Form 0920-XXXX 2024 Marburg Symptom Monitoring - Weekly Group_Web Surve

Department of Health and Human Services  Version 11/12/2024 
Centers for Disease Control and Prevention  
Form Approved 

OMB Control No: 0920-XXXX 

Exp. Date: XX/XX/XXXX

 

2024 Marburg Web Survey for Symptomatic Travelers

Please take a few minutes to confirm your location and answer some questions about the symptoms you are experiencing so we can connect you to a public health worker in your area. Your health and the health of your loved ones are important to us.

1. What is your current location? Enter your county/zip code.

2. Have you had a fever (100.4° F / 38° C or higher), felt feverish, or had chills? ☐ Yes ☐ No

3. Have you had new or unusual headache or muscle aches? ☐ Yes ☐ No

4. Do you have a rash? ☐ Yes ☐ No

5. Have you had chest pain? ☐ Yes ☐ No

6. Have you had a sore throat? ☐ Yes ☐ No

7. Have you had nausea, vomiting, or diarrhea? ☐ Yes ☐ No

SUBMIT [button]

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Thank you for providing this information. Please separate yourself from others (isolate). A public health worker will be in touch shortly to discuss your symptoms and provide recommendations.

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