0920-1443 CDC Initial Screening Form_Marburg_

Department of Health and Human Services Version 11/04/2024
Centers for Disease Control and Prevention
Form Approved

OMB Control No: 0920-1443

Exp. Date: 03/31/25

CDC Initial Screening at POE (CDC Primary) – Marburg Response
Date of Arrival in U.S. mm/dd/yy: _______________ Flight #:__________POE: ___________
CDC Initial Screening Start Time: _________ AM/PM
Date arrived in Rwanda? mm/dd/yy ____________ Date left Rwanda? ____________

Body Temperature: ______°F Visible signs of illness? ☐ Yes ☐ No

Today or in the past 2 days: have you had any of the following symptoms?
Fever (100.4° F / 38° C or higher), feeling feverish, or chills? ☐ Yes ☐ No
New or unusual headache or muscle aches? ☐ Yes ☐ No

Rash ☐ Yes ☐ No

Chest pain or sore throat? ☐ Yes ☐ No
Nausea, vomiting or diarrhea? ☐ Yes ☐ No

While you were in Rwanda, in the past 21 days:

Were you in any of the following districts? ☐ Yes ☐ No [Screener to provide current list of outbreak districts]

While you were in any of the districts listed above in the past 21 days:
Were you present in any healthcare facility (such as hospital or clinic) or did you visit a traditional healer? ☐ Yes ☐ No

Did you provide health care to or have any other contact with patients? ☐ Yes ☐ No

Did you have any contact with or were you near a sick person? ☐ Yes ☐ No

Did you come into contact with anyone's blood or other body fluids

(such as vomit, saliva, feces, or urine)? ☐ Yes ☐ No

Did you touch a dead body or attend a funeral? ☐ Yes ☐ No

What was the main reason you were in Rwanda? (mark all that apply)
☐ Healthcare Service/Mission (includes training, clinical laboratory) ☐ Public Health Deployment
☐ Other Humanitarian Service (not healthcare or public health) ☐ Business ☐ Faith-based

☐ Visit Family/Friends ☐ Tourism ☐ Lives in Rwanda ☐ Other _____________________

Traveler’s Contact Information for Destination in the United States:
Traveler’s Last Name: ___________________ ___________ First: __________________________
Date of Birth (mm/dd/yyyy): __________________ Duration of stay at U.S. destination: _______days (if ≥21, enter 21)
Street Address at U.S. Destination:______________________________________________________
City: _______________________State: ________ ZIP: ____________
Telephone/Texting APP Number in U.S. __________________________________________________
Is number a U.S. mobile phone (circle one): Y / N Name of Texting APP, if applicable? ____________

Email address: ___________________________________________________

☐ Self-monitoring ☐ Traveler referred for additional risk assessment at POE
PHARS#: _______________ CDC Initial Screening End Time: ________________ AM/PM

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, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-1443).