Ebola Virus Disease Case Contact Questionnaire
Interviewee Name: Age: _______ Gender: _____________
Ebola Virus Disease (EVD) patient: .
Relationship to patient:
Address: City: State:
Phone number (home): (work):
Email: @
Did you have contact with the patient with ebola virus disease (EVD) while they had symptoms?
No (Skip to Question 2)
Yes IF YES: Date of LAST direct contact with the patient:
1a. IF YES: What was the nature of your contact with the patient?
No contact due to appropriate PPE
Contact with your intact skin
Contact with your broken skin (fresh cut, burn, or abrasion that had not dried)
Mucous membrane contact (eyes, nose, mouth, etc.)
Other (Specify):
1b. IF PPE Used: Check all that were used.
Gloves Double gloves Gown Glasses/goggles Face Shield Mask Leg Cover Tyvek suit
Did you come into contact with body fluid(s) from the patient with EVD while they had symptoms?
No (Skip to Question 3)
Yes IF YES: Date of LAST contact with the body fluids:
2a. IF YES: What was the nature of your contact with the patient?
No contact due to appropriate PPE
Contact with your intact skin
Contact with your broken skin (fresh cut, burn, or abrasion that had not dried)
Mucous membrane contact (eyes, nose, mouth, etc.)
Other (Specify):
2b. What body fluids did you contact (check all that apply)?
Tears Saliva Respiratory/Nasal secretions
CSF Vomitus Urine
Blood Stool Sweat
Semen/Vaginal fluid Other (Specify):
2c. IF PPE Used: Check all that were used.
Gloves Double gloves Gown Glasses/goggles Face Shield Mask Leg Cover Tyvek suit
If the patient with EVD has expired (died), did you have contact with the body?
No, the patient is alive. (Skip to Question 4)
No, did not contact the body and did not attend the funeral. (Skip to Question 4)
No, but attended the funeral services. Date of the funeral:
Yes, direct contact with the body. Date of LAST contact with the body:
3a. What was the nature of your contact with the body?
No contact due to appropriate PPE
Contact with your intact skin
Contact with your broken skin (fresh cut, burn, or abrasion that had not dried)
Mucous membrane contact (eyes, nose, mouth, etc.)
Other (Specify):
2c. IF PPE Used: Check all that were used.
Gloves Double gloves Gown Glasses/goggles Face Shield Mask Leg Cover Tyvek suit
Are/were you a healthcare worker providing health services for the patient?
No (Skip to Question 5)
Yes
5a. IF YES, in what manner did you provide health services to the patient?
Direct clinical care services (physician, nurse, clinical aide, etc.)
Laboratory services (phlebotomy, other sample collection, laboratory processing)
Custodial services (launder sheets, cleaning equipment, cleaning patient’s room)
Other (Specify):
Did you have any other contact with the patient (Specify):
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Classification:
High Risk
Direct exposure to body fluids of the EVD patient
Direct care of a confirmed or suspected EVD patient without PPE
Laboratory worker processing body fluids without appropriate laboratory biosafety precautions
Participation in funeral rites or body preparation of the EVD patient without appropriate PPE
Low Risk
No high risk exposures identified
Providing patient care while using PPE of an EVD patient
Household member or casual contact of an EVD patient
No Known Risk
No other high or low risk exposures identified
Had no contact with EVD patient
Follow-up Actions:
No further follow-up required. Does not meet high or low risk criteria or last exposure was >21 days.
Fever Monitoring Recommended (for High and Low Risk only)
Who will conduct the follow up for fever monitoring?
Name
Phone Number
Fever monitoring recommended but respondent is refusing follow up
Respondent has had a fever since having contact with the patient
Where will the patient be evaluated for fever?
Who at the Department of Health was notified?
Phone Number
Interviewer’s Name: ______________________Date: ___________
| File Type | application/msword |
| Author | Diana Martinez |
| Last Modified By | CDC User |
| File Modified | 2014-10-15 |
| File Created | 2014-10-15 |