Introduction and confirmation

OMB Approved

0920-XXXX

Exp XX/XX/XXXX

Department of Health and Human Services

Centers for Disease Control and Prevention

Script for DGMQ Hot Line — Introduction, Flight and Seat Confirmation

Ebola Air Contact Investigation

INSERT FLIGHT INFORMATION AND DATE

Hello my name is _______________________. Thank you for calling the CDC Global Migration Task Force Hotline.

CDC and the ­INSERT NAME OF STATE HEALTH DEPARTMENT have confirmed a diagnosis of Ebola in a person who traveled on a commercial airline from INSERT LOCATION to INSERT LOCATION on INSERT DATE. The patient was admitted to a hospital in INSERT LOCATION on INSERT DATE. Blood samples submitted to CDC tested positive for Ebola. While it appears that the person was not symptomatic while on the flight, CDC along with state health departments, are working to follow-up with all passengers on this flight.

First, can I get your name? First Name: ________________________

Last Name: ___________________________

Can I also get a phone number in case we get disconnected?

Phone number: (___ __)_______–_______________ (Circle one: Cell Home Other)

Did you fly on INSERT AIRLINE NAME AND FLIGHT # on INSERT DATE from INSERT LOCATION, to INSERT LOCATION?

Yes No Unsure

If NO, stop here and say the following:

It appears that you were not on the flight of interest. Thank you for your time. Do you have any questions at this time? [if so, answer questions using the Ebola Q&A document or connect them with Epi/Surveillance Team. if not say: If you have additional questions about Ebola, you can call 1-800-CDC-INFO or send an email through www.cdc.gov.]

If the caller is UNSURE, suggest checking e-mail confirmation, airline website, boarding documents, asking travel companion, to determine whether on flight. The flight time was INSERT FLIGHT DEPARTURE AND ARRIVAL TIMES.

If YES, continue:

It appears that you were on the flight of interest. Can I get some additional contact information from you?

E-mail address: _________________________________

Home address (or address for next 21 days if nonresident/traveling): ____________________

______________________________________________________________________

City _________ State______________ Zip ____________

If non-US resident, country of residence: _________________________________

Alternate phone number: (_____)_______–_______________ (Circle one: Cell Home Other)

Can you tell me where you were seated on the plane? Seat Number: ________________________

We are giving your information to your state health department and they will be following up with you. We will ensure that this is done.

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/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.