Form 0920-25-0004 Attachment D - POE Public Health Risk Assessment Form_SA

Traveler’s Name: __________________ PHARS#:____________________

CDC RISK ASSESSMENT AT POE (CDC Secondary) – [SAMPLE VHF] Response
IF TRAVELER CLINICALLY UNSTABLE: DO NOT DELAY EMS TRIAGE AND TRANSPORT. ENSURE ISOLATION, ADVANCE NOTIFICATION/PLANNING WITH STATE/LOCAL HEALTH DEPARTMENT AND RECEIVING FACILITY.

Reason for Referral: ☐ Symptomatic ☐ Presence in a healthcare facility

☐ Healthcare mission/professional/student ☐ Contact/near sick person
☐ Contact with blood or other body fluids ☐ Contact with dead body/funeral attendance
☐ Other: _____________________________________

Tell traveler: You were referred for this additional public health assessment because we need to get more information to determine if [select reason as appropriate based on referral]:
- you had a possible exposure to [SAMPLE VHF] virus.

- your symptoms are concerning for [SAMPLE VHF] disease.
These questions will help us decide next steps. (Be cognizant of any flight connections, or other travel).

HEALTH ASSESSMENT
(Complete if febrile/feverish, ill appearance, symptomatic on CDC Primary)
Appears well? ☐ YES ☐ NO, specify: _____________________________________________

Temperature measurement: ____________(°C/°F) Method: ________________________

Signs/symptoms in the past 2 days?

☐ Fever (≥100.4°F/38.0°C )– if YES, T-max: _____(C/F) Method: _________
Date (mm/dd/yy): __ /__ /_____ Time:_______ AM/PM (calculate using your time zone of POE)
☐ Subjective Fever ☐ Chills ☐ New/Unusual Fatigue ☐ New/Unusual Weakness
☐ New/Unusual Headache ☐ New/Unusual Muscle Pains ☐ Loss of appetite
☐ Cough/difficulty breathing/sore throat, other resp symptoms ☐ Chest pain
☐ Nausea ☐ Vomiting ☐ Diarrhea ☐ Abdominal pain ☐ Unexplained bruising/bleeding
☐ Skin rash [If yes, describe appearance and location(s)]:____________________________
___________________________________________________________________________
Date of 1^st symptom onset (mm/dd/yy): ____ /____ /_____ ☐ No symptoms reported

Comments: ______________________________________________________________________________
___________________________________________________________________________________________

Use of antipyretic medication(s) in past 24 hours: ☐ YES ☐ NO
Name of antipyretic: ___________________ Dose: _______ Time: ______ Purpose: ________________ Name of antipyretic: ____________________ Dose: _______ Time: ______ Purpose: _______________

Was malaria prophylaxis taken as prescribed? ☐ YES ☐ NO Name of antimalarial: _______________

SPONSORING ORGANIZATION & PREDEPARTURE ASSESSMENT AVAILABILITY
(Complete if part of healthcare mission, health personnel)
If healthcare provider or part of a healthcare mission (includes students, trainees), was the traveler under an affiliation with a sponsoring organization?
☐ Yes ☐ No If yes, provide name of organization: ____________________________________
Name of representative/POC in the U.S.: ______________________Phone #: _______________
Does traveler have a copy of the Predeparture Assessment Form?
☐ Yes ☐ No (not done) ☐ No (completed a form, even if org’s own version, but traveler does not have it)
Review the form and return it to the traveler. The health department may ask them for that form.

HEALTHCARE FACILITY & ROLE
(Complete if any presence in healthcare facility)
Presence in Healthcare Facility:
Healthcare facility(ies) name(s) and location(s) in [COUNTRY] visited or worked in (check here ☐ if none visited/worked in): ___________________________________________________________

Reason for presence in HCF (check all that apply): ☐ Patient care ☐ Laboratorian
☐ Cleaning/laundry service ☐ Nonclinical role (clergy, social work, meal service)
☐ Patient ☐ Patient’s companion/visitor
☐ Presence in patient care areas ☐ Presence in non-patient care areas only
☐ Other: ____________________
Traditional Healer ☐ Yes ☐ No
If yes, describe visit with traditional healer: _____________________________________________

Last day present in HCF (mm/dd/yy): ____ /____/_____

EXPOSURE ASSESSMENT:
(Complete if contact/near a sick person, healthcare personnel/student, blood/body fluid contact)
The following questions apply to any setting (healthcare or non-healthcare):
Did you stay in the same household as a person who had [SAMPLE VHF] or may have had [SAMPLE VHF]?
☐ YES ☐ NO ☐ UNSURE

Did you provide care to or have other physical contact with a sick person who had [SAMPLE VHF] or may have had [SAMPLE VHF]?
☐ YES ☐ NO ☐ UNSURE

Did you provide this care in a healthcare facility or another location (such as a home)?
☐ HCF ☐ Home ☐ Other: ________________
Was this sick person confirmed to have [SAMPLE VHF]? ☐ YES ☐ NO ☐ UNSURE
Did the sick person have vomiting, diarrhea, or bleeding? ☐ YES ☐ NO ☐ UNSURE
Comments: ____________________________________________________________________
Did you have a needlestick, other injury with a sharp object (that is, piercing of your skin), or splash to the eye, nose, or mouth, or skin contact with blood or other body fluids of a person who had [SAMPLE VHF] or may have had [SAMPLE VHF]? ☐ YES ☐ NO ☐ UNSURE

Any contact with blood or body fluids that I have not asked about? ☐ YES ☐ NO

[HCWs only] When you provided care for this person, what personal protective equipment did you use? ☐ N/A
☐ Disposable fluid-resistant or impermeable gown/coverall
☐ Disposable full-face shield ☐ Disposable facemask ☐ Boot covers ☐ Disposable apron
☐ N95 respirator ☐ PAPR ☐ Two pairs of disposable gloves (outer gloves with extended cuffs)

[HCWs only] Did you experience any breach in infection control precautions? ☐ YES ☐ NO ☐ UNSURE ☐ N/A

[HCWs only] Did you conduct or assist with an invasive procedure on the ill person or aerosol-generating procedure? ☐ YES ☐ NO ☐ N/A
Comments: _______________________________________________________________

___________________________________________________________________________

CLINICAL LABORATORY:
(Complete if any work as laboratorian)
Did you handle clinical specimens? ☐ YES ☐ NO
Did you have a needlestick, other sharps injury (that is, piercing of your skin), or splash to the eye, nose, or mouth, or skin contact with blood or other body fluids of a person who had [SAMPLE VHF] or may have had [SAMPLE VHF]? ☐ YES ☐ NO ☐ UNSURE

Any contact with blood or body fluids that I have not asked about? ☐ YES ☐ NO

Please describe: ________________________________________________________________

ENVIRONMENTAL:
(Complete if any work as cleaner, custodial, or doing laundry in HC facility)
Did you perform environmental cleaning in any patient care areas? ☐ YES ☐ NO
What PPE did you use? ☐ Disposable fluid-resistant or impermeable gown/coverall

☐ Disposable full-face shield ☐ Disposable facemask ☐ Disposable apron

☐ N95 respirator ☐ Disposable gloves ☐ Other: __________________________________
Did you get any body fluids on your skin or clothes? ☐ YES ☐ NO ☐ UNSURE

Comments: ______________________________________________________________________

FUNERAL OR MORTUARY:
(Complete if attended a funeral or reported contact with dead body)
Please describe presence in a funeral or touching a dead body (touched deceased garments?)

☐ Mortuary/burial worker ☐ Traditional rituals
Was the cause of death known?

If a mortuary/burial worker, what PPE did you use?
☐ Disposable fluid-resistant or impermeable gown/coverall

☐ Disposable full-face shield ☐ Disposable facemask ☐ Disposable apron

☐ N95 respirator ☐ Disposable gloves ☐ Other: __________________________________

Did you have any problems with your PPE that resulted in skin or clothes becoming contaminated?
☐ YES ☐ NO ☐ UNSURE

Please describe any other situations/events not listed above that are of concern to the staffer/volunteer/traveler:

_____________________________________________________________________________________

_____________________________________________________________________________________

SUMMARY RISK ASSESSMENT:
☐ Asymptomatic ☐ Symptomatic but no suspicion of [SAMPLE VHF]
☐ Suspect [SAMPLE VHF] virus disease ☐ High-risk exposure to [SAMPLE VHF] virus

☐ Situation(s) with Additional Exposure Potential:
☐ Present in patient care area ☐ Provided healthcare/interacted with sick person(s)
☐ Received healthcare ☐ Performed clinical lab work/handled specimens
☐ Conducted mortuary, funerary, burial work
☐ Present in healthcare facility (not patient care areas such as only administrative spaces)

☐ Presence in [COUNTRY] (no high risk exposure or situations with additional exposure potential identified)

If any high-risk exposures are reported, or if [SAMPLE VHF] is suspected or confirmed, please do the following:

• Quarantine/isolate the individual.

• If not already done as part of assessment, contact the CDC Viral Special Pathogens Epidemiologist on-call.

• Person may not travel commercially.

• Need to notify and consult with State/Local health department and facility (if applicable) for isolation/quarantine and further public health and clinical (if applicable) management.
  

Date of Evaluation (mm/dd/yy): _______________Time: ______________ AM/PM

Name of person performing the assessment: _______________________________________________

Title: _____________________________________ Signature: _______________________________

Name of CDC SME Consulted (if applicable): ____________________________________

ACTIONS TAKEN:
☐ Isolation ☐ Quarantine ☐ Federal Public Health Order ☐ No onward travel allowed
☐ Briefed/consulted state/local health department
☐ Assessment documents shared with state/local health department
☐ Other: ______________________________________________________________

ACTIONS RECOMMENDED:
☐ Prompt Follow up of traveler by state/local HD at destination

☐ Self-monitoring (all travelers with nexus to [COUNTRY] in prior 21 days)
☐ Post Arrival Monitoring
☐ Abstain from working in either clinical or non-clinical roles in a U.S. healthcare facility until 21 days after their last presence in patient care area(s) in [COUNTRY] healthcare facility
☐ Other: ____________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1031.

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