Yes No Unknown Details Laboratory exposure Yes No Unknown Specify Did the case visit a healthcare including date facility or hospital during their last attended: exposure period? Other high risk settings (e.g. funeral / burial of suspected/confirmed EVD patient) -Specify For any exposure Location of possible exposure Nature of possible exposure- specify Dates of possible exposure __ /__ /____ To __ /__ /____ PLACE Australian state or territory 7 INFECTION Specify ACQUIRED Country - specify __ /__ /____ (10 weeks __ /__ /____ after onset or INFECTIOUS 8 Between dates (onset of To as long as PERIOD symptoms) blood/ secretions contain virus) Yes No Unknown Isolation commenced If yes, date isolation commenced __ /__ /____ Details of isolation Yes No Unknown Did case travel during their infectious period? Flight no. or PLACE VISITED Arrival date Departure Date mode of transport 1 2 3 4
Laboratory exposure Yes Details No Unknown Did the case visit a healthcare facility or hospital during their exposure period? Yes Specify including date last attended: No Unknown Other high risk settings (e.g. funeral / burial of suspected/confirmed EVD patient) -Specify For any exposure Location of possible exposure Nature of possible exposure- specify Dates of possible exposure __ /__ /____ To __ /__ /____ 7 PLACE INFECTION ACQUIRED Australian state or territory Specify Country - specify 8 INFECTIOUS PERIOD Between dates __ /__ /____ (onset of symptoms) To __ /__ /____ (10 weeks after onset or as long as blood/ secretions contain virus) Isolation commenced Yes No Unknown If yes, date isolation commenced __ /__ /____ Details of isolation Did case travel during their infectious period? Yes No Unknown PLACE VISITED Arrival date Departure Date Flight no. or mode of transport 1 2 3 4
EVD-SoNG.docx