Symptom Monitoring Form
Ebola Virus Disease in the United States:CDC Support for Case and Contact Investigation
Att6 Symptom Monitoring Form
Symptom Monitoring Form - Health Care Workers
OMB: 0920-1045
Symptom Monitoring Form 11/13/2014
Form Approved OMB
No. 0920-XXXX Exp.
Date XX/XX/20XX
Symptom Monitoring Form
Instructions: These forms can be used as a template to facilitate daily monitoring.
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 Information Collection Review Office, 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-XXXX).
21-day fever and symptom follow-up form for contacts of Ebola patients, days 1-10
Name: _______________________________________ Age (yrs): _______ Sex: M F
Street address: ________________________________ City, State: ____________________________ Telephone number: ______________________
Case ID number (from contact listing form): _______________ Contact number (from contact listing form): _________
Where did contact with the case occur: _________________________________ Date of last contact with the case (mm/dd/yyyy): _________________
Instructions: Take your temperature twice each day, in the morning and in the evening, preferably around the same time. Indicate whether you have any of the symptoms listed on this form. Circle ‘Y’ if you have the symptom and ‘N’ if you do not. Don’t leave any spaces blank. If you have any of the symptoms, immediately call the public health department at XXX-XXX-XXXX.
Day number (after last contact) |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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Temperature |
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Fatigue or weakness |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Muscle pain |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Headache |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Sore throat |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Vomiting |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Diarrhea |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Rash |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Unexplained bleeding* |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
*Unexplained bleeding means bleeding from your mouth or nose, bloody diarrhea, or coughing up blood, or bruising under the skin |
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21-day fever and symptom follow-up form for contacts of Ebola patients, days 11-21
Name: _______________________________________ Age (yrs): _______ Sex: M F
Street address: ________________________________ City, State: ____________________________ Telephone number: ______________________
Case ID number (from contact listing form): _______________ Contact number (from contact listing form): _________
Where did contact with the case occur: _________________________________ Date of last contact with the case (mm/dd/yyyy): _________________
Instructions: Take your temperature twice each day, in the morning and in the evening, preferably around the same time. Indicate whether you have any of the symptoms listed on this form. Circle ‘Y’ if you have the symptom and ‘N’ if you do not. Don’t leave any spaces blank. If you have any of the symptoms, immediately call the public health department at XXX-XXX-XXXX.
Day number (after last contact) |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
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Temperature |
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Fatigue or weakness |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Muscle pain |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Headache |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Sore throat |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Vomiting |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Diarrhea |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Rash |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Unexplained bleeding** |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
Y N |
*Unexplained bleeding means bleeding from your mouth or nose, bloody diarrhea, or coughing up blood, or bruising under the skin |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | mrh7 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |
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