Ebola Exposure Screening Form
Please answer the following questions to help assess recent risk of Ebola exposure. All questions are for practical screening purposes only.
Full Name
*
First Name
Last Name
Age
*
Current City and Country
*
Have you traveled outside your current country in the past 21 days?
*
Yes
No
If yes, which countries did you visit in the past 21 days?
Have you had direct physical contact with anyone diagnosed with or suspected of having Ebola in the past 21 days?
*
Yes
No
Not sure
In the past 21 days, have you cared for or handled the belongings of someone with Ebola symptoms (such as vomiting, diarrhea, or bleeding)?
*
Yes
No
Not sure
Have you worked in a healthcare or laboratory setting in the past 21 days?
*
Yes
No
Have you experienced any of the following symptoms in the past 21 days? (Select all that apply)
*
Fever
Unexplained bleeding or bruising
Vomiting
Diarrhea
Muscle pain
None of the above
Please provide a contact phone number (for follow-up if needed)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Screening
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