Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation printable pdf download

This form must be completed electronically when possible. Handwritten forms will be accepted.

OMB No. 0720-0056

EBOLA VIRUS DISEASE EXPOSURE RISK EVALUATION

OMB approval expires

(IN THEATER USE ONLY)

May 31, 2018

The public reporting burden for this collection of information is estimated to average 12 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA

222350-3100 (0720-0056). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it

does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ADDRESS.

PRIVACY ACT STATEMENT

This statement serves to inform you of the purpose for collecting the personal information requested by this form and how it may be used.

AUTHORITY:

10 U.S.C. 1074f, Medical Tracking System for Members Deployed Overseas; 42 U.S.C. 264-272, Quarantine and Inspection, Executive Order 13295, Revised List of

Quarantinable Communicable Diseases; 42 CFR Part 70, Interstate Quarantine; 42 CFR Part 71, Foreign Quarantine; DoDI 6490.03, Deployment Health;

and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): Your information may be used for the purpose of collecting certain communicable disease(s) data IAW regulations providing for the apprehension, detention, or

conditional release of individuals to prevent the introduction, transmission, or spread of suspected communicable diseases, pursuant to section 361(b) of the Public

Health Service Act. Your information will be collected in order to identify any health concerns and, if necessary, refer you for additional assessment and/or care.

ROUTINE USE(S):

Use and disclosure of your records outside of DoD may occur in accordance with the DoD Blanket Routine Uses published at:

and as permitted by the Privacy Act of 1974, as amended (5 U.S.C. 552a(b)).

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45 CFR Parts 160 and 164),

as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, healthcare operations, and the

containment of certain communicable diseases.

DISCLOSURE:

Mandatory. To protect the health of the public from Ebola, a highly infectious virus of significant public health threat, you are hereby required to provide the

requested information. Care will not be denied if you decline to provide the requested information, but you may not receive the care you deserve and may face

administrative delays.

INSTRUCTIONS:

DoD personnel must IMMEDIATELY report any potential Ebola Virus Disease [EVD] exposure while deployed in an Ebola outbreak country

or region. Prompt medical evaluation is critical. You are required to truthfully answer all questions. Failure to disclose the requested medical

information regarding potential EVD contact or exposure risks while deployed to an Ebola outbreak area may result in UCMJ and/or criminal

punishment. If you do not understand a question, please discuss the question with a healthcare provider.

DEMOGRAPHICS

Last Name:

First Name:

Middle Initial:

Social Security Number:

Today’s Date

(dd/mmm/yyyy)

Date of Birth

Gender:

⃝ Male

⃝ Female

(dd/mmm/yyyy)

Service Branch:

Component:

Pay Grade:

⃝ Air Force

⃝ Active Duty

⃝ E1

⃝ O1

⃝ W1

⃝ Army

⃝ National Guard

⃝ E2

⃝ O2

⃝ W2

⃝ Navy

⃝ Reserves

⃝ E3

⃝ O3

⃝ W3

⃝ Marine Corps

⃝ Civilian Government Employee

⃝ E4

⃝ O4

⃝ W4

⃝ Coast Guard

⃝ Contractor

⃝ E5

⃝ O5

⃝ W5

⃝ Civilian Expeditionary Workforce

⃝ E6

⃝ O6

⃝ USPHS

⃝ E7

⃝ O7

⃝ Other Defense Agency (List):

⃝ E8

⃝ O8

⃝ Other

⃝ Other (List):

⃝ E9

⃝ O9

⃝ O10

Home Station/Unit:

Current Contact Information:

Point of contact who can always reach you:

Phone:

Name:

Cell:

Phone:

DSN:

Email:

Address:

Deployment location(s):

⃝ Liberia ⃝ Sierra Leone

⃝ Guinea

⃝ Senegal

⃝ Nigeria

⃝ Other:

Deployed Station/Unit:

Duties while deployed:

Date arrived in theater

(dd/mmm/yyyy)

DD FORM 2990, JUL 2015

PREVIOUS EDITION IS OBSOLETE.

Page 1 of 4 Pages

Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation

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