Attach_3_Confidential_Post_Deployment_Health_Assessment.doc

Confidential Post-Deployment Health Assessment Thank you for helping CDC complete its mission by deploying during the recent hurricane response. Assuring your health and well-being during and after such responses is a primary goal of CDC’s Occupational Health Clinics.

· This health assessment is voluntary but is very important. It is designed to help us determine if you need any assistance, other evaluation, or a face-to-face visit with one of our clinical providers.

· Documenting incidents may also help you preserve your Workers Compensation rights. Therefore, it is especially important to complete this assessment if you experienced any injury, illness, or other incident during your deployment, or have any symptoms currently.

· After you submit this completed form, CDC Clinic personnel may contact you with further instructions and recommendations. This document will become a part of your confidential medical record in the CDC Occupational Health Clinic. See the Privacy Act statement at the conclusion of this form for additional privacy information. Please follow the instructions at the end of this assessment to submit your completed record.

· All deployed persons may complete this form; however, non-government employees should also contact their own employers for further guidance.

Today’s Date ________________ Name (Last, First, MI): __________________________User ID: _____________

Date of Birth (month/day/year) __________________ Gender: Male___ Female___ Job Title and Usual Job Duties at CDC: ________________________________

Phone: _____________ (work) _____________ (home) _____________ (cell) Date(s) Deployment Started ________________ Ended ________________ To Which Hurricane did You Deploy? ___Katrina ___Rita ___Both Location(s) of Deployment: ___________________________________________ Primary Duties during Deployment: ____________________________________ Health Assessment:

1. Did your health change during this deployment?

___ Health stayed about the same or got better

___ Health got worse

2. How many times were you seen by a health care provider during or after this deployment? _____ times

3. Did you take any medications during this deployment?

___ No ___ Yes (please list: ___________________________________)

4. Did you discontinue any medications immediately before or during this deployment? ___ No ___ Yes (please list: _______________________)

5. Please list any medical and/or mental health conditions you had before this deployment: _____________________________________________ ___________________________________________________________

6. Did you have any injuries during your deployment? ______ No _____ Yes (If yes, please provide details: __________________________________)

7. Describe any other health concerns or problems during your deployment or since your return? _________________________________________

8. Do you have any of these symptoms now or did you develop them anytime during this deployment? If so, provide details below.

___ Chronic cough

___ Swollen, stiff, or painful joints

___ Runny nose

___ Skin diseases, rashes, or unhealed sores

___ Fever

___ Redness of eyes with tearing

___ Weakness

___ Chest pain or pressure

___ Headaches

___ Dizziness, fainting, lightheadedness

___ Muscle aches

___ Numbness or tingling in hands or feet

___ Difficulty breathing

___ Difficulty remembering

___ Diarrhea

___ Frequent indigestion

___ Vomiting

___ Ringing of the ears

___ Shortness of breath

___ Rapid or irregular heartbeat

___ Nightmares

___ Feeling down, depressed, or hopeless

___ Insomnia

___ Other (________________________) Explain: _____________________________________________________

9. Please list any personal protective equipment (PPE) used during this deployment: _________________________________________________ Did you have any difficulty with or concerns about your PPE or need additional PPE that was not available to you?

___ No __ Yes (please explain__________________________________

10. While you were deployed, were you exposed to:

___ Solvents

___ DEET insect repellent applied to skin ___ Dust

___ Smoke from burning trash or buildings ___ Industrial pollution

___ Standing water contacting your skin

___ Vehicle exhaust fumes

___ Environmental pesticides (like area fogging)

___ Other exposures (please list: ____________________________________________)

11. At any time during your deployment did you feel your life was in danger?

___No ___Yes

12. Did you see anyone die, see dead bodies, or have other exposure to death during your field work? ___No ___Yes

13. How concerned are you about your physical health? (Please circle the number below that best describes your concern: 1= low; 5= high.)

14. Would you like to be contacted confidentially by a CDC Occupational Health Clinic Provider to discuss deployment health-related issues? (Please note that a contact may be necessary to clarify your responses above.)

___ No, contact me only if you need to do so.

___ Yes, please contact me.

15. Would you like to be contacted confidentially by a CDC Employee Assistance Program (EAP) counselor?

___ No

___ Yes

Please return completed assessment in one of the following ways to Dr. Eli Warnock, Medical Director of CDC Occupational Health Clinics.

Inter-Office Mail: CDC Mailstop E-23 In Person: At one of 3 CDC Occupational Health Clinics in Atlanta:

Executive Park, Building 57, 2nd Floor

Roybal Campus, Building 4, 1st Floor

Chamblee Campus, Building 101, Ground Floor

US Mail:

CDC Occupational Health Clinic at Executive Park

Mailstop E-23

57 Executive Park Drive South

Building 57, Room 2301

Atlanta, GA 30329 or

CDC Occupational Health Clinic at Roybal

Mailstop A-29

1600 Clifton Road

Building 4, Room 121

Atlanta, GA 30333

For more information, to arrange a clinic appointment, or for any other assistance, please call 404-498-4775.

Privacy Act Notification Statement for Workers Leaving Public Health Response Activities The purpose of this medical screening program for workers leaving public health response activities is to: (1) determine the extent, if any, to which individual workers have been adversely affected by the conditions under which they worked; (2) protect worker health by early identification of adverse mental or physical health effects related to work or exposure, and (3) identify potential risk to others with similar exposures. Furnishing the requested information is voluntary; however, with more complete information, CDC will be better able to identify those who need further medical evaluation or treatment and to monitor developing trends and patterns of illness. Identifiable information will be viewed only by authorized CDC Occupational Health Clinic medical personnel. Aggregate data without personal identifiers may be shared with authorized U.S. Department of Health & Human Services' personnel and public health or cooperating medical authorities. The information requested on this form is collected under the authority of Executive Orders 12107, 12196, and 12564 and 5 U.S.C. Chapters 11, 31, 33, 43, 61, 63, and 83.