Direct Active Monitoring Tracking Report

Emergency Submission for Active Monitoring of Travelers Coming from Ebola-affected Countries and Their Contacts Currently Residing in State, Territorial, and Local Jurisdictions

AttC - Daily DAM Recording High Some EVD Risk - Excel.xlsx

Daily Active Monitoring Tracking Report - excel

OMB: 0920-1066

Document [xlsx]
Download: xlsx | pdf

Overview

Report
Dictionary
Sheet1


Sheet 1: Report

Traveler Information Daily Monitoring
City State State assigned ID CDC Id / Traveller's Health ID CDC Risk Category (High, Some) Healthcare Worker (y/n) Citizenship Status (if not U.S. Citizen) Arrival in Jurisdiction Date U.S. Entry Airport If other U.S. Entry Date Hospital Identified (y/n) Local Hospital Transport Plan to Hospital (y/n) Travelling During Monitoring Period (y/n) Summary of travel plans Comments Date of Last Some or High Risk Exposure Today's Date Contacted? Reason for No Contact Symptom (y/n) Description of Symptoms Referred for Evaluation (y/n) Referred for testing?(y/n) Comments




















































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































10/27/2014

























Sheet 2: Dictionary

Variable Name Variable Description Response
State assigned ID A unique ID for the traveler, ascribed by the state conducting the direct active monitoring (DAM), should stay the same throughout the DAM reporting period (typically 21 days) text
Traveler Health Declaration ID A unique ID for the traveler, ascribed by CDC when form is received from CBP; should stay the same throughout the DAM reporting period (typically 21 days) text
State State that is conducting the DAM and reporting text
CDC Risk Category (High, Some, Low) Risk category according to CDC's Interim Guidance for the Monitoring and Movement of persons with potential exposure to ebola virus disease* some or high*
HCW Was the traveler a healthcare worker treating patients in W. Africa y/n
Hospital Identified Has a hospital been identified that the travel will be taken to if he or she becomes symptomatic? y/n
Hospital Name Name of hospital identified that the traveler will be taken to if he or she becomes symptomatic text
Transfer Plan Is a transfer plan in place for moving the traveler to the hospital if he or she becomes symptomatic y/n
Travel Plans Does the person have travel plans during the monitoring period yes/no
Travel Plans Summary of person's plans for travel within the monitoring period and jurisdiction's plans for continued monitoring text
Date of person's last exposure Date person was last exposed to the event that put them in the some or high category Date
Date of entry into the US Date person was last exposed to the event that put them in the some or high category Date
Days until DAM completed Number of days until the 21 day incubation period is over (=Today's date -Date of last exposure) Number (0-21)
Date 21 days post-exposure Date the 21 day incubation period should end (=exposure +21) Date
Date of last DAM (as of midnight) 1 Day for which this report reflects (normally yesterday) Date
If no, why (Txt) If not, why not; could reflect "DAM Period Completed" text
Total Number of Days DAM was required Total number of days that DAM was required; will usually be (= Today - Date of Entry to U.S) but might defer for unique situations (DAM officially began 10/27/14) Number
Number of Days until DAM is completed Total number of days until DAM period is completed (# of days required minus number of days completed or missed) Number
Total Number of Days DAM completed Total number of days that DAM was completed successfully (based on "y" on tracking worksheet) Number
Total Number of Days DAM missed Total number of days that DAM was missed (based on "n" on tracking worksheet) Number
% of days completed Percentage of number of days DAM completed within the required period Percent
Symptom (y/n) Did traveler have fever or other symptom such as severe headache, muscle pain, vomitting, diarrhea, stomach pain, unexplained bruising or bleeding yes/no
Refered for Evaluation (y/n) Was the person referred for medical evaluation? yes/no
Refered for testing (y/n) Was the person referred for testing for EVD? yes/no



High risk includes any of the following:


Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of a person with Ebola while the person was symptomatic

Exposure to the blood or body fluids (including but not limited to feces, saliva, sweat, urine, vomit, and semen) of a person with Ebola while the person was symptomatic without appropriate personal protective equipment (PPE)(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html)

Processing blood or body fluids of a person with Ebola while the person was symptomatic without appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) or standard biosafety precautions

Direct contact with a dead body without appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) in a country with widespread Ebola virus transmission(http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html)

Having lived in the immediate household and provided direct care to a person with Ebola while the person was symptomatic



Some risk includes any of the following:


In countries with widespread Ebola virus transmission(http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html): direct contact while using appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) with a person with Ebola while the person was symptomatic

Close contact in households, healthcare facilities, or community settings with a person with Ebola while the person was symptomatic

Close contact is defined as being for a prolonged period of time while not wearing appropriate PPE(http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html) within approximately 3 feet (1 meter) of a person with Ebola while the person was symptomatic

Sheet 3: Sheet1

Look up Table

High
Some
Low (but not zero)
No identifiable risk



yes
no



H - Healthcare Worker
T- Traveler on airplane
M - Household Member
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy