Form CDPH8530 "Healthcare Worker (Hcw) Contact to Ebola Patient Interview Form" - California

What Is Form CDPH8530?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2014;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form CDPH8530 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8530 "Healthcare Worker (Hcw) Contact to Ebola Patient Interview Form" - California

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State of California-Health and Human Services Agency
California Department of Public Health
Contact ID # ____________________
Interview Date: ____________
HEALTHCARE WORKER (HCW) CONTACT TO EBOLA PATIENT INTERVIEW FORM
SECTION I: GENERAL INFORMATION
Interviewer Information
Interviewer Name (Last, First): _______________________________________________________________
State/Local Health Department: ______________________________________________________________
Phone number: ________________________ Email address: _____________________________________
Ebola Patient Information (Patient Associated with Contact)
Please complete the questions below if the exposure occurred in a U.S. healthcare facility.
Ebola Case CalREDIE ID # ________________________________
Last Name: ________________________________ First Name: ___________________________________
DOB:
MM
/
DD
/
YYYY
Date of illness onset:
MM
/
DD
/
YYYY
Date of hospital admission:
MM
/
DD
/
YYYY
Name of admitting hospital: _________________________________________
Date patient was isolated in a healthcare facility:
MM
/
DD
/
YYYY
At the time of this report, is the patient? ☐ Confirmed ☐ Probable ☐ Unknown
Notes:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________________________________________________________
CDPH 8530 (12/14)
Page 1 of 10
State of California-Health and Human Services Agency
California Department of Public Health
Contact ID # ____________________
Interview Date: ____________
HEALTHCARE WORKER (HCW) CONTACT TO EBOLA PATIENT INTERVIEW FORM
SECTION I: GENERAL INFORMATION
Interviewer Information
Interviewer Name (Last, First): _______________________________________________________________
State/Local Health Department: ______________________________________________________________
Phone number: ________________________ Email address: _____________________________________
Ebola Patient Information (Patient Associated with Contact)
Please complete the questions below if the exposure occurred in a U.S. healthcare facility.
Ebola Case CalREDIE ID # ________________________________
Last Name: ________________________________ First Name: ___________________________________
DOB:
MM
/
DD
/
YYYY
Date of illness onset:
MM
/
DD
/
YYYY
Date of hospital admission:
MM
/
DD
/
YYYY
Name of admitting hospital: _________________________________________
Date patient was isolated in a healthcare facility:
MM
/
DD
/
YYYY
At the time of this report, is the patient? ☐ Confirmed ☐ Probable ☐ Unknown
Notes:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____________________________________________________________________________________
CDPH 8530 (12/14)
Page 1 of 10
State of California-Health and Human Services Agency
California Department of Public Health
Contact ID # ____________________
Interview Date: ____________
HCW Contact Information
Last Name: ________________________________ First Name: ___________________________________
Date of birth:
MM
/
DD
/
YYYY
Age: ________
Sex: ☐ Male ☐ Female
If female, are you currently pregnant? ☐ Yes ☐ No
If yes, what is your EDD:
MM
/
DD
/
YYYY
Home address: (add all places where the contact resides including temporary residence due to travel)
Street Address #1: ______________________________________________________ Apt. # _____________
City: _________________________ County: _________________ State: _________ Zip: _______________
Phone number: ________________________ Email address: _________________________________
Alternate phone number/email: ________________________________________________
Is this the current residence: ☐ Yes ☐ No
Is this the permanent residence: ☐ Yes ☐ No
Is this a congregate setting (dorm, assisted living, etc.): ☐ Yes ☐ No
How many people live at this address: ______
Street Address #2: ______________________________________________________ Apt. # _____________
City: _________________________ County: _________________ State: _________ Zip: _______________
Country: _________________________
Is this the current residence: ☐ Yes ☐ No
Is this the permanent residence: ☐ Yes ☐ No
CDPH 8530 (12/14)
Page 2 of 10
State of California-Health and Human Services Agency
California Department of Public Health
Contact ID # ____________________
Interview Date: ____________
HCW Contact Information (Continued)
Is this a congregate setting (dorm, assisted living, etc.): ☐ Yes ☐ No
How many people live at this address: ______
Notes regarding address section:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
(Add additional addresses and contact information on the back of the form)
Who is providing information for this contact?
☐ Contact (Self)
☐ Other, specify person (Last, First): __________________________________________
Relationship to contact: __________________________
Reason contact unable to provide information: ☐ Contact is a minor ☐ Other ____________________
Contact primary language: _________________________
Was this form administered via a translator? ☐ Yes ☐ No
CDPH 8530 (12/14)
Page 3 of 10
State of California-Health and Human Services Agency
California Department of Public Health
Contact ID # ____________________
Interview Date: ____________
Symptoms
Do you currently have any of the following symptoms?
Symptom
Date of onset
☐ No symptoms
☐ Temperature
>
99.6
F (oral)
MM
/
DD
/
YYYY
☐ Chills
MM
/
DD
/
YYYY
☐ Weakness
MM
/
DD
/
YYYY
☐ Headache
MM
/
DD
/
YYYY
☐ Muscle Aches
MM
/
DD
/
YYYY
☐ Abdominal Pain
MM
/
DD
/
YYYY
☐ Diarrhea ____times/day
MM
/
DD
/
YYYY
☐ Vomiting
MM
/
DD
/
YYYY
☐ Unexplained hemorrhage
MM
/
DD
/
YYYY
If yes, location: ____________________________
☐ Other _______________
MM
/
DD
/
YYYY
Do you belong to a health network? ☐ Yes ☐ No
Name of health network: _____________________
Occupation
What is your job and title?
________________________________________________________________________________________
CDPH 8530 (12/14)
Page 4 of 10
State of California-Health and Human Services Agency
California Department of Public Health
Contact ID # ____________________
Interview Date: ____________
Occupation (Continued)
Please select the category that best describes the contact’s occupation:
☐ Direct care healthcare worker (physician, nurse, respiratory therapist, phlebotomist, etc.)
☐ Laboratorian
☐ Non-direct care provider (e.g., front desk clerk, admissions clerk)
☐ Environmental services (e.g., housekeeping, central processing staff)
☐ Security
☐ Patient transporter
☐ Other, specify: ____________________________________________________________
Place of work and address:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
SECTION II: EXPOSURE ASSESSMENT
Exposure History
Did you work with the patient in:
☐ US
☐ Guinea
☐ Sierra Leone
☐ Liberia
☐ Mali
☐ Other______________________
If Guinea, Sierra Leone, Liberia, or Mali did you work in:
☐ An Ebola treatment facility
☐ A healthcare facility not designated as an Ebola treatment facility
CDPH 8530 (12/14)
Page 5 of 10