Get the free Ebola Contact Monitoring Form (PDF) - doh wa

EBOLA CONTACT MONITORING FORM Local Health Jurisdiction: Contact IDs LBJ ID: DOH ID: CDC ID: Name Last: First: Middle initial: DOB / / Local Address Sex: Age: Years Street: Months Apt: City: State:

How to fill out ebola contact monitoring form

How to fill out the Ebola contact monitoring form:

1. Start by providing your personal information, such as your full name, contact information, and date of birth. This will help in identifying and contacting you if needed.
2. Next, indicate your relationship to the Ebola patient or the reason for potential exposure. This could be a healthcare worker, a family member, or someone who had close contact with an infected individual.
3. Specify the dates and times of contact with the Ebola patient. Include any potential exposure incidents, such as providing care or being in close proximity to the patient while they were exhibiting symptoms.
4. Detail the nature of contact and the level of exposure. This may include whether you had direct physical contact with the patient, touched their bodily fluids, or had prolonged face-to-face interaction within a certain distance.
5. Indicate any personal protective equipment (PPE) used during the contact. This includes gloves, masks, gowns, or other equipment that may have been used to protect yourself from potential exposure.
6. Provide information about any symptoms you may have experienced after the contact. This is important for monitoring and early detection of possible Ebola infection. If you did not experience any symptoms, mention that as well.
7. Lastly, sign and date the form to confirm the accuracy of the information provided.

Who needs an Ebola contact monitoring form:

1. Healthcare workers who are involved in the care and treatment of Ebola patients.
2. Family members or close contacts of Ebola patients who may have had prolonged and close contact with the infected individual.
3. Anyone who may have been exposed to the Ebola virus and requires monitoring and follow-up to ensure early detection and treatment if necessary.

It is important to note that the specific requirements and procedures for filling out an Ebola contact monitoring form may vary depending on the organization or public health authority providing the form. It is recommended to follow the instructions provided with the form and consult with healthcare professionals if needed.

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