Additional information about medical care F-01340 (Rev. 11/12/2014) Page 2 of 2 Does traveler intend to have dental care within 21 days since last date of exposure? Yes No If yes, list name of dental clinic and additional information about dental care. Dental Clinic Location Clinic – Additional information about dental care Does traveler own or currently care for any pet(s)? Yes No If yes, list type(s) of pet(s) and how many of each Type How many Type How many Type How many Type How many Type How many Type How many Does traveler participate in other activities that involve contact with animals (e.g., occupations, hobbies, farm or zoo visits, or work with service animals)? Yes No If yes, describe activity and type of animals Is traveler planning to travel within 21 days since last date of exposure? Yes No If yes, list location(s) and dates of planned travel below. Location(s) Dates From / To – / Did anyone else accompany traveler on the trip from Africa? Yes No If yes, list name(s) and contact information below. (If child, list parent/guardian name and information) 1. Name Contact Contact - Telephone No. (Include area code) – 2. Name Contact Contact - Telephone No. (Include area code) – 3. Name Contact Contact - Telephone No. (Include area code) – 4. Name Contact Contact - Telephone No. (Include area code) – 5. Name Contact Contact - Telephone No. (Include area code) – 6. Name Contact Contact - Telephone No. (Include area code) – 7. Name Contact Contact - Telephone No. (Include area code) – Name Telephone Number (include area code) Interviewer’s *Check CDC website () for most current list of countries with active EV transmission.
Additional information about medical care F-01340 (Rev. 11/12/2014) Page 2 of 2 Does traveler intend to have dental care within 21 days since last date of exposure? Yes No If yes, list name of dental clinic and additional information about dental care. Dental Clinic Location – Clinic Additional information about dental care Does traveler own or currently care for any pet(s)? Yes No If yes, list type(s) of pet(s) and how many of each Type How many Type How many Type How many Type How many Type How many Type How many Does traveler participate in other activities that involve contact with animals (e.g., occupations, hobbies, farm or zoo visits, or work with service animals)? Yes No If yes, describe activity and type of animals Is traveler planning to travel within 21 days since last date of exposure? Yes No If yes, list location(s) and dates of planned travel below. Location(s) Dates – From / To / Did anyone else accompany traveler on the trip from Africa? Yes No If yes, list name(s) and contact information below. (If child, list parent/guardian name and information) 1. Name – Contact Contact - Telephone No. (Include area code) 2. Name – Contact Contact - Telephone No. (Include area code) 3. Name – Contact Contact - Telephone No. (Include area code) 4. Name – Contact Contact - Telephone No. (Include area code) 5. Name – Contact Contact - Telephone No. (Include area code) 6. Name – Contact Contact - Telephone No. (Include area code) 7. Name – Contact Contact - Telephone No. (Include area code) Interviewer’s Name Telephone Number (include area code) *Check CDC website () for most current list of countries with active EV transmission.