Ebola Risk Assessment Form

Region:
Los Angeles County
Source:
Los Angeles County Public Health Acute Communicable Disease Control Program (LACDPH ACDC)
Resource Updated:
Apr. 03, 2019
Ebola Risk Assessment Form

About this Resource

Official California Department of Public Health form to assess for Ebola Virus Disease (EVD) symptoms and for potential exposure risk in the U.S. or while traveling in an Affected/Endemic Area with widespread EVD transmission within the past 21 days.

Audience

Hospital staff caring for patients under investigation or patients with confirmed Ebola virus disease (EVD).

Key Takeaways

  • California Department of Public Health (CDPH) form to assess for Ebola Virus Disease (EVD) symptoms and for potential exposure risk to an EVD case in the United States OR while traveling in an Affected/Endemic Area with widespread EVD transmission within the past 21 days.
  • This form is intended to be utilized to determine the risk exposure category for EVD contacts.
  • Depending upon the risk exposure category, EVD contacts may be required to be monitored by LAC DPH for fever and EVD symptoms for 21 days following the last date of exposure.
  • Completed Ebola Risk Assessment forms must be faxed to Acute Communicable Disease Control (ACDC) (Fax:213-202-5999).