Form 0920-25-0004 Attachment E3 - SAMPLE VHF Symptom Monitoring Web Survey

Department of Health and Human Services  Version XX/XX/XXXX
Centers for Disease Control and Prevention  
Form Approved 

OMB Control No: 0920-XXXX

Exp. Date: XX/XX/XXXX

 

[SAMPLE VHF] Web Survey for Symptomatic Travelers

Please take a few minutes to confirm your location and answer some questions about the symptoms you are experiencing so we can connect you to a public health worker in your area. Your health and the health of your loved ones are important to us.

1. What is your current location? Enter your county/zip code.

2. Have you had a fever (100.4° F / 38° C or higher), felt feverish, or had chills? ☐ Yes ☐ No

3. Have you had new or unusual headache or muscle aches? ☐ Yes ☐ No

4. Do you have a rash? ☐ Yes ☐ No

5. Have you had chest pain? ☐ Yes ☐ No

6. Have you had a sore throat? ☐ Yes ☐ No

7. Have you had nausea, vomiting, or diarrhea? ☐ Yes ☐ No

SUBMIT [button]

[The following message will appear on the website after they click submit]

Thank you for providing this information. Please separate yourself from others (isolate). A public health worker will be in touch shortly to discuss your symptoms and provide recommendations.

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-XXXX).