0920-1376 Risk Assessment and Post-Arrival Monitoring Outcome REDC

Risk Assessment and Post-Arrival Monitoring Outcome REDCap Reporting Process for Persons with Travel History from Uganda in the Prior 21 Days

Notes

Initial Survey – Sent only once

1. In which state is your health department located?

   1. Drop down with all states and territories AND large cities that have separate HDs

2. What is the full name of your health department? _____

3. Please note how your staff will handle reporting:

   1. State HD will report for all jurisdictions

   2. State HD will report for some but not all jurisdictions

      1. The locations that will be reporting separately are: ________

   3. Other___________ (please specify)

4. Please include the name(s) and email address(s) for those who will be reporting for your jurisdiction:

   1. Name __________

   2. Email____________

Monthly Survey Sent to HD POCs Identified in Initial Survey

1. During the last month (Please see guidance page for monitoring recommendations and definitions Interim Guidance on Risk Assessment and Management of Persons with Potential Ebola Virus Exposure | Quarantine | CDC):

Categories are NOT mutually exclusive	For how many travelers did you receive contact information from CDC because they were in Uganda in the previous 21 days?	How many of the travelers listed in the first column were you able to contact?	How many travelers completed the 21-day monitoring period in your jurisdiction?
Total
Present in outbreak country but not designated outbreak area
Present in designated outbreak area
Reported high-risk exposures

2. In the past month, how many travelers were on the SAMS/SDX list you received from CDC, who you were unable to contact (Categories not mutually exclusive):

• Total_____

• Due to non-working phone number____

• Due to incorrect address_____

• Due to other reasons______ (please specify)

3. For those travelers who began monitoring in your jurisdiction, how many did not complete monitoring?

   • Total___________

   • Due to travel to another state_____

• Due to travel to another country_____

• Due to other reasons______ (please specify)

4. Did you contact anyone who was not on the SAMS/SDX list? yes/no

• If yes, how did you obtain identifying and contact information for these travelers (check all that apply)

  1. Traveler notified the health department

  2. Traveler seen by provider who called the health department

  3. Other ______ (please specify)

5. For how many travelers did you receive contact information who should have been assigned to another jurisdiction? _______

6. For how many travelers did you receive contact information who reported not being in Uganda in the past 21 days?) _________