Airport or Other Port of Entry Staff Assessment

***Note: If contact is determined to have a fever ≥100.4° F, immediately call EOC at 770.488.7100.

Date of initial interview: ______/_____/______ Interviewed by: ____________________________________

1. Last Name: __________________ First Name: ______________________ Age:_____________

Sex: ____ Country of Birth: __________________ Country of Residence: ________________________

Travel Plans through insert date: ________________________________________________________

Street Address: ______________________________________________________ State: __________

Phone numbers- Home: _________________ Cell:__________________ Work:___________________

Job title: ____________________________________________________________________________

Circle flight(s) in which interviewee was involved: [Complete flight information]

[Complete second flight information]

2. Did interviewee have any interactions with sick passengers from this flight(s)? Yes No

If yes, describe this event including location, degree of contact (talking with or touching) and length of time: ______________________________________________________________________________

3. Did interviewee have direct contact with any body fluids while working with the flight(s) circled above? Yes No (If no, skip to question 4)

If yes, were masks or gloves worn? Mask Gloves None

If yes, describe the contact including location of the body fluid in the airport and any other individuals involved: ___________________________________________________________________________

___________________________________________________________________________________

If yes, which body fluids did interviewee come into contact with? (Check all that apply)

Tears Saliva Respiratory secretions (cough and sneeze droplets)

Vomit Urine Blood Stool Sweat

If yes, did these fluids come in contact with the interviewee’s?

Intact skin

Broken skin (fresh cut or scratch which bled within 24 hours before the contact; burn or abrasion that had not dried)

Mucous membrane contact (eyes, nose or mouth)

Other (Specify): ____________________________________________________________

4. Were there any incidents that the interviewee can recall when other individuals were in contact with a person’s blood and/or body fluids while working with the flight(s)?

Yes No

If yes, please describe situation and location in the airport, including time of the occurrence: __________

___________________________________________________________________________________

___________________________________________________________________________________

5. What protective equipment (i.e. gloves, face mask) was the interviewee wearing when he/she was working (if any)? _____________________________________________________________________

6. Please check all symptoms interviewee has had since flight:

Fever ≥100.4° F Sore throat Body aches/muscle pain Headache

Abdominal pain Vomiting Diarrhea Weakness

Rash Hiccups Unusual bleeding (e.g. from gums, eyes or nose)

7. Has interviewee travelled in any of the following countries within the last 21 days (check all that apply)? Sierra Leone Guinea Liberia Other

If any of the above countries are selected, please notify CDC by calling EOC. Contact will need to complete additional brief interview with CDC SME involving in-country exposure risk.

__________________________________________________________________________________

Classification of interviewee risk (Consult the CDC to classify each contact after interview. Refer to http://www.cdc.gov/vhf/ebola/hcp/case-definition.html for additional information):

High Risk: The index case’s body fluids came in contact with the interviewee’s bare skin (intact or

broken) or mucous membranes (eyes, mouth, nose).

Some Risk: Interviewee had close contact* with the index case but not body fluids; or was only exposed on protected areas of the body (e.g. on hands while wearing gloves).

No Known Risk**: Interviewee did not have any some risk or high risk exposures listed above.

Follow-up Actions:

Ebola information distributed

Fever watch: For all contacts regardless of classification of risk, provide fever watch form that should be reviewed at least weekly.

Referred for medical evaluation due to presence of symptoms. If yes,

Where was (s)he referred? _____________________________________________________________

What was the outcome? _______________________________________________________________

Declined medical evaluation after it was recommended

Was interviewee placed under conditional release? Yes No

Was interviewee placed under state issued quarantine order? Yes No

Final Disposition:

Was interviewee contacted again after [Fill in the date of the last day of the incubation period]?

Yes, Date of second interview: ______/_____/______ No

If yes, did interviewee develop any symptoms of Ebola between the time of flight and [Fill in date]? Yes No

If yes, please describe the symptoms, timing and outcome of medical evaluation below: ____________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________

Evaluating healthcare provider name/phone number: __________________________/(____)____________

* Close contact is defined as a) being within approximately 3 feet (1 meter) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., droplet and contact precautions–see Infection Prevention and Control Recommendations); or b) having direct brief contact (e.g., shaking hands) with an EVD case while not wearing recommended personal protective equipment (i.e., droplet and contact precautions–see Infection Prevention and Control Recommendations). At this time, brief interactions, such as walking by a person or moving through a hospital, do not constitute close contact.

**No known risk may include passengers who were seated within 3 feet of the passenger for only a short amount of time.

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