Assessment on Ebola Inquiries - word

Form approved

OMB No. 0920-0879

Expiration date: 04/30/2017

Attachment A: State/Local Health Department Assessment on Ebola Viral Disease (Ebola) Inquiries and Preparedness

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The purpose of this assessment is to collect data on domestic inquiries and health department preparedness for the Ebola Viral Disease (Ebola) response. A domestic inquiry refers to any communication about a person who has presented to a U.S. health care setting for medical evaluation, and is ill with possible symptoms of Ebola. Such persons will be referenced as a Person under Investigation (PUI) for this assessment. A person who has had a high or low-risk exposure to an Ebola patient is considered a contact. Please be assured that your responses will be kept anonymous, and reports from the data collected will be reported in aggregate form only (by regions rather than individual states). This collection of information is estimated to take up to12 minutes to complete. Thank you for your participation!

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1. Name of State/Local Health Department:

2. Since April 1, 2014, has your health department received inquiries about persons possibly exposed to Ebola? Yes No

(If no, please skip to question #7)

1. What is your earliest date of inquiry?

2. How many inquiries have you received between your earliest inquiry date and July 9^th, 2014?

3. How many inquiries have you received since July 9^th, 2014?

4. How many inquires did you receive for the month of July?

5. How many inquiries did you receive for the month of August?

6. How many inquiries did you receive for the month of September?

7. Have you contacted CDC for any of these inquiries? Yes No

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Public reporting burden of this collection of information is estimated 12 minutes to complete this assessment, 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 (0920-0879)

3. Which Ebola-affected countries were your PUIs associated with? (please check all that apply)

Liberia

Guinea

Sierra Leone

Nigeria

Senegal

Democratic Republic of Congo

4. From which country did the majority of the PUIs come from? (Please check one)?

Liberia

Guinea

Sierra Leone

Nigeria

Senegal

DRC

5. Which entity was your primary source of notification for PUIs (please check one):

Hospital/Health Center

Quarantine station

Law enforcement/Military

Customs and border control agencies

Airport personnel

Other (please specify)

6. What were your primary reasons for contacting the CDC about a PUI? (please check all that apply)

PUI had a low/high risk exposure status

PUI had an unknown exposure status

Uncertain about need for PUI testing

Assessed that PUI testing is indicated and need CDC assistance with testing protocols

Other (please specify)

7. If a person is identified as a PUI by your department, who would be the immediate next entity (outside of the state/local health department) that your department notifies? (please check one)

CDC EOC Ebola Response Team

Division of Global Migration and Quarantine

Customs and border control agencies

Other (please specify)

1. After reaching out to your primary notification agency (in question 7), please check all other entities you contact about the PUI? (please check all that apply)

CDC EOC Ebola Response Team

Division of Global Migration and Quarantine

Customs and border control agencies

Other (please specify)

8. Did your state set up special teams or procedures to handle Ebola inquiries in response to the West African outbreak? Yes No

If yes, please describe: _____________

9. Do you currently have a database to keep track of PUIs/or future PUIs? Yes No

Questions 10-12 refer to tracing of contacts who had a high or low risk exposure to a person with confirmed or suspected Ebola virus disease.

10. Do you have an identified individual(s) within your department who is responsible for PUI follow-up and contact tracing? Yes No

11. Has your health department officially completed 21 day follow-up/monitoring of any individuals following a high-risk or low-risk exposure? Yes No

12. Is your health department currently tracking a PUI for 21 days following a high-risk or low-risk exposure? Yes No

13. Do you have a protocol for tracking probable or suspected contacts? Yes No

If yes, what data management methods do you use to trace contacts? (Please check all that apply)

Database/excel spreadsheet

Paper contact forms

Other (please specify)

14. Have you ever contacted the CDC for guidance on any of the following: Yes No

    1. Laboratory handling of specimens

    2. Healthcare setting/EMS infection control

    3. Monitoring and Movement of PUIs and Contacts

    4. Shipping of specimens and lab testing

15. Have you conducted health center trainings on protocols for contacting the health department for suspected Ebola cases? (If no, please skip to question #15b) Yes No

    1. If yes, what is your earliest training session date?

    2. If not, what type of guidance have you given to health centers for PUI identification? (please check all that apply)

Written or electronic materials from the CDC

Written or electronic materials generated by your health department

Telephone guidance

Other (please specify)

16. Have you developed health department-specific protocols for advising healthcare providers on: Yes No

    1. Evaluating patients with suspected Ebola

    2. Specimen handling

    3. Patient transport

    4. Infection control practices (includes PPE and decontamination guidance)

    5. Waste removal

17. If you answered yes to any training area in Questions 16a-16e, have you utilized CDC guidance on preparedness in the preparation of the training protocol? (If no, skip to question #18) Yes No

1. If yes, what documents have you used? (please check all that apply)

Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons under Investigation for Ebola Virus Disease in the United States

http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html

Interim Guidance Regarding Compliance with Select Agent Regulations for Laboratories Handling Patient Specimens that are known or Suspected to Contain Ebola Virus

http://www.cdc.gov/vhf/ebola/hcp/select-agent-regulations.html

Interim Guidance for Monitoring and Movement of Persons with Ebola Virus Disease Exposure

Guidance on Air Medical Transport for Patients with Ebola Virus Disease

http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States

http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html

Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings

http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html

Safe Management of Patients with Ebola Virus Disease (EVD) in U.S. Hospitals

http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html

Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

Guidance for Safe Handling of Human Remains of Ebola Patients in U. S. Hospitals and Mortuaries

http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html

Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus

http://www.cdc.gov/vhf/ebola/hcp/environmental-infection-control-in-hospitals.html

Recommendations for Breastfeeding/Infant Feeding in the Context of Ebola

http://www.cdc.gov/vhf/ebola/hcp/recommendations-breastfeeding-infant-feeding-ebola.html

18. Have you distributed guidance or training materials to health centers or EMS/First responders for the handling of suspected Ebola patients? Yes No

19. Is there any additional guidance or clarification of existing guidance from CDC that you would like to have? (please specify)

Thank you for your participation!