DD Form 2991 Ebola Virus Disease Redeployment Risk Assessment and Med

This form must be completed electronically when possible. Handwritten forms will be accepted.
OMB No. 0720OMB approval expires

EBOLA VIRUS DISEASE REDEPLOYMENT RISK ASSESSMENT AND MEDICAL CLEARANCE

The public reporting burden for this collection of information is estimated to average 12 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Suite 02G09, Alexandria,
VA 22350-3100 (0720-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if
it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ADDRESS.

PRIVACY ACT STATEMENT
This statement serves to inform you of the purpose for collecting the personal information requested by this form and how it may be used.
AUTHORITY:

10 U.S.C. 1074f, Medical Tracking System for Members Deployed Overseas; 42 U.S.C. 264-272, Quarantine and Inspection, Executive Order 13295, Revised List of
Quarantinable Communicable Diseases; 42 CFR Part 70, Interstate Quarantine; 42 CFR Part 71, Foreign Quarantine; DoDI 6490.03, Deployment Health;
and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): Your information may be used for the purpose of collecting certain communicable disease(s) data IAW regulations providing for the apprehension, detention, or
conditional release of individuals to prevent the introduction, transmission, or spread of suspected communicable diseases, pursuant to section 361(b) of the Public
Health Service Act. Your information will be collected in order to identify any health concerns and, if necessary, refer you for additional assessment and/or care.
ROUTINE USE(S):

Use and disclosure of your records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at:
http://dpclo.defense.gov/privacy/SORNsIndex/BlanketRoutineUses.aspx and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164),
as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the
containment of certain communicable diseases.

DISCLOSURE:

Mandatory. To protect the health of the public from Ebola, a highly infectious virus of significant public health threat, you are hereby required to provide the
requested information. Care will not be denied if you decline to provide the requested information, but you may not receive the care you deserve and may face
administrative delays.

INSTRUCTIONS:

All DoD personnel are required to complete this form within 12 hours prior to departure from an Ebola outbreak country or region.
You are required to truthfully answer all questions. Failure to disclose the requested medical information regarding potention EVD contact
or exposure risk while deployed to an Ebola outbreak area may result in UCMJ and/or criminal punishment. If you do not understand a question,
please discuss the question with a healthcare provider.

D R A F T

DEMOGRAPHICS
Last Name:

First Name:

Social Security Number:

Middle Initial:

Today’s Date (dd/mmm/yyyy):

Date of Birth (dd/mmm/yyyy):

Gender:

Service Branch:

Component:

Pay Grade:

⃝ Air Force
⃝ Active Duty
⃝ Army
⃝ National Guard
⃝ Navy
⃝ Reserves
⃝ Marine Corps
⃝ Civilian Government Employee
⃝ Coast Guard
⃝ Contractor
⃝ Civilian Expeditionary Workforce
⃝ USPHS
⃝ Other Defense Agency (List):
⃝ Other (List):

⃝ E1
⃝ E2
⃝ E3
⃝ E4
⃝ E5
⃝ E6
⃝ E7
⃝ E8
⃝ E9

⃝ Male

⃝ Female

⃝ O1
⃝ O2
⃝ O3
⃝ O4
⃝ O5
⃝ O6
⃝ O7
⃝ O8
⃝ O9
⃝ O10

⃝ W1
⃝ W2
⃝ W3
⃝ W4
⃝ W5
⃝ Other

Home Station/Unit:
Current Contact Information:

Point of contact who can always reach you:

Phone:

Name:

Cell:

Phone:

DSN:

Email:

Email:

Address:

Address:
Deployment location(s):

⃝ Liberia ⃝ Sierra Leone

Deployed Station/Unit:

⃝ Guinea

⃝ Senegal

⃝ Nigeria

⃝ Other:

Duties while deployed:

Theater departure location (airport):

DD FORM 2991, 20141022 DRAFT

Page 1 of 5 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE REDEPLOYMENT RISK ASSESSMENT AND MEDICAL CLEARANCE
Deployer’s SSN (Last 4 digits):

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

PART I: Individual Ebola Virus Di sease Exposure Questionnaire
[To be completed by all redeploying DoD personnel.]
Please respond “Yes”, “No”, or “Don’t Know” to all questions below.
Over the past 21 days were you deployed to an area known or suspected of having
and Ebola Virus Disease outbreak?
Over the past 21 days were you in contact with someone known or suspected of
having Ebola Virus Disease?
Over the past 21 days did you have contact with, or exposure to, the blood or body
fluids (e.g., vomit, diarrhea, saliva), of someone known or suspected of having Ebola
Virus Disease?
Over the past 21 days did you handle any items that may have come in contact with
an infected person’s blood or body fluids?
Over the past 21 days did you touch the body or bodies of people who died from
Ebola Virus Disease?
Over the past 21 days did you attend a funeral or burial ritual that required touching
the body of someone who died from Ebola Virus Disease?
Over the past 21 days did you have contact with bats, nonhuman primates, blood
fluids, or raw meat prepared from these animals?
Over the past 21 days were you in or assigned to a hospital where Ebola Virus Disease
patients were being treated?
While deployed did you evaluate or treat patients known or suspected of having
Ebola Virus Disease?
While deployed did your duties require the use of personal protective equipment
[PPE] for the purpose of protecting against Ebola Virus Disease?
Are you a pilot or flight crew member traveling from an Ebola endemic area?
Are you a pilot or flight crew member involved in the transport of known or
suspected Ebola Virus Disease patients from a country or region currently
experiencing an Ebola outbreak?

D R A F T

Yes

No

Don’t Know

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

If “Yes” to any of the above questions, please explain. Please be sure to detail date of last possible exposure.

DD FORM 2991, 20141022 DRAFT

Page 2 of 5 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE REDEPLOYMENT RISK ASSESSMENT AND MEDICAL CLEARANCE
Deployer’s SSN (Last 4 digits):
COMPLETED BY DESIGNATED MEDICAL PROVIDER ONLY – Provider Review, Interview, Assessment and Medical Clearance Recommendations

4.

PART II-A: Ebola Virus Disease Clinical Evaluation [Mark all that apply.]
Ask “Are you currently experiencing any of the following signs and symptoms?”
o
a. Fever (temperature of > 100.4 F)
⃝ Don’t Know
b. Subjective fever (e.g., chills, night sweats)
c. Severe headache
d. Joint and muscle aches
e. Abdominal/stomach pain
f. Vomiting
g. Diarrhea
h. Unexplained bruising or bleeding
i. New skin rash
j. Other
Ask “Have you taken any fever reducing
- medications within the past twelve [12] hours?”
(e.g., aspirin, Tylenol, Motrin, Ibuprofen)
Conduct and record temperature check.
Temperature:
Time:
.
Date and time of onset of symptoms Date (dd/mmm/yyyy)
:
Time:

5.

Comments:

1.

2.
3.

DD FORM 2991, 20141022 DRAFT

Yes
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝

No
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝

⃝

⃝

⃝ N/A

D R A F T

Page 3 of 5 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE REDEPLOYMENT RISK ASSESSMENT AND MEDICAL CLEARANCE
Deployer’s SSN (Last 4 digits):

1.

PART II-B: Ebola Virus Disease Risk Assessment [Mark all that apply. If “Yes” document date, time & type of MOST recent exposure.]
SOME RISK OF EXPOSURE: One or more of the following within the past 21 days.
Yes
Close contact with an Ebola Virus Disease (EVD) patient in any of the following settings:
household, living quarters, workplace, or community? If yes, document date, time and
type of contact and/or exposure.
Date (dd/mmm/yyyy):

Time:

No

Type:

Close contact is defined as:

⃝

⃝

⃝

⃝

HIGH RISK OF EXPOSURE: One or more of the following within the past 21 days.

Yes

No

Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids
of an EVD patient? If yes, document date, time and type of contact and/or exposure.

⃝

⃝

⃝

⃝

⃝

⃝

⃝

⃝

a.

Being within approximately 3 feet (1 meter) of an EVD patient for a prolonged period of time while not
wearing recommended personal protective equipment (PPE) or PPE was compromised.

b.

Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment (PPE) or PPE was compromised.
(Brief interactions, such as walking by a person, do not constitute close contact.)

2.

Other close contact with EVD patients in healthcare facilities? If yes, document date,
time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

Time:

Type:

Close contact is defined as:
a.

b.

Being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area
for a prolonged period of time (e.g., health care personnel, household members) while not wearing
recommended personal protective equipment (PPE) (standard droplet and contact precautions) or PPE
was compromised.

D R A F T

Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment (PPE) or PPE was compromised.
(Brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact.)

3.

Date (dd/mmm/yyyy):

4.

Time:

Type:

Processing blood or body fluids of a confirmed EVD patient without appropriate personal
protective equipment (PPE), standard biosafety precautions, or PPE was compromised?
If yes, document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

6.

Type:

Direct skin contact with, or exposed to, blood or body fluids of an EVD patient without
appropriate personal protective equipment (PPE) or PPE was compromised? If yes,
document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

5.

Time:

Time:

Type:

Direct contact with a dead body without appropriate personal protective equipment
(PPE), or PPE was compromised in a country where an EVD outbreak is occurring? If yes,
document date, time and type of contact and/or exposure.
Date (dd/mmm/yyyy):

DD FORM 2991, 20141022 DRAFT

Time:

Type:
Page 4 of 5 Pages

This form must be completed electronically when possible. Handwritten forms will be accepted.

EBOLA VIRUS DISEASE REDEPLOYMENT RISK ASSESSMENT AND MEDICAL CLEARANCE
Deployer’s SSN (Last 4 digits):
PART II-C: EBOLA VIRUS DISEASE RISK CATEGORY [Mark ONLY one.]
Disposition Guidance: Document patient’s risk category in the individual’s medical record.
Asymptomatic:
•

⃝

•

No Known
Exposure

Trained personnel at home station must perform twice daily face-to-face review of symptoms
and temperature check for 21 days.
Upon return to home station, leave or TDY/TAD is NOT authorized outside the local area
during the 21 day monitoring period.

Symptomatic: (Fever WITH or WITHOUT other symptoms)
•
•

Evaluation by medical authorities.
Implement infection control precautions.

Asymptomatic:
⃝

•
•

Some Risk of
Exposure

Evaluation by medical authorities.
Transfer to a DoD designated facility to monitor for signs and symptoms of EVD for 21 days
IAW official policy.

D R A F T

Symptomatic: (Fever or other symptoms)

(“Yes” to
questions 1 or 2,
PART II-B)

•
•
•

Evaluation by medical authorities.
Isolate and separate from “High Risk” individuals. Implement infection control precautions.
Transfer via regulated movement to a DoD designated medical facility capable of providing
care for EVD patients IAW official policy.

Asymptomatic:

⃝

•
•

High Risk
Exposure

Evaluation by medical authorities.
Transfer via regulated movement to a DoD designated medical facility capable of monitoring
for signs and symptoms and/or providing care for EVD patients IAW official policy.

Symptomatic: (Fever or other symptoms)

(“Yes” to
questions
3, 4, 5, or 6,
PART II-B)

•
•
•

Evaluation by medical authorities.
Isolate and separate from “Some Risk” individuals. Implement infection control precautions.
Transfer via regulated movement to a DoD designated medical facility capable of providing
care for EVD patients IAW official policy.

Patient is cleared to
travel.

Medical
Disposition

⃝

Provider’s Name:
Title:

⃝ MD

Patient is NOT cleared to
travel. Requires further
medical evaluation.

⃝

⃝

Date (dd/mmm/yyyy):
⃝ DO

⃝ PA

⃝ Nurse Practitioner

Patient must be transferred via
regulated movement.

⃝ Adv Practice Nurse

Time:
⃝ Other:

⃝ I certify this assessment process has been completed. Provider’s Signature:

DD FORM 2991, 20141022 DRAFT

Page 5 of 5 Pages