Public Health Assessment For Travelers From Ebola Outbre

Department of Health and Human Services Form Approved

Centers for Disease Control and Prevention OMB Control No: 0920-XXXX

Exp. XX/XX/XXX

PUBLIC HEALTH ASSESSMENT FOR TRAVELERS FROM EBOLA OUTBREAK-AFFECTED COUNTRIES

When to use this form: This questionnaire is used for a traveler that is referred following the initial screening process (i.e., visibly ill, elevated measured temperature ≥100.4°F/38°C, or yes to a screening question.)

Instructions to Q-station staff: Read the following risk assessment questions to the traveler. We are interested in the highest level of exposure the traveler has experienced. Get a description of any high-risk activities identified. NOTE: “person with Ebola” includes confirmed or suspect cases.

Reason for referral:

☐ Visibly ill

☐ Elevated temperature (Recorded temperature: _____ ^oF)

☐ Yes, to any symptoms

☐ Yes, to exposure questions: Circle which question: A B C

Tell the traveler: You were referred for public health assessment because we need to investigate further to determine if you had a possible exposure to the Ebola virus. I am going to ask you a few questions to get more information. This will help us decide if you need additional evaluation.

All questions refer to your experiences in [outbreak country] over the last 21 days.

1. Were you in contact with or around a person with Ebola or a person who was sick with or died of an unknown illness?

☐ Yes ☐ No

1. If YES, which one?

☐ Person with Ebola

☐ Person with an unknown illness (List district: _____________)

☐ Person who died of an unknown illness (List district: _____________)

2. If YES, what type of contact?

   1. Stayed in the same residence as the person while the person was sick? ☐ Yes ☐ No

   2. Provided direct care to the person? ☐ Yes ☐ No

If YES, check one: □ Healthcare (complete additional questions below) or □ Home (or another non-healthcare setting)

Have other direct contact with the person? ☐ Yes ☐ No

3. Was near (within 3 feet/1 meter) the person but had no physical contact. ☐ Yes⁺ (Duration: __________) ☐ No

2. Were you ever exposed to the blood or other body fluids (including feces, saliva, sweat, urine, vomit, sputum, breast milk, tears, or semen) of a person with Ebola or an unknown illness?

   1. If YES which one?

☐ Person with Ebola

☐ Person with an unknown illness (List district: _____________)

☐ Person who died of an unknown illness (List district: _____________)

2. Did the exposure include:

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

2. Splashing blood or body fluids in the eye, nose, or mouth? ☐ Yes ☐ No

3. Direct skin contact with the ill person’s blood or body fluids? ☐ Yes ☐ No

3. Did you have any exposure to dead bodies? ☐ Yes ☐ No

   1. If YES, was the person known to have Ebola? ☐ Yes ☐ No (List district: ______________)

   2. If YES (to exposure to dead bodies), what type of exposure?

      1. Touched a dead body? ☐ Yes ☐ No

      2. Prepared a body for burial? ☐ Yes ☐ No

      3. Touched any items that had been in contact with a dead body? ☐ Yes ☐ No

      4. Worked as a burial worker? ☐ Yes ☐ No

         1. If YES (to burial worker): Did you wear personal protective equipment (including gloves, gowns, masks, and eye protection) at ALL times? ☐ Yes ☐ No

Healthcare-specific questions:

1. During all encounters with a patient with Ebola, did you wear the recommended personal protective equipment (gloves, gown, mask, and eye protection)? ☐ Yes ☐ No

1. If NO (to PPE use):

   1. Did you have any physical contact with the person with Ebola? ☐ Yes ☐ No

If NO physical contact, were you within 3 feet (1 meter) of the person with Ebola? ☐ Yes⁺ (Duration: _________) ☐ No

2. Did you have unprotected exposure to any of the following? Unprotected exposure means without the use of the recommended personal protective equipment (gloves, gown, mask, and eye protection) or experiencing a breach in infection control precautions.

   1. Blood or other body fluids (including feces, saliva, sweat, urine, vomit, sputum, breast milk, tears, or semen) of a person with Ebola? ☐ Yes ☐ No

   2. A person who died of suspected or known Ebola or of an unknown cause?

☐ Person with Ebola

☐ Person who died of an unknown illness (List district: _____________)

All YES answers indicate a HIGH-RISK exposure, except for those indicated with a ⁺

Please describe all known or potential exposures for any of the above answers.

Exposure date(s): ___________________

Duration of exposure(s): _______________

Description of the exposure(s):

Exposure date(s): ___________________

Duration of exposure: _______________

Description of the exposure:

Exposure date(s): ___________________

Duration of exposure: _______________

Description of the exposure:

Exposure risk assessment:

☐ High-risk (Any YES except if no physical contact is reported)

☐ No known high-risk exposure but may have had a lower-risk exposure (Answered YES to either “no physical contact” question indicated with ⁺). Further assessment is needed.

☐ No known exposure (Answered NO to all questions).

Health status assessment:

☐ Symptomatic

☐ Asymptomatic

Disposition:

☐ Transfer to hospital for isolation and medical evaluation

☐ Quarantine/conditional release

☐ Cleared to continue travel

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 0920-0821.