Ebola Screening

 
 
 
The University of South Alabama is committed to providing a safe environment for our students, faculty, and staff. Currently USA is following the Centers for Disease Control and Prevention (CDC) travel screening guidelines for Ebola.

Please answer the following four (4) questions:
1. Have you traveled to Africa in the past 21 days?
  Yes         No
If yes, what countries?
2. Have you been in close contact with anyone who has traveled to Africa or been diagnosed with Ebola in the past 2 months?
  Yes         No
3. Do you plan to Travel to Africa?
  Yes         No
If you have answered NO to questions 1, 2 and 3, stop here
If you have answered YES only to question 3, skip question 4 and enter your contact information
If you have answered YES to questions 1 or 2, answer Question 4 and enter your contact information

4. Do you have the following symptoms:
Fever higher than 100.4°F (38°C)
  Yes         No
Chills
  Yes         No
Headache
  Yes         No
Abdominal Pain
  Yes         No
Diarrhea
  Yes         No
Nausea
  Yes         No
Vomiting
  Yes         No
Weakness
  Yes         No
Joint or Muscle Aches
  Yes         No

If you answered "Yes" to EITHER questions 1 or 2 AND you answered "Yes" to at least one of the symptom questions above, you will need to contact the USA Medical Center IN ADDITION to completing and submitting this form. Please call the USA Medical Center at 471-7000, ask for the Clinical Supervisor on call, and identify yourself as a person with possible Ebola exposure.

Name  *
J Number (i.e. J00XXXXXX)  *
Date  *
Email Address
Phone Number  *
Alternative Phone Number


 
Form 0008