N.C. Contact Listing Questionnaire- Part 1 (B1)

EID ______EBOLA CONTACT TRACING N.C. Contact Listing Questionnaire - Part 1 Date of Interview ______

Contact Tracer: First Name ______Last Name ______Affiliation ______Telephone ______Email ______Case: First Name ______Last Name ______NC EDSS Event Number ______Telephone ______Email ______Person Being Interviewed:  Patient  Family member, specify ______ Other, specify ______If other than case: First Name ______Last Name ______Address ______Telephone ______Email ______

L ist all places the case visited since the day of symptom onset. Include the name and address for each location, date and time that the Ebola patient was at that location, and the type of transit used. Example: Arby’s, 1001 Food St. City, State Zip. 10/06/2014 11:00 AM - 1:00 PM Joe’s Taxi

DHHS:EPI/N.C. Contact Listing Questionnaire- Part 1 (B1) 10/12/2014 Draft Page 1 of 3 EID ______

DHHS:EPI/N.C. Contact Listing Questionnaire- Part 1 (B1) 10/12/2014 Draft Page 2 of 3 EID ______Continuation from page 1 L ist all places the case visited since the day of symptom onset. Include the name and address for each location, date and time that the Ebola patient was at that location, and the type of transit used. Example: Arby’s, 1001 Food St. City, State Zip. 10/06/2014 11:00 AM - 1:00 PM Joe’s Taxi

DHHS:EPI/N.C. Contact Listing Questionnaire- Part 1 (B1) 10/12/2014 Draft Page 3 of 3