Get the free Ebola Screening Form - American Jail Association

Ebola Screening Form Patient Name: Book-in Number: Date of Birth: Age: Race: Date: Step:1 Initial Screen at Intake 1. In the last 21 days, have you been in one or more Ebola outbreak-affected countries

How to fill out ebola screening form

How to fill out an Ebola screening form:

1. Begin by carefully reading the instructions provided on the form. Make sure you understand each section and the information it requires.
2. Start by providing your personal details such as your name, date of birth, and contact information. This information is necessary for identifying the individual filling out the form.
3. Next, provide information about your recent travel history. This may include details like countries visited, dates of travel, and modes of transportation used. Be as accurate and specific as possible.
4. The form may also ask about any potential exposure to Ebola. Answer honestly and provide details if necessary. This may include contact with individuals diagnosed with Ebola, visiting areas with ongoing outbreaks, or handling potentially infected material.
5. If the form includes a section for symptoms, carefully read the list provided and mark any symptoms you are currently experiencing. Common Ebola symptoms may include fever, headache, muscle pain, weakness, diarrhea, vomiting, or bleeding.
6. Finally, review your answers to ensure accuracy and completeness. Any incorrect or missing information may lead to delays or confusion in the screening process.
7. Once you have filled out the form, ensure that you sign and date it as required. This signifies that the information provided is accurate to the best of your knowledge.
8. Submit the completed form to the appropriate authorities or healthcare professionals as instructed.

Who needs an Ebola screening form?

1. Individuals traveling to or from areas with known Ebola outbreaks may be required to fill out an Ebola screening form. This allows authorities to monitor and prevent the spread of the virus.
2. Healthcare professionals and airport personnel may also request individuals with potential exposure or symptoms to fill out an Ebola screening form. This helps in identifying potential cases and providing appropriate care and isolation if needed.
3. Additionally, individuals participating in medical missions, humanitarian work, or research projects in areas with Ebola outbreaks may be required to complete an Ebola screening form to ensure their safety and the safety of others.

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