Dd Form 2990 - Ebola Virus Disease Exposure Risk Evaluation Page 4
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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):
PART I-C: Ebola Virus Disease Risk Category [Mark ONLY one.]
Disposition Guidance: Document risk category in the individual’s medical record.
Asymptomatic:
•
Return to duty and continue twice daily unit monitoring for exposure risk and clinical
⃝
symptoms.
No Known
Symptomatic (Fever WITH or WITHOUT other symptoms)
Exposure
•
Evaluation by medical authority.
•
Implement infection control precautions.
Asymptomatic:
•
Evaluate for potential medical evacuation IAW official policy.
⃝
•
If determined to be “minimal risk” return to duty and begin twice daily monitoring by medical
authorities for 21 days.
Some Risk of
Symptomatic: (Fever WITH or WITHOUT other symptoms)
Exposure
•
Evaluation by medical authority.
(“Yes” to
•
Isolate and separate from “High Risk individuals. Implement infection control precautions.
questions 1 or 2,
•
Evacuate from theater via regulated movement to a DoD designated medical facility capable
PART I-A)
of providing care for EVD patients IAW official policy.
Asymptomatic:
⃝
•
Evaluation by medical authorities.
High Risk
•
Quarantine and evacuate from theater via regulated movement to a DoD designated facility
Exposure
capable of monitoring for signs and symptoms and providing care for EVD patients IAW official
policy.
(“Yes” to
Symptomatic: (Fever or other symptoms)
questions
3, 4, 5, or 6 ,
•
Evaluation by medical authorities.
PART I-A)
•
Isolate and separate from “Some Risk” individuals. Implement infection control precautions.
•
Evacuate from theater via regulated movement to a DoD designated facility capable of
providing care for EVD patients IAW official policy.
Provider’s Name:
Date (dd/mmm/yyyy):
Time:
Title:
⃝ MD ⃝ DO
⃝ PA
⃝ Nurse Practitioner
⃝ Adv Practice Nurse
⃝ Other:
⃝ I certify this assessment process has been completed.
Provider’s Signature:
DD FORM 2990, JUL 2015
Page 4 of 4 Pages
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