Yes No Unknown During this time was there contact with a confirmed/probable case/s? Case Contact 1 name Living Deceased Case Contact 1 type patient patient Visit sick Care for sick Bury patient patient deceased – specify type of patient care Specify type of contact  Exposed to Exposed to blood, saliva, blood, saliva, urine, vomit or urine, vomit faeces of or faeces of deceased sick patient patient Case Contact 2 name Living Deceased Case Contact 2 type patient patient Visit sick Care for sick Bury patient patient deceased – Specify type of contact specify type of patient care  Exposed to Exposed to blood, saliva, blood, saliva, urine, vomit or urine, vomit faeces of or faeces of deceased sick patient patient Yes No Unknown Recent residence or travel in an area with active Ebola disease/outbreak If yes, specify country, region Specify dates of travel __ /__ /____ To __ /__ /____ Animal exposures Yes No Unknown Contact with bats, primates or Details other animals from area? Yes No Unknown Contact with people who are in Details close contact with bats or primates from disease-endemic areas b/c of their work?
During this time was there contact with a confirmed/probable case/s? Yes No Unknown Case Contact 1 name Case Contact 1 type Living patient Deceased patient Specify type of contact Visit sick patient Care for sick patient – specify type of care Bury deceased patient Exposed to blood, saliva, urine, vomit or faeces of sick patient  Exposed to blood, saliva, urine, vomit or faeces of deceased patient Case Contact 2 name Case Contact 2 type Living patient Deceased patient Specify type of contact Visit sick patient Care for sick patient – specify type of care Bury deceased patient Exposed to blood, saliva, urine, vomit or faeces of sick patient  Exposed to blood, saliva, urine, vomit or faeces of deceased patient Recent residence or travel in an area with active Ebola disease/outbreak Yes No Unknown If yes, specify country, region Specify dates of travel __ /__ /____ To __ /__ /____ Animal exposures Contact with bats, primates or other animals from area? Yes Details No Unknown Contact with people who are in close contact with bats or primates from disease-endemic areas b/c of their work? Yes Details No Unknown