Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation (Page 3 of 4) in pdf

Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation Page 3

This 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):

PART I -

Ebola Virus Disease Clinical Evaluation [Mark all that apply.]

Ask “Are you currently experiencing any of the following signs and symptoms?”

Yes

a. Fever (temperature of > 100.4

⃝ Don’t Know

⃝

b. Subjective fever

⃝

( e.g., chills, night sweats)

c. Severe headache

⃝

d. Joint and muscle aches

⃝

e. Abdominal/stomach pain

⃝

f. Vomiting

⃝

g. Diarrhea

⃝

h. Unexplained bruising or bleeding

⃝

i . New skin rash

⃝

j. Other

⃝

(describe in block #5)

Ask “Have you taken any fever-reducing medications within the past twelve [12] hours?”

⃝

(e.g ., aspirin, Tylenol , Motrin, Ibuprofen )

Conduct and record temperature check.

Temperature:

Time:

Date and time of onset of symptoms . Date

Time:

⃝ N/A

(dd/mmm/yyyy)

Comments:

DD FORM 2990, JUL 2015

Page 3 of 4 Pages

Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation Page 3

Related Articles

Related forms

Related Categories