaviors
1. What are people in the communities you visit saying about Ebola? What are some of their
concerns?
2. What are your job responsibilities of a contact tracer supervisor?
3. How is your team notified about which contacts to follow?
4. How do they know which homes to visit?
5. What are contact tracers supposed to do once they arrive at a home?
6. What kind of information do they collect?
7. What are they supposed to do if the people they are supposed to see are not at home?
8. What do you do with the information the contact tracers collect?

Challenges of the Job

9. What are the biggest challenges of your job?
10. What was the reason you decided to work as contact tracer supervisor?
11. How long have you been a supervisor?
12. How were you recruited?
13. What type of training did you receive?
14. Who provided the training and how long did the training last?
15. Have you received any refresher training? If yes, when?
16. What kinds of things did you learn?

Final Comments or Suggestions

17. What do you think the government should do about Ebola?

CDC and MOHSW_Rapid Assessment of Community-Based Deaths_Supervisor KII Topic Guide_Dec 2014

3

18. What do you think the government should do when people die at home?
19. Is there anything else about Ebola in this community that you think I should know? Is there
anything you think the government should know?

Demographics
20. How old are you?
21. What is the last grade you completed in school?
22. Which languages do you speak?

CDC and MOHSW Rapid Assessment of Community-Based Deaths_Supervisor KII Topic Guide_Dec 2014

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Ebola Virus Disease Contact Tracing Form
State/Local ID:

CDC ID:

I. Interview Information
Date of interview: MM / DD / YYYY
Interviewer:
Interviewer Name (Last, First): _______________________________________________________________
State/Local Health Department: ______________________________________________________________
Business Address: ________________________________________________________________________
City: ________________________ State: ________ Zip: __________County: _______________________
Phone number: ________________________ Email address: _____________________________________
Contact:
Who is providing information for this form?
ÿ Contact
ÿ Other, specify person (Last, First): __________________________________________
Relationship to contact: __________________________
Reason contact unable to provide information: ÿ Contact is a minor

ÿ Other _______________

Contact primary language: _________________________
Was this form administered via a translator?

□ Yes □ No

II. Ebola Case Information (Case associated with Contact)
At the time of this report, is the patient?

□ Confirmed □ Probable □ Unknown

Date of illness onset of patient: MM / DD / YYYY
Notes:
Public reporting burden of this collection of information is estimated to average 45 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 (0920-1011)

III.

Contact Information

Last Name: ________________________________ First Name: ___________________________________
Home Street Address: __________________________________________________ Apt. # _____________
City: ________________________ County: _________________ State: _________ Zip: _______________
Time at current residence: ___________
Previous address (if less than 1 month at current residence):
Home Street Address: __________________________________________________ Apt. # _____________
City: _____________________County: ____________ State: ________

Zip: _______________

Country:_________________
Phone number: ________________________ Email address: _________________________________
Other Phone number or contact information:: ________________________________________________

IV. Contact Demographics
Date of birth: MM / DD / YYYY

Sex:

ÿ Male

Age:

ÿ Female

What is your occupation? _____________________ ÿ If HCW that provided care to Ebola patient or
worker (in any capacity including janitorial, lab, medical waste, food services, etc.)at a healthcare
facility that treated Ebola patient, skip to Section VII now
Place of work and address:
_______________________________________________________________________________________
_______________________________________________________________________________________
Do you have any pets in your household?:
ÿ Yes Give species and number_____________ ÿ No
NOTES:

V. Exposure History *Question assesses LOW exposure; †Question assesses HIGH exposure; ‡Question
assesses casual contact or NO KNOWN exposure; Note: direct contact requires contact with skin and or
mucous membranes.

1) What is your relationship to the patient?
 P a rtne r/s pous e

 Fa m ily m e m be r

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_____________

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2) *Do you live in the same house as the patient?

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3) Did you have any contact with the patient while he/she was ill?

If yes, please describe and provide dates of first and last contact (include description of any PPE used):
________________________________________________________________________________
________________________________________________________________________________
4) †Did you have any contact with blood or body fluids from the patient while he/she was ill (including
Ye sto Q5)No９ＣＨＪＧ
(skip
〦

contaminated objects or surfaces such as bedding or clothing)?
If yes, what body fluids were you in contact with? (check all that apply)
 Blood

Fe ce s

Vom it

 Te a rs

Re s pira tory s e cre tions

Urine

S we a t

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Last date of contact: MM / DD / YYYY (Skip to Section VI)
5) *Were you within approximately 3 feet of the patient or within his/her room or care area for a prolonged
period of time (at least one hour)?

Ye s

No

Uns ure

If yes, date of last contact: MM / DD / YYYY
6) *Did you have any direct contact with the patient (e.g. shaking hands) no matter how brief?
Ⅳ〦Ｈ
糎
糎 Date of last contact: MM / DD / YYYY (Skip to Section VI)
No

Uns ure

7) ‡Did you have any casual contact with the patient (meaning a brief interaction, such as walking by him/her
or being in the same room for a very short period of time) in which you did not directly touch him/her?
Ye s

No

Uns ure

If yes, date of last contact: MM / DD / YYYY

VI.

Activities During Period Of Exposure

Did you participate in any of the following activities with the patient while he/she was ill?
Caregiving
Did you take care of the patient when he/she was sick (e.g. bathe,
feed, help to bathroom)?

ÿYes ÿNo ÿUnsure

Did you do house cleaning or provide indirect care for the patient
(e.g. wash clothes or bedding, wash dishes)?

ÿYes ÿNo ÿUnsure

Sharing Meals
Did you eat meals with the patient?

ÿYes ÿNo ÿUnsure

Did you share utensils or a cup with the patient?

ÿYes ÿNo ÿUnsure

Other close contact
Did you use the same bathroom as the patient?

ÿYes ÿNo ÿUnsure

Did you sleep in the same room as the patient?

ÿYes ÿNo ÿUnsure

Did you sleep in the same bed as the patient?

ÿYes ÿNo ÿUnsure

Did you hug the patient?

ÿYes ÿNo ÿUnsure

Did you kiss the patient?

ÿYes ÿNo ÿUnsure

Transportation
Did you share any transport with the patient (car, bus, plane, taxi, etc.)?

ÿYes ÿNo ÿUnsure

If yes, give for all shared transport: Conveyance _______________________ Dates of travel:
________
Name of airline and flight number: _____________________________________________
Origin: _____________________ Destination: ___________________________________
Any transit points: __________________________________________________________

Notes:

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Ebola Exposure Assessment Questionnaire for Airline Passengers
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 contact is determined to have a fever ≥100.4° F, immediately call EOC at 770.488.7100.

Date of initial interview: ______/_____/______Interviewed by: ____________________________________
1. Last Name:

__________________ First Name: ______________________

Age:_____________

Sex: ____ Country of Birth: __________________ Country of Residence: ______
Travel Plans through insert date: _______________________________________
Street Address: ______________________________________________________ State: __________
Phone numbers- Home: _________________ Cell:__________________ Work:___________________
Circle flight(s) interviewee was on:

[Complete flight information]

[Complete second flight information]

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 (0920-1011)

Assigned seat number: _________________ Did interviewee move to a different seat?
Yes
If yes, which seat did interviewee move to? ___________ Document time in each seat:

No

_________________________________________________________________
2. Did interviewee have any interactions with sick passengers from this flight(s)?

Yes

No

If yes, describe this event including location, degree of contact (talking with or touching) and length of
time:______________________________________________________
3. Did interviewee have direct contact with body fluids of any passengers during the flight(s) circled above?
Yes

No (If no, skip to question 4)

If yes, describe the contact including location of the body fluid 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 during or after the flight(s) that the interviewee can recall when other
individuals were in contact with a person’s blood and/or body fluids?
Yes

No

If yes, please describe situation and location in the plane and/or airport:
_________________________________________________________________
5. Please check all symptoms interviewee has had since flight:
Fever ≥100.4° F

Sore throat

Body aches/muscle pain

Headache

Abdominal pain

Vomiting

Diarrhea

Weakness

Rash

Hiccups

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

6. Has interviewee travelled in any of the following countries within the last 21 days (check all that apply)?
Sierra Leone

Guinea

Liberia

Other

If any of the above countries are selected, please notify CDC by calling EOC. Contact will need to
complete additional brief interview with CDC SME involving in-country exposure risk.

__________________________________________________________________________
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 (intact or
broken) 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 any some risk or high risk exposures listed 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 by health department at least weekly.
Referred for medical evaluation due to presence of symptoms. If yes,
Where was (s)he referred? ______________________________________________________
What was the outcome? ________________________________________________________
Declined medical evaluation after it was recommended
Was interviewee placed under conditional release?

Yes

Was interviewee placed under state issued quarantine order?

No
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.

**No known risk may include passengers who were seated within 3 feet of the passenger for only a short amount of time.

Bridal Store Visitor Questionnaire
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

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 (0920-1011)

Daily Contact Symptom Follow-up Log
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

VII.

Contact Symptom Follow-Up Diary

1 day after last exposu 2 days after last expos 3 days after last
exposure
MM / DD / YYYY
MM / DD / YYY
MM / DD / YYYY
□ No symptoms
□ No symptoms
□ No symptoms
○
○
□ Fever ________ F
□ Fever ________ F
□ Fever ________○F
□ Chills
□ Chills
□ Chills
□ Weakness
□ Weakness
□ Weakness
□ Headache
□ Headache
□ Headache
□ Muscle Aches
□ Muscle Aches
□ Muscle Aches
□ Abdominal Pain
□ Abdominal Pain
□ Abdominal Pain
□ Diarrhea ____times/d □ Diarrhea ____times/ □ Diarrhea
____times/day
□ Vomiting
□ Vomiting
□ Unexplained hemorrha □ Unexplained hemorrh □ Vomiting
□ Other _____________ □ Other _____________□ Unexplained
hemorrhage
□ Other
_______________

4 days after last
5 days after last
exposure
exposure
MM / DD / YYYY
MM / DD / YYYY
□ No symptoms
□ No symptoms
○
□ Fever ________ F □ Fever ________○F
□ Chills
□ Chills
□ Weakness
□ Weakness
□ Headache
□ Headache
□ Muscle Aches
□ Muscle Aches
□ Abdominal Pain
□ Abdominal Pain
□ Diarrhea ____times □ Diarrhea
____times/day
□ Vomiting
□ Vomiting
□ Unexplained
□ Unexplained
hemorrhage
□ Other ____________ hemorrhage
□ Other
_______________

6 days after last expos 7 days after last expos 8 days after last
exposure
MM / DD / YYYY
MM / DD / YYYY
MM / DD / YYYY
□ No symptoms
□ No symptoms
□ No symptoms
□ Fever ________○F
□ Fever ________○F
□ Fever ________○F
□ Chills
□ Chills
□ Chills
□ Weakness
□ Weakness
□ Weakness
□ Headache
□ Headache
□ Headache
□ Muscle Aches
□ Muscle Aches
□ Muscle Aches
□ Abdominal Pain
□ Abdominal Pain
□ Abdominal Pain
□ Diarrhea ____times/d □ Diarrhea ____times/ □ Diarrhea
____times/day
□ Vomiting
□ Vomiting
□ Unexplained hemorrha □ Unexplained hemorrh □ Vomiting
□ Other _____________ □ Other _____________□ Unexplained
hemorrhage
□ Other
_______________

9 days after last
10 days after last
exposure
exposure
MM / DD / YYYY
MM / DD / YYYY
□ No symptoms
□ No symptoms
□ Fever ________○F □ Fever ________○F
□ Chills
□ Chills
□ Weakness
□ Weakness
□ Headache
□ Headache
□ Muscle Aches
□ Muscle Aches
□ Abdominal Pain
□ Abdominal Pain
□ Diarrhea ____times □ Diarrhea
____times/day
□ Vomiting
□ Vomiting
□ Unexplained
□ Unexplained
hemorrhage
□ Other ____________ hemorrhage
□ Other
_______________

11 days after last
12 days after last
13 days after last
exposure
exposure
exposure
MM / DD / YYYY
MM / DD / YYYY
MM / DD / YYYY
□ No symptoms
□ No symptoms
□ No symptoms
□ Fever ________○F
□ Fever ________○F
□ Fever ________○F
□ Chills
□ Chills
□ Chills
□ Weakness
□ Weakness
□ Weakness
□ Headache
□ Headache
□ Headache
□ Muscle Aches
□ Muscle Aches
□ Muscle Aches
□ Abdominal Pain
□ Abdominal Pain
□ Abdominal Pain
□ Diarrhea ____times/d □ Diarrhea ____times/ □ Diarrhea
____times/day
□ Vomiting
□ Vomiting
□ Unexplained hemorrha □ Unexplained hemorrh □ Vomiting
□ Other _____________ □ Other _____________□ Unexplained
hemorrhage
□ Other
_______________

16 days after last
exposure
MM / DD / YYYY
□ No symptoms
□ Fever ________○F
□ Chills
□ Weakness
□ Headache
□ Muscle Aches
□ Abdominal Pain
□ Diarrhea
____times/day
□ Vomiting
□ Unexplained
hemorrhage
□ Other
_______________

17 days after last
exposure
MM / DD / YYYY
□ No symptoms
□ Fever ________○F
□ Chills
□ Weakness
□ Headache
□ Muscle Aches
□ Abdominal Pain
□ Diarrhea
____times/day
□ Vomiting
□ Unexplained
hemorrhage
□ Other
_______________

18 days after last
exposure
MM / DD / YYYY
□ No symptoms
□ Fever ________○F
□ Chills
□ Weakness
□ Headache
□ Muscle Aches
□ Abdominal Pain
□ Diarrhea
____times/day
□ Vomiting
□ Unexplained
hemorrhage
□ Other
_______________

14 days after last
15 days after last
exposure
exposure
MM / DD / YYYY
MM / DD / YYYY
□ No symptoms
□ No symptoms
□ Fever ________○F □ Fever ________○F
□ Chills
□ Chills
□ Weakness
□ Weakness
□ Headache
□ Headache
□ Muscle Aches
□ Muscle Aches
□ Abdominal Pain
□ Abdominal Pain
□ Diarrhea ____times □ Diarrhea
____times/day
□ Vomiting
□ Vomiting
□ Unexplained
□ Unexplained
hemorrhage
□ Other ____________ hemorrhage
□ Other
_______________

19 days after last
exposure
MM / DD / YYYY
□ No symptoms
□ Fever ________○F
□ Chills
□ Weakness
□ Headache
□ Muscle Aches
□ Abdominal Pain
□ Diarrhea
____times/day
□ Vomiting
□ Unexplained
hemorrhage
□ Other
_______________

20 days after last
exposure
MM / DD / YYYY
□ No symptoms
□ Fever ________○F
□ Chills
□ Weakness
□ Headache
□ Muscle Aches
□ Abdominal Pain
□ Diarrhea
____times/day
□ Vomiting
□ Unexplained
hemorrhage
□ Other
_______________

21 days after last exposure
MM / DD / YYYY

NOTES:

□ No symptoms
□ Fever ________○F
□ Chills
□ Weakness
□ Headache
□ Muscle Aches
□ Abdominal Pain
□ Diarrhea ____times/day
□ Vomiting
□ Unexplained hemorrhage
□ Other _______________

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 (0920-1011)

Domestic Animal Questionnaire for Contacts under Active Monitoring
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Name__________________________________________________________________
Address________________________________________________________________
Phone Number__________________________________________________________
Please provide the following information on your pet:

·

Species (i.e. dog, cat)_________________________

·

Name_______________________________

·

Breed_______________________________

·

Sex and Spay/Neuter Status_________________________________

·

Age__________________________

·

Markings( provide a photo if possible)________________________________________

·

Other identifying characteristics____________________________________________

·

Vaccination history- esp. Rabies __________________________________________

·

Medical Issues/ Need for Medication _______________________________________

·

Name/ Phone Number of Veterinarian ____________________________________

·

Microchip Number- If Applicable___________________________

·

Contact Information/ Address for an Alternate Decision Maker/ Location
___________________________________________

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
(0920-1011)

Form Approved
OMB No. 0920-1011
Exp Date: 3/31/2017

Ebola Virus Disease Contact
Questionnaire

“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 E-11
Atlanta, Georgia 30333; ATTN: PRA (0920-1011).”

Form Approved
OMB No. 0920-1011
Exp Date: 3/31/2017

Ebola Virus Disease Contact
Questionnaire (Revised)

“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 E-11
Atlanta, Georgia 30333; ATTN: PRA (0920-1011).”

Ebola Virus Disease Contact Questionnaire (Revised)
Date of interview:
EVD patient name:
EVD patient symptom onset date:
EVD patient date of death, if applicable:
Contact Name:
Age:
Address:
Telephone Number:
Occupation/Job of Contact:
Workplace Name and Address:
Workplace Telephone Number:
Emergency Contact # 1:
Emergency Contact # 2:

1. What is your relationship to the case? ______________________________________
If the interviewee is not the contact, please indicate the relationship to the contact (i.e. interviewing the parent of a child)
☐Family member of contact
☐Co-worker/classmate
☐Friend
☐Housemate/roommate
☐Other, specify
2. What was your last date of contact with the case (mm/dd/yyyy)? ________________________________

Community/Household Contacts
3. Did you visit the household while the case had symptoms?

☐Yes

☐No

4. Did you have contact with the case outside of his/her home?
☐Yes
☐ No
If yes, what was the nature of your contact with the case while they were symptomatic?
☐Share transportation (plane, taxi bus, etc.)
☐Casual contact (i.e. school, office, bank)
☐Other, specify:____________________________________________________________

5. Did the case come in contact with any people while you were with them? If so, please provide the location, date, person’s
name, and duration of interaction:
Name
Date
Location
Duration (minutes)

6. Describe the level of contact you had with the case while they had symptoms (check all that apply):
☐Within 3 feet (close contact) for over 1 hour duration
☐Within 3 feet of case for less than 1 hour duration
☐Had a brief casual contact (i.e. touch, shaking hands, hug etc.)
☐Other, please describe_______________________________________
☐None
7. Did you engage in any of the following behaviors with the case (check all that apply):
☐Touch
☐Touch bedding or clothing or other objects that may have had bodily fluids on them
☐Share food or drinks with them
☐Eat/drink food prepared by them
☐Have sex with them
☐Kiss them
☐Sleep or lie in the same bed with them
☐Provide care for them, for example (check all that apply):
☐Cleaned/wiped bodily fluids (sweat, vomit, diarrhea, i.e. provide personal care (wash/dress))
☐Did laundry for the patient
☐Other,
specify:_________________________________________________________________________________
8. If you answered yes to any of the questions in question #4, specify length of time the contact was with the case, the
location, and date for each interaction:
Activity/Interaction
Date
Length of time (minutes)
Location

9. Did you have contact with blood or body fluid(s) from the case while they had symptoms?
☐Yes
☐No

10. What Body Fluid(s) did you contact? (check all that apply)
☐Blood
☐Vomitus
☐Stool

☐Saliva

☐Sweat

☐Urine
☐Tears
☐Breast Milk
☐Respiratory/Nasal Secretions
☐Semen
☐Vaginal Fluid
☐Cerebral spinal Fluid (CSF)
☐Other, specify:_____________________________________
11. If the case died, did you touch the body?
☐Yes
☐No
If yes, please describe the level of contact you had with the
body___________________________________________________
____________________________________________________________________________________________________

Healthcare Contacts:
12. What was the nature of your healthcare contact with the case while they were symptomatic? (check all that apply)
☐Attend to the case’s direct care in a hospital/outpatient setting (physician, nurse, EMS, etc.)
☐Perform laboratory services (phlebotomy, other specimen collection, laboratory testing, etc.)
☐Perform custodial services (launder linens, disinfect equipment, clean case’s room)
☐Attend to the case’s food service needs (deliver food tray to room, pick up food tray, etc.)
☐Registration/triage/initial healthcare assessment (i.e. vitals, pulse ox, etc…)
☐Radiological exam (i.e. CT scan, X-Ray, MRI, ultrasound, etc..)
☐Patient Transport Services
☐Perform an autopsy, surgery, or other medical examination
☐Other, specify:_________________________________________________
13. In your own words, briefly describe the nature of your healthcare interaction with the case:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________
14. Describe the level of physical contact you had with the case while they had symptoms (check all that apply):
☐Within 3 feet of the case with appropriate PPE
☐Within 3 feet of the case while not wearing PPE
☐In case’s room or area of care with appropriate PPE
☐In case’s room or area of care while not wearing PPE
☐Had a brief casual contact (i.e. touch, triage, transport etc.)
☐Other, please describe_______________________________________
☐None
15. While you were near the EVD case, did you engage in any of the following behaviors?
☐Touch
☐Touch bedding or clothing or other objects that may have had bodily fluids on them
☐Provide care for them
☐Cleaned/wiped bodily fluids (sweat, vomit, diarrhea, i.e. provide personal care (wash/dress))
☐Cleaned/wiped patient’s area (bed linens/bathroom/washing clothes)
☐Other, specify:___________________________________________________________________________

If so, please describe where the contact occurred:
Date
Name of Location

Address of Location

Details of Contact

16. Did you have contact with blood or body fluid(s) from the case while they had symptoms?
☐Yes
☐No
17. What Body Fluid(s) did you contact? (check all that apply)
☐Blood
☐Vomitus
☐Stool
☐Saliva
☐Urine
☐Tears
☐Breast Milk
Secretions
☐Cerebral spinal Fluid (CSF)
☐Vaginal Secretions
specify:______________

☐Sweat
☐Respiratory/Nasal
☐Other,

18. What was your type of contact with bodily fluids (check all that apply):
☐No direct contact due to appropriate PPE
☐Contact with your intact skin
☐Contact with your broken (fresh cut, burn, abrasion that had not dried) skin or mucous membranes
☐Other, specify:_________________________________________________________________
Please describe the exposure (provide date(s)):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________
19. What personal protective equipment was used for case interactions (check all that apply):
☐Gloves
☐Tyvek Suit
☐Leg Covers
☐Surgical Mask ☐Double Gloves
☐Face Shield
☐Shoe Covers ☐Gown
☐Glasses/goggles
☐Facemask
☐Surgical scrub suit
20. Were there any deviations from the use of recommended levels of PPE, or malfunctions of PPE when interacting with the
EVD case, handling specimens, or contacting a contaminated environment? If yes, describe (please provide date(s)):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________
21. Laboratory only: Did you process blood, or bodily fluid without appropriate PPE? If yes, describe (please provide
date(s)):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________

22. If the case died, did you touch the body?
☐Yes
☐No
If yes, please describe the level of contact you had with the body______________________________
__________________________________________________________________________________________
23. Did you have any other contact with the case not previously mentioned?

Risk 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/burial rites or body preparation of the EVD patient without appropriate PPE
☐Low Risk
 No high risk exposures identified
 Direct brief contact with an EVD patient (e.g., shaking hands)
 Close contact with an EVD patient (within 3 feet (1 meter) for a prolonged period)
☐No known risk
 No high or low risk exposures identified
 No contact with the EVD patient
Follow-up Actions:
☐Active surveillance (health department to monitor temperature and symptoms twice daily)
☐Passive surveillance (contact to monitor own temperature and symptoms twice daily )
☐No further follow-up required (no known risk or last exposure >21 days)

Form Approved
OMB No. 0920-1011
Exp Date: 3/31/2017

Ebola Virus Disease Case Contact
Questionnaire

“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 E-11
Atlanta, Georgia 30333; ATTN: PRA (0920-1011).”

DRAFT

Interviewee name:

State ID No.:

09/30/2014

Ebola Virus Disease Case Contact Questionnaire
The purpose of this questionnaire is to assess the type of contact you may have had with a confirmed or probable case of
Ebola Virus Disease (EVD). The information obtained from these questions will determine your risk of exposure to EVD -high risk, low risk, or no known risk. Depending upon your risk exposure category you may be required to monitor
yourself for any signs or symptoms of EVD for 21 days following your last date of contact. A form should be completed
per confirmed or probable case of EVD with whom you had contact.

Important terms:

Symptoms

Fever (>101.5°F or 38.6°(); Severe headache;Muscle pain;
Weakness;Diarrhea;Vomiting;Abdominal pain;Unexplained
hemorrhage (bleeding or bruising).

Close contact

A.) Being within 3 feet (1 meter) of an EVD patient or within the
patient's room or care area for a prolonged period oftime (e.g.,
household member,healthcare personnel) while not wearing
personal protective equipment,OR
B.) Having direct brief contact (e.g.,shaking hands) with an EVD
patient while not wearing recommended personal protective
equipment.
NOTE:Brief interactions,such as walking by a person,do NOT
constitute close contact.

Personal Protective Equipment

Protective equipment used for standard, contact,and droplet
precautions (e.g., gloves,impermeable gown,eye protection,
facemask, etc.)

Interviewer Information:
Date of interview:

(M, 0, Yr)

Interviewer:
Affiliation:
Address:

---------------------------

-----------------------------

City: --------Telephone (cell):
Email:

Zip code:

State:

---------

Telephone (office):

------

---------

State ID No.:

Interviewee name:

EVD Patient Information:
EVD patient name:

------------------------------

Symptom onset date:

o

,EM, ,Yr)

State ID No.:

Date of death (if applicable): ---------------- ,E,M,o,Yr )

0. What is your position or title?

D
1. What department (s) do you work in?

D
2. Do you work in any healthcare facilities?

D

Yes

If yes, specify:

D No
3. Did you have close contact with the patient while they had symptoms?
(see important terms on page 1 for definition of close con tact and symptoms of EVD)

D

No (If no, then see 'No Known Risk' under risk classification on page x)

D Yes

4. What was the LAST date of close contact with the patient?
5. What was the nature of your contact with the patient while they were symptomatic?
Healthcare

D Attend

to the patient's direct care in a hospital/ outpatient setting (physician, nurse, EMS, etc.)

D

Perform laboratory services (phlebotomy, other sample collection, laboratory testing, etc.)

D

Perform custodial services (launder linens, disinfect equipment, clean patient's room)

D Attend
D

to the patient's food service needs (deliver food tray to room, pick up food tray, etc.)

Perform surgery or other medical examination

(question continued on next page)

(UQ Yry

(check all that apply)

State ID No.:

Interviewee name:

5. What was the nature of your contact with the patient while they were symptomatic? (continued)

D Describe:
Length oftime (hours):

----

6. Did you have contact with blood or other body fluid(s) from the patient while they had symptoms?
D No
D Yes

7. What body fluid(s) did you contact? (check all that apply)
Blood

D Saliva

D Tears

D Vomitus

D Sweat

D

Breast milk

D Respiratory Nasal secretions

Stool

D Urine

D

Semen

D Cerebral spinal fluid

D
D

D Vaginal fluid
(CSF)

D Other, specify:
8. Was your contact with body fluids the result of an occupational exposure?
D No
D Yes

If yes, facility name:

--------------------------------------

9. What was your type of contact with the body fluids? (check all that apply)

D

No direct contact due to appropriate PPE

D Contact

with your intact skin

D Contact

with your broken skin (fresh cut, burn, abrasion that had not dried)

D Contact

with your mucous membranes (eyes, nose, mouth, etc.)

D Other, specify:
10. What personal protective equipment was used? (check all that apply)

D Gloves

D Double

D Tyvek suit
D Leg covers

D Face shield

D Facemask

D Shoe covers

D Surgical scrub suit

D

Surgical mask

gloves

D Gown (fluid

D Glasses/goggles

resistant and impermeable)

D Double gown

(fluid resistant and impermeable)

11.Did you have any other contact with the patient not previously mentioned?

12. Where would you seek healthcare if you developed a fever or symptoms consistent with Ebola? (list facility)
___________________________________________________________________________________

Risk Classification:

D

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/burial rites or body preparation of the EVD patient without appropriate PPE

D

Low Risk

• No high risk exposures identified
• Direct brief contact with an EVD patient (e.g., shaking hands)
• Close contact with an EVD patient (within 3 feet (1 meter) for a prolonged period)

D

No known risk

• No high or low risk exposures identified
• No contact with the EVD patient

Follow-up Actions:

D

No further follow-up required (no known risk or last exposure >21 days).

D

Fever monitoring recommended (high and low risk only)
Last exposure date:

(M, 0,Yr)

Last day of monitoring (day 22):

(M, 0, Yr)

Who will conduct the follow-up for fever and symptom monitoring?
Contact:--------------------

Telephone:

-----------

Affiliation: -------------------(hand out paperwork for monitoring- fever Isymptom log and guidance document if contact develops symptoms)

D

Fever monitoring recommended but respondent is refusing follow-up

D

Respondent has had a fever or other symptom(s) of EV since having contact with the patient
First symptom:
Temperature:

----

oF

Onset date:

(M,0, Yr)

Fever onset date:

(M,0, Yr)

Where will the respondent be evaluated? -------------------(ifthe respondent is symptomatic complete a case investigation form)

Respondent Information:
Respondent:

------------------

Date of birth:

Sex:

(M,0, Yr)

D

Female

D

Male

Address:

-----------------------------

City:

----------

Telephone (cell):

-------

State:

-----------

Telephone (home):

Email: ___________________

--------

Zip code: ------Telephone (work):

--------

Form Approved
OMB No. 0920-1011
Exp Date: 3/31/2017

Healthcare Worker Interview
Form 10/11/2014 (Interactions
since 30 September 2014)

“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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Healthcare Worker Interview Form 10/11/2014 (Interactions since 30 September 2014)
Dates of exposure (range):

EVD Patient name:

Health worker name:

Person completing form:

Health worker address:
County:
Health worker phone number:
Health worker Phone number (alternate):
Specialty (circle all that apply):
Lab

Radiology

Environmental Services

MICU

Respiratory Therapy

Other (specify): _______________________________________

Screening Questions: (if the person answers “NO” to both questions, this person is NOT a contact, skip to classification section and end
the questionnaire)
1. Did you ever enter (check all that apply):
☐Ante-Room
☐Case Room
☐MICU floor
☐None
What PPE did you wear (include dates)? ___________________________________________________________________
2.

Did you ever have contact with the case patient samples?
☐Yes
☐No
What PPE did you wear? Plexiglass shield used? _____________________________________________________________

3.

Briefly describe the nature of your contact with the patient, patient’s blood or body fluids, specimens, or potentially contaminated
surfaces (please provide date(s)):

If the contact answered “YES” to screening question 1 or 2:
1.

Any deviations from the use of recommended levels of PPE, or malfunctions of PPE when interacting with the EVD case,
handling specimens, or contacting a contaminated environment? If yes, describe (please provide date(s)):

2.

Any known exposure to your skin or mucous membranes with patient blood or body fluids? If yes, describe (please provide
date(s)):

3.

Any known skin to skin exposure to patient (without PPE)? If yes, describe (please provide date(s)):

4.

Laboratory only: Did you process blood, or bodily fluid without appropriate PPE? If yes, describe (please provide date(s)):

Classification:
5. ☐High Risk

☐Low Risk

☐No Known Exposure

☐Not a contact

Form Approved
OMB No. 0920-1011
Exp Date: 3/31/2017

Healthcare Worker
Supplemental Interview Form

“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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Form Approved
OMB No. 0920-1011
Exp Date: 3/31/2017

21-day fever and symptom
follow-up form for contacts of
probable or confirmed Ebola
patients

“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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

CCHF Case Investigation Questionnaire

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 (0920-1011)

CCHF Case Investigation Questionnaire
Name of examiner
_______________________

№

Date of filling
___/_____/_______

№ of history record
Y
N
Hospitalization
Hospital name___________________________________
Date of hospitalization ___/_____/2011
Demographic data
Date of birth
Sex
м
F
_____/_____/_______
Residence located in:
Rayon:___________
Sub-district:____________
yes
no
Employed
Occupation ____________________________________________________________________________
Kind of activity __________________________________________________________________________

Risk factors for CCHF (within 2 weeks before developing a fever)
Y
N
Tick bite
Date of tick bite: _____/_____/______
Y
N
Livestock activity
Species contacted:________________________________________
Y
N
Slaughtering livestock
Species contacted:_________________________________________
Y
N
Butchering/handling raw meat
Type of meat handled(species):_____________________________
Y

Nursing for person with bleeding
Handling ticks with bare hands

Y

N
N

Y
N
Seeking of medical care due to tick bite
Date of seeking of medical care:_____/_____/_______
Medical facility:_______________________________________
Geographic location of tick bite Rayon:________________

Sub-district:_____________________

Number of ticks removed:____
Tick ID # _______
Species:__________________
Clinical data
Date of symptom/illness onset _____/_____/2011
resolved: _____/_____/2011
Y
N onset date: _____/_____/2011
resolved: _____/_____/2011
Fever
Y
N onset date: _____/_____/2011 resolved: _____/_____/2011
Headache
Y
N onset: _____/_____/2011
resolved: _____/_____/2011
Myalgia/muscle ache
Y
N onset date: _____/_____/2011
resolved: _____/_____/2011
Vomiting
Y
N onset date: _____/_____/2011
resolved: _____/_____/2011
Diarrhea

Hemorrhagic syndrome

Y

N

Y
N Date of onset _____/_____/2011 resolved: _____/_____/2011
Hemorrhagic rash
Body Arms/Legs
Rash Location: Head/face
Hemorrhages/bruising
Hemorrhage Location:

Y
N Date of onset_____/_____/2011
Head/face
Body Arms/Legs

Y
N Date of onset_____/_____/2011
Bleeding
Urogenital
Bleeding Location: Gastrointestinal

resolved: _____/_____/2011

resolved: _____/_____/2011
Nasal
Respiratory

Daily body temperature (maximum value) and blood characteristics
Date
(dd.mm)

Тemperature
°C

Thrombocyte
count

White
blood cell
count

Red blood
cell
count

Hemoglobin

Alanine
Transferase
(ALT)

Aspartate
Transferase
(AST)

(Other symptoms/attributes):________________________________________________________________________
Treatment
Y
N
Ribavirin
Date of treatment start:____/_____/2011
Date of end of treatment: _____/_____/2011г.
Dosage:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Y
N Intravenous
Y
N
Mode of administration: Oral
Y
N
Immune plasma
Date of treatment start: _____/_____/2011г.
Date of end of treatment: _____/_____/2011г.
Total volume/units given: ____________________________________________________________
Date of discharge from the hospital: _____/_____/2011г.
Diagnosis: ____________________________________________
Suspect
Probable
Confirmed
Negative
Outcome
survived

died

unknown

If patient died, date of death: ____/_____/2011

Diagnostic Tests Performed
Blood collection #1
Date of blood collection ___/_____/_______
CCHF diagnostic testing
Tests
Result
positive
Negative
Uncertain
IgM ELISA
positive
Negative
Uncertain
IgG ELISA
positive
Negative
Uncertain
Antigen ELISA
positive
Negative
Uncertain
PCR
Other relevant test results:_______________________________
Blood collection #2
Date of blood collection ___/_____/_______
CCHF diagnostic testing
Tests
Result
positive
Negative
Uncertain
IgM ELISA
positive
Negative
Uncertain
IgG ELISA
positive
Negative
Uncertain
Antigen ELISA
positive
Negative
Uncertain
PCR
Other relevant test results:_______________________________
Blood collection #3
Date of blood collection ___/_____/_______
CCHF diagnostic testing
Tests
Result
positive
Negative
Uncertain
IgM ELISA
positive
Negative
Uncertain
IgG ELISA
positive
Negative
Uncertain
Antigen ELISA
positive
Negative
Uncertain
PCR
Other relevant test results:_______________________________
Tissue Collection
Date of Tissue collection: ___/_____/_______
Spleen
Tissues sampled: Liver

Blood clot

CCHF diagnostic testing
Tests
Result
positive
Antigen ELISA
positive
PCR

Uncertain
Uncertain

Negative
Negative

Lymph node

Other relevant test results:_______________________________
Tick testing for CCHF
Date of test: ___/_____/_______
positive
Antigen ELISA
positive
PCR

Negative
Negative

Uncertain
Uncertain

other:

Form Approved
OMB No. 0920-1011
Exp. Date 3/31/2017

Crimean-Congo Hemorrhagic Fever
Knowledge, Attitudes, and Practice Survey
October 2014
Tbilisi, Georgia

LABEL

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333;
ATTN: PRA (0920-1011)

SCREENING FORM
Interview Date:
Interviewer Name:
Household Number Assigned:
Location (Village/Rayon/District):
GPS Coordinates:
1. If you are unable to interview this household state why:
a) No one is home
b) No one meets the inclusion criteria in the house (circle all that apply):
i. Less than 18 years old
ii. Cannot give consent
iii. Lived in the household/immediate area for less than 2 months
c) Declined to participate (Go to Consent Form Question 2b)
d) Abandoned property (Go to next question)
e) Commercial property (Go to next question)
f) Other, explain ________________
2. If the property was abandoned or is commercial property, please enter the new GPS
coordinates of the next household chosen? _________________

CONSENT FORM

LABEL
Investigation of Crimean-Congo hemorrhagic fever in Georgia, 2014
Hello my name is ______________________________, I am with the Centers for Disease
Control and Prevention on behalf of the National Center for Disease Control and Public Health.
During the past few months in Georgia there have been some cases of a disease called
Crimean-Congo hemorrhagic fever. We are trying to better understand why some Georgians
have become ill with Crimean-Congo hemorrhagic fever. We would like to administer a brief
questionnaire to you and to draw blood from you. We hope to use the results of our
investigation to help prevent future illness in Georgians.
We would like to take a small sample of blood from your arm to find out if you were infected
with the Crimean-Congo hemorrhagic fever virus recently or in the past. There may be a small
risk with the blood sample collection including discomfort, bruising, or bleeding at the site of
the blood draw. The blood specimen will be stored at Lugar laboratories for up to two years in
the event that repeat Crimean-Congo hemorrhagic fever testing needs to be performed. The
sample you provide will not be used for any other research.
The benefits of participating in this investigation and the testing will be that you will know if
you were infected with the virus, and the information from this investigation will help the
Georgian government prevent people from becoming infected with this virus in Georgia in the
future.
All the information you share with us will be kept completely private. You are free to choose
whether or not to participate in this investigation, and you can withdraw from any part of this
investigation at any time.
1. Would you be willing to take about 30 minutes to answer some questions about
yourself and your activities prior to your illness?
a) If yes: Thank you.
b) If no: Why don’t you want to take the survey?
____________________________________________________________
Would another day or time be more convenient for you?
Yes
No
3

If yes:
If no:
i.
ii.
iii.
iv.
v.

vi.

vii.

viii.
ix.

When? ____________________________
Can you give us some very basic information?
Residence: (village/rayon/district)_________________________
Date of Birth: __ __ /__ __ / __ __ __ __
D D M M Y Y Y Y
Sex (circle one):
Male, Female
Nationality (circle one): Georgian, Azery, Armenian
Highest education level:
a. Elementary
b. Secondary
c. Vocational
d. Higher
e. None
f. Other: ______________
What daily activity do you perform for greater than 6 hours a day?
a. Farmer
b. Herder
c. Gardening/Work in the Field
d. Slaughterhouse worker
e. Butcher
f. Healthcare worker
g. Veterinarian
h. Work in an office
i. Other
What is your monthly household income?
a. <100 Lari
b. 100-500 Lari
c. 501-1000 Lari
d. 1001-1500 Lari
e. 1501-2000 Lari
f. 2001-3000 Lari
g. >3001 Lari
Do you receive social security?
a. Yes
b. No
How much land do you own?
a. I rent the land
b. <1000m2
c. 1000-2000m2
d. 2001-3000m2
e. 3001-4000m2
f. 4001-8000m2
g. >8000m2
4

2. Would you be willing to have your blood drawn?
a. If yes: Thank you. Let’s get started with the questions.
b. If no: Why don’t you want to have your blood drawn?
___________________________________________________________
Can you give us some very basic information?
i. Residence: (village/rayon/district)_________________________
ii. Date of Birth: __ __ /__ __ / __ __ __ __
D D M M Y Y Y Y
iii. Sex (circle one):
Male, Female
iv. Nationality (circle one): Georgian, Azery, Armenian
v. Highest education level:
a. Elementary
b. Secondary
c. Vocational
d. Higher
e. None
f. Other: ______________
vi. What daily activity do you perform for greater than 6 hours a day?
a. Farmer
b. Herder
c. Gardening/Work in the Field
d. Slaughterhouse worker
e. Butcher
f. Healthcare worker
g. Veterinarian
h. Work in an office
i. Other
vii. What is your monthly household income?
a. <100 Lari
b. 100-500 Lari
c. 501-1000 Lari
d. 1001-1500 Lari
e. 1501-2000 Lari
f. 2001-3000 Lari
g. >3001 Lari
viii. Do you receive social security?
a. Yes
b. No
ix.
How much land do you own?
a. I rent the land
b. <1000m2
c. 1000-2000m2
d. 2001-3000m2
5

e. 3001-4000m2
f. 4001-8000m2
g. >8000m2

Thank you so much for your time and consideration.

6

SURVEY

LABEL
Introduction
Note: When administering the following survey, do not prompt any of the multiple choice
answers; please have the participant state their own answers.
To the interviewee: “Thank you for being willing to participate in this survey. I am going to start
by asking you basic questions about yourself to get to know you better. Please note that your
name and any other identifying information will not be collected during this survey. If you want
to have the survey stopped at any time or for any reason, please tell us immediately.”

Demographics
1. Date of birth (DD/MM/YYYY):
2. Sex:
a. Male
b. Female
3. Nationality:
a. Georgian
b. Azery
c. Armenian
d. Other:
4. Residence:
a. Rural
b. Urban
5. Household Size (including the participant): ____________
6. Are you registered to vote?
a. Yes
b. No
7. Highest education level: (one answer only)
a. Elementary
b. Secondary
c. Vocational
d. Higher
e. None
7

f. Other: ______________
8. What daily activity do you perform for greater than 6 hours a day? (circle one answer only)
a. Farmer
b. Herder
c. Gardening/Work in the Field
d. Slaughterhouse worker
e. Butcher
f. Healthcare worker
g. Veterinarian
h. Work in an office
i. Other
9. What is your monthly household income?
a. <100 Lari
b. 100-500 Lari
c. 501-1000 Lari
d. 1001-1500 Lari
e. 1501-2000 Lari
f. 2001-3000 Lari
g. >3001 Lari
h. I don’t know
10. Do you receive social security?
a. Yes
b. No
11. How much land do you own?
a. I rent the land
b. <1000m2
c. 1000-2000m2
d. 2001-3000m2
e. 3001-4000m2
f. 4001-8000m2
g. >8000m2

Risk Factors
12. Do you own or take care of animals? (circle all the apply)
a. No
b. If yes, what type?
i. Sheep
ii. Goats
iii. Cattle
iv. Buffalo
v. Chickens
vi. Horses
vii. Donkeys
viii. Other ________________
8

13. In the last four months, have you performed the following activities (circle all the
apply):
a. Herding
i. No
ii. Sheep
iii. Goats
iv. Cattle
v. Buffalo
vi. Other
b. Have you assisted an animal birth?
i. Have assisted in animal birthing but have used PPE (gloves, gowns,
boots)
ii. Have assisted in animal birthing but have not used PPE
iii. Have not assisted in animal birthing
c. Slaughtering
i. No
ii. Sheep
1. Slaughter sheep using PPE (gloves, gowns, boots)
2. Slaughter sheep without PPE (gloves, gowns, boots)
iii. Goats
1. Slaughter goats using PPE (gloves, gowns, boots)
2. Slaughter goats without PPE (gloves, gowns, boots)
iv. Cattle
1. Slaughter cattle using PPE (gloves, gowns, boots)
2. Slaughter cattle without PPE (gloves, gowns, boots)
v. Buffalo
1. Slaughter buffalo using PPE (gloves, gowns, boots)
2. Slaughter buffalo without PPE (gloves, gowns, boots)
vi. Other
1. Slaughter animals using PPE (gloves, gowns, boots)
2. Slaughter animals without PPE (gloves, gowns, boots)
d. Butchering/handling raw meat
i. No
ii. Sheep
iii. Goats
iv. Cattle
v. Buffalo
vi. Other
e. Handled ticks with bare hands
i. No
ii. Removed ticks from animal and threw is out
iii. Removed ticks from animals and killed with bare hands
iv. Removed ticks from yourself and threw it out
v. Removed ticks from yourself and killed with bare hands
9

vi. Other
________________
f. Worked in a health care setting
i. No
ii. Primary healthcare
iii. Clinic
iv. Hospital
v. Other
g. Drank unpasteurized milk
i. Yes
ii. No
h. Gardening
i. Yes
ii. No
i. Any other outdoor activity not previously asked:
i. None
ii. Hiking
iii. Camping
iv. Hunting
v. Fishing
vi. Picnicking outside
vii. Other_____________
14. In the last four months, have you had a tick bite?
a. No
b. Yes, describe each situation:
Date of Tick Bite Where?
Where?
How much time did it take
(MM/YYYY)
(village/rayon/region)
(body location)
to get it removed after it
was found?

15. Any travel or migration outside your rayon in the last four months?
a. No
b. Yes, describe:
Location (village/rayon/region)
Reason

Dates

16. Were you visited by the household educational campaign last few months?
a. Yes
b. No
10

c. I don’t remember

KAP Information
Reminder: When administering the survey, do not prompt any of the multiple choice answers;
please have the participant state their own answers.
To the interviewee: “Now I am going to ask you questions regarding what you know about
Crimean-Congo Hemorrhagic Fever and what you do to protect yourself and your animals.”

Knowledge
17. Have you ever heard about Crimean-Congo Hemorrhagic Fever, also known as
CCHF?
a. Yes (proceed to question 2)
b. No (proceed to Attitudes section)
c. I don’t know
18. Where have you learned/heard about CCHF? (circle all that apply)
a. School
b. Media
i. TV
ii. Radio
iii. Newspaper/Magazines
iv. Pamphlets
1. Where did you receive it? _________________
v. Posters
1. Where did you see it? _________________
c. Educational campaign last few months (July-October)
d. Training courses
e. Health care worker
f. Know someone who had CCHF
a. Who?
g. I don’t know
h. Other____________________
19. What are ways in which a human can become infected? (circle all that apply)
a. Bite from a tick
b. Crushing a tick with bare hands
c. Contact with blood from infected animals
d. Contact with birthing tissues/fluids from infected animals
e. Eating raw, infected meat
f. Contact with blood from people sick from CCHF
g. Drinking unpasteurized milk
h. I don’t know
i. Other _____________________
11

20. What activities can put you at risk of getting the disease? (circle all that apply)
a. Working with livestock
b. Working in produce/vegetable/grain fields
c. Working in the garden
d. Working in a rural, woody area
e. Slaughtering animals
f. Butchering meat
g. Working in a hospital
h. Being a abattoir/slaughterhouse worker
i. Working as a veterinarian
j. Working as a health care worker
k. I don’t know
l. Other______________________
21. What are the signs and symptoms of CCHF? (circle all that apply)
a. Fever
b. Headache
c. Nausea/Vomiting
d. Diarrhea
e. Muscle pain
f. Joint pain
g. Weakness
h. Cough
i. Blood in the urine
j. Blood in the stool (black or bright red)
k. Coughing blood
l. Red eyes
m. I don’t know
n. Other_________________

Attitudes
22. Do people frequently get bitten by ticks in your community?
a. Yes
b. No
c. I don’t know
23. Do you think ticks are a problem in your community?
a. Yes
b. No
c. I don’t know
24. Do you think there are more ticks this year than previously?
a. Yes
b. No
c. I don’t know
25. Do you think CCHF is a problem in your community?
12

a. Yes
b. No
c. I don’t know
26. Do you think CCHF is something you should be worried about?
a. Yes
b. No
c. I don’t know
27. Do you think you can protect yourself from CCHF?
a. Yes
i. How? _________________
b. No
c. I don’t know

Practices
28. Do you have any interaction with ticks during your job?
a. Yes
i. Please describe_________________
b. No
29. Do you have any interaction with ticks at home?
a. Yes
i. Please describe__________________
b. No
30. If you interact with ticks, what method do you use to remove ticks off yourself?
(circle only one answer)
a. Remove by hand
b. Remove with tweezers
c. Go to a hospital/health care center
d. I don’t interact with ticks
e. I don’t remove ticks
f. Other_________________
31. What do you do to protect yourself from ticks/CCHF? (circle all that apply)
a. Protective clothing (i.e. long pants, socks, etc.)
i. How often? Always Sometimes Never
b. Treat your clothing with repellent
i. How often? Always Sometimes Never
c. Insect repellent on yourself
i. How often? Always Sometimes Never
d. Use pesticides in the environment
i. How often? Always Sometimes Never
e. Avoid woody/rural areas
i. How often? Always Sometimes Never
f. Nothing
g. I don’t know
13

h. Other_________________
i. How often? Always Sometimes Never
32. What care would you seek, if any, if you experienced symptoms of CCHF (fever,
muscle aches, nausea/vomiting, bloody stools or urine, etc.)? (circle one answer
only)
a. Go to a hospital/healthcare facility
i. Primary healthcare
ii. District
iii. Regional
iv. Tbilisi ID hospital (IPC)
v. Any other clinic in Tbilisi:
vi. Other:_________________
b. Stay at home
c. Try local pharmacy
d. Go to a local healer
e. Nothing
f. Other_________________
The following questions refer to livestock; if the participant said NO to Question 12, skip to the
question below and proceed to the Educational Campaign section.
33. How do you prevent ticks for your animals? (circle all that apply)
a. Use insecticides/acaricide
i. Spray
ii. Pour on
iii. Other_______________
b. Injectable medication
c. Nothing
d. Other________________
34. What method do you use to remove ticks off your livestock? (circle one answer
only)
a. Remove by hand
b. Remove with tweezers
c. Go to a veterinarian
d. Pour liquid/mixture onto the tick/animal
What kind?
i. Oil
ii. Alcohol
iii. Insecticide
iv. Other______________
e. There’s never been a tick on my animal(s)
f. Nothing
g. Other________________
14

Educational Campaign
Note: If the participant answered no to Question 16 and/or is not from the following regions,
skip this section and proceed to the Past Illness section.
Please check which one applies:
o Samtskhe-Javakheti Region
· Borjomi
o Shida Kartli Region
· Khashrui
o Shida Kartli Region
· Kreli, Gori, Kaspi

To the interviewee: “Now I am going to ask you questions about the educational campaign that
was performed recently regarding Crimean-Congo Hemorrhagic Fever.”
35. Has your understanding of CCHF changed since the educational campaign? (circle all
the apply)
a. Yes
i. I understand how CCHF is transmitted
ii. I understand the signs and symptoms
iii. I know ways to protect myself/others
iv. Other____________________
b. No
i. The information was not useful
ii. I didn’t understand the information
iii. I already knew all about CCHF
iv. Other___________________
c. I don’t know
36. Has your perception of CCHF changed since the educational campaign? (circle all
that apply)
a. Yes
i. I am more aware of CCHF
ii. I am aware this is a problem in the community
iii. I am aware this is a problem in Georgia
iv. I believe protective equipment/procedures are important
v. I am aware that CCHF can be dangerous
vi. I am concerned about my safety
vii. I am concerned about my family/community’s safety
viii. I am concerned about my job
ix.
Other____________________
b. No
i. The information was not useful
15

ii. I didn’t understand the information
iii. I already knew all about CCHF
iv. Other__________________
c. I don’t know
37. Has the way you protect yourself changed since the educational campaign? (circle all
that apply)
a. Yes
i. I wear long shirts/long pants
ii. I use repellent
iii. I use insecticides
iv. I avoid outdoor/woody areas
v. Other__________________
b. No
i. The information was not useful
ii. I didn’t understand the information
iii. I already knew how to protect myself
iv. I don’t like wearing protective clothing
v. I don’t like using repellent
vi. I don’t like using insecticides
vii. Other__________________
c. I don’t know
38. Has the way you interact with ticks for both yourself and livestock changed since the
educational campaign? (circle all that apply)
a. Yes
i. I don’t handle ticks with my bare skin
ii. I remove ticks immediately
iii. I use repellent
iv. I use insecticides
v. I use injections
vi. I consult a healthcare worker
vii. I consult the veterinarian
viii. Other_______________
b. No
i. The information was not useful
ii. I didn’t understand the information
iii. I already knew how to handle ticks properly
iv. Other_________________
c. I don’t know

16

Past Illness
39. Have you ever been diagnosed with CCHF?
a. No
b. If yes, describe:
i. Date:
ii. Where were you diagnosed:
iii. What symptoms did you have (choose all answers that apply)?
a. Fever
b. Headache
c. Nausea/Vomiting
d. Diarrhea
e. Muscle pain
f. Weakness
g. Cough
h. Blood in the urine
i. Bloody or black stools
j. Coughing blood
k. Bleeding from the gums
l. Other_________________
To the interviewee: “Now I am going to ask about any illnesses you might have had in the last
five years”
40. Have you ever had both fever and hemorrhaging at the same time in the last 5
years?
a. No (Skip question 41, and go to question 42)
b. Yes
iv. What Date ______________________
v. What Symptoms (choose all answers that apply):
a. Fever
b. Headache
c. Nausea/Vomiting
d. Diarrhea
e. Muscle pain
f. Weakness
g. Cough
h. Blood in the urine
i. Bloody or black stools
j. Coughing blood
k. Bleeding from the gums
l. Other_________________
41. Did you seek any care for your symptoms?
17

a. Yes
i.
ii.
b. No
i.

Where?_______________
When?________________
Why not? ______________________

Recent Illness
To the interviewee: “Now I am going to ask about any illnesses you might have had during the
past four months”
42. Have you had any illness in the last four months?
a. Yes
b. No (End questionnaire)
43. What are dates for each illness you had in the last four months? (show calendar)
Date Started (DD/MM/YYYY)
Date Ended (DD/MM/YYYY)
1.
2.
3.
44. What signs or symptoms did you have during this illness?
Signs/Symptoms
Fever
Weakness/Lethargy
Headache
Body / muscle pain
Joint pain
Cough
Abdominal Pain
Nausea
Vomiting
Diarrhea
Jaundice (yellowing of the skin)
Bruising
Petechiae (small dark purple or dark
red dots that don’t go away when you
push down on them)
Nose Bleeding
Bleeding from gums

1st Illness
Yes
No

18

2nd Illness
Yes
No

3rd Illness
Yes
No

Blood in vomitus
Blood in stool
Blood in urine
Coughing blood
Red Eyes
Bleeding gums
Other, please list:

45. Did you seek any care for your symptoms?
a. Yes
i. Where? _____________
ii. When? ______________
b. No
i. Why not? ______________________ (End questionnaire)
46. If you were hospitalized, how long were you in the hospital for? ___________
47. Did you receive any medications or treatments?
a. No
b. Yes
i. What? ________________
ii. Received medication or treatment from (choose one answer only):
a. Primary healthcare
b. District
c. Regional
d. Tbilisi ID hospital
e. Any other clinic in Tbilisi:
f. Local pharmacy
g. Local healer
h. Other

19

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

PARENT FOCUS GROUP GUIDE

Public reporting burden of this collection of information is estimated to average 90 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 (0920-1011)

1. Number of participants:
2. Parent organizations participants represent:
3. How long have you all lived in the area?
4. How large of a problem is suicide in your school? How about your community? Do you think this
problem is larger, smaller, or similar to other schools and communities?
5. How has your community been affected by the recent suicides in the community? How have you
personally been affected by the recent suicides in the community?
6. How do people in the community respond when a young person dies by suicide?
a.
b.
c.
d.
e.

How does the media respond?
How does the town respond?
How do schools respond?
How do parents respond?
How do young people respond?

7. What are issues in the community that affect the way people think about or respond to suicide?
8. What are issues in the community that you think increases the risk for youth suicide?
9. What are issues in the community that you think decrease the risk for youth suicide?
10. What resources are available in the community to help young people who might be depressed,
anxious, or thinking about suicide?
a. Are resources accessed by young people? Why or why not?
11. What resources are available in the community to help families? Are these resources being
accessed? Why or why not?
12. When it comes to addressing the needs and problems of young people, what do you think the
community needs most?
13. What additional activities or resources should the community be using to prevent suicide among
youth? Who should be responsible for these activities/resources?
a. What do parents need in order to help prevent suicides among youth?
14. What are barriers to seeking and accessing mental health care/resources? Any particular barriers
for youth? Any barriers to accessing family services?
15. What role, if any, has social media played in the recent suicides in the community?

16. What role, if any, had traditional media (newspapers, TV, radio) played in the recent suicides in the
community?
17. Is there anything else you think we should know?

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

SCHOOL ADMINISTRATOR AND GUIDANCE COUNSELOR INTERVIEW GUIDE

Public reporting burden of this collection of information is estimated to average 60 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 (0920-1011)

1. I’d like to start by getting a sense for your role at the school.
Probe for:
·
·
·
·
·

Length of time associated with school
Role in school
How would you describe your school’s community? What is it like for students? What is
student’s class load, extracurricular activities, etc.? Teachers? Staff? How are parents
involved?
What challenges are present for school administration? Teachers? Students?
What assets are present for school administration? Teachers? Students?

2. How large of a problem is suicide in your school? How about your community? Do you think this
problem is larger, smaller, or similar to other schools and communities?
3. Has your school been affected by the recent suicides in the community? How?
4. How do people in the community respond when a young person dies by suicide?
a.
b.
c.
d.
e.

How does the media respond?
How does the community respond?
How do schools respond?
How do parents respond?
How do you young people respond?

5. What are issues in the school that you think increases the risk for youth suicide?
6. What are issues in the school that you think decrease the risk for youth suicide?
7. What are issues in the community that you think increases the risk for youth suicide?
8. What are issues in the community that you think decrease the risk for youth suicide?
9. Is there something about this community that affects the way people think about or respond to
suicide?
10. What resources are available for helping youth who might be depressed, anxious, or thinking about
suicide?
a. At school?
b. In the larger community?

11. What kind of resources or people do you think might help prevent youth suicide?
a. At school?
b. In the larger community?

12. What are the barriers to seeking and accessing mental health care and other resources? Anything
particular to youth?
a. At school?
b. In the larger community?
13. What role, if any, has social media played in the recent suicides in the community?
14. What role, if any, had traditional media (newspapers, TV, radio) played in the recent suicides in the
community?
15. Has your district or school implement activities or policies in response to suicide/suicide-related
behaviors among youth in the community? Tell me about the activities and policies and how that
process unfolded.
a. What activities/policies do you believe has been most effective for your school in working to
prevent youth suicide?

16. What resources have you received to implement suicide prevention activities? [probe about
financial, personnel, and material. Probe about source…who provided this resource? How did you
access this resource? What partnerships/other community organizations are involved?]
17. Are activities in your school similar to others across the district? Have tailored any activities to
respond to the needs of your school?

18. What suicide prevention activities that are being implemented do you think are the most effective?
Why?
19. Are suicide prevention approaches unique or the same relative to other affected schools or the
district as a whole?
20. What barriers have you encountered in carrying out these suicide prevention activities? How has
the school worked to resolve the barriers?

21. What do you see as the next step in your school/district’s implementation of suicide prevention
strategies?

22. What additional information do you need in order to integrate suicide prevention strategies into your
school(s)?

23. Finally, my last question is, do you have anything else you’d like to add or is there anything else you
think is important for us to know?