Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation Page 2
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4This form must be completed electronically when possible. Handwritten forms will be accepted.
EBOLA VIRUS DISEASE EXPOSURE RISK EVALUATION
(IN THEATER USE ONLY)
Deployer’s SSN (Last 4 digits):
COMPLETED BY DESIGNATED MEDICAL PROVIDER ONLY – Provider Review, Interview, Exposure Risk Evaluation
PART I - A : Ebola Virus Disease Risk Assessment
[Mark all that apply . If “Yes” document date, time & type of MOST recent exposure.]
SOME RISK OF EXPOSURE: One or more of the following within the past 21 days.
Yes
No
1.
Close contact with an Ebola Virus Disease (EVD) patient in any of the following settings:
household, living quarters, work, or community? If yes, document date, time and type of
contact and/or exposure.
Date
:
Time:
Type:
(dd/mmm/yyyy)
Close contact is defined as:
⃝
⃝
a.
Being within approximately 3 feet (1 meter) of an EVD patient for a prolonged period of time while not
wearing recommended personal protective equipment (PPE) or PPE was compromised.
b.
Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment (PPE) or PPE was compromised.
(Brief interactions, such as walking by a person, do not constitute close contact.)
2.
Other close contact with EVD patients in healthcare facilities or community settings? If
yes, document date, time and type of contact and/or exposure.
Date
:
Time:
Type:
(dd/mmm/yyyy)
Close contact is defined as:
a.
Being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area
for a prolonged period of time (e.g., health care personnel, household members) while not wearing
⃝
⃝
recommended personal protective equipment (PPE) (standard droplet and contact precautions) or PPE
was compromised.
b.
Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended
personal protective equipment (PPE) or PPE was compromised.
(Brief interactions, such as walking by a person or moving through a hospital, do not constitute close
contact.)
HIGH RISK OF EXPOSURE: One or more of the following within the past 21 days.
Yes
No
3.
Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids
of an EVD patient? If yes, document date, time and type of contact and/or exposure.
⃝
⃝
Date
:
Time:
Type:
(dd/mmm/yyyy)
4.
Direct skin contact with, or exposed to, blood or body fluids of an EVD patient without
⃝
⃝
appropriate personal protective equipment (PPE) or PPE was compromised? If yes,
document date, time and type of contact and/or exposure.
Date
:
Time:
Type:
(dd/mmm/yyyy)
5.
Processing blood or body fluids of a confirmed EVD patient without appropriate personal
protective equipment (PPE), standard biosafety precautions or PPE was compromised? If
⃝
⃝
yes, document date, time and type of contact and/or exposure.
Date
:
Time:
Type:
(dd/mmm/yyyy)
6.
Direct contact with a dead body without appropriate personal protective equipment
(PPE), or PPE was compromised in a country where an EVD outbreak is occurring? If yes,
⃝
⃝
document date, time and type of contact and/or exposure.
Date
:
Time:
Type:
(dd/mmm/yyyy)
DD FORM 2990, JUL 2015
Page 2 of 4 Pages
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