Initial Ebola Screening Script

Department of Health and Human Services DRAFT

Centers for Disease Control and Prevention OMB Control: 0920-XXXX

XX/XX/XXXX

INITIAL EBOLA SCREENING SCRIPT

Symptoms

1) Today or in the past 2 days, have you had any of the following symptoms?

• Fever (100.4° F / 38° C or higher) or feeling feverish

• Vomiting or diarrhea

• Unexplained bleeding or bruising

Exposure

2) In the last 21 days, while in Uganda did you:

A. Have any contact with or were you around a person sick with Ebola, or a person who was sick with or died of an unknown sickness?

B. Have any exposure to blood or other body fluids?

C. Touch a dead body or attend a funeral?

Temperature Check

3) Take and record temperature

Verify Contact Data

4) Verify or record (when available):

1. Name

2. Email

3. US Address

4. Cell #

E. Emergency contact #

Provide EVD Information

5) Ensure entrants have appropriate information on if they develop symptoms.

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.