CDC Initial Screening at POE (CDC Primary) – Marburg Res

Department of Health and Human Services Version 10/08/2024
Centers for Disease Control and Prevention
Form Approved

OMB Control No: ####-####

Exp. Date: XX/XX/XXXX

CDC Initial Screening at POE (CDC Primary) – Marburg Response
Date of Arrival in U.S. mm/dd/yy: _______________ Flight #:__________POE: ___________
CDC Initial Screening Start Time: _________ AM/PM
Date arrived in Rwanda? mm/dd/yy ____________ Date left Rwanda? ____________

Body Temperature: ______°F Visible signs of illness? ☐ Yes ☐ No
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? ☐ Yes ☐ No
Chills? ☐ Yes ☐ No
New or unusual headache or body aches? ☐ Yes ☐ No
Vomiting, or diarrhea? ☐ Yes ☐ No

In the last 21 days:
Were you present in any healthcare facility (such as hospital, clinic, saw traditional healer) ☐ Yes ☐ No

Have you had any contact with or were you near a sick person? ☐ Yes ☐ No

Have you come into contact with anyone's blood or other body fluids

(such as vomit, saliva, feces, or urine)? ☐ Yes ☐ No

Did you touch a dead body or attend a funeral? ☐ Yes ☐ No

What was the main reason you were in Rwanda? (mark all that apply)
☐ Healthcare Service/Mission (includes training, clinical laboratory) ☐ Public Health Deployment
☐ Other Humanitarian Service (not healthcare or PH) ☐ Business ☐ Faith-based

☐ Visit Family/Friends ☐ Tourism ☐ Resides in Rwanda ☐ Other _____________________

Traveler’s Contact Information for Destination in the United States:
Traveler’s Last Name: ___________________ First __________________________
Date of Birth (mm/dd/yyyy): _____________________
Street Address at U.S. Destination:_________________________________________________ ______
City: _______________________State: __________ ZIP: _______________
Telephone/Texting APP Number in U.S. __________________________________________________
Is number a U.S. mobile phone (circle one): Y / N Name of Texting APP, if applicable? _______________

Email address: ___________________________________________________

Traveler Referred for CDC Risk Assessment at POE? ☐ Yes ☐ No
PHARS#: _______________ CDC Initial Screening End Time: ________________ AM/PM

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, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).