Form No number No number International Maritime Illness or Death Investigation Fo

I nternational Maritime Conveyance

Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

If requested by Centers for Disease Control and Prevention (CDC) Quarantine Station, please use this form to submit additional information about the reported onboard illness or death, pursuant to 42 CFR 71.21(a).

• Complete and fax this form to the CDC Quarantine Station to which the illness or death was reported. Quarantine Station jurisdictions and contact information can be found at www.cdc.gov/ncidod/dq/quarantine_stations.htm

• Contact the CDC Quarantine Station to confirm receipt of the faxed report or if you have any questions.

• If you are unable to reach a CDC Quarantine Station, call +1-770-488-7100. Alternate: +1-877-764-5455 (at-sea use).

• Reminder to cruise ships: do not use this form for gastrointestinal (GI) illnesses, which are reportable to CDC Vessel Sanitation Program (VSP) per established protocol. More information about VSP can be found at: http://www.cdc.gov/nceh/vsp/default.htm or by calling +1-800-323-2132.

Section 1. Contact information of vessel staff completing form
Name: ______________________________________ Title: ___________________________________________________________ Telephone: ___________________________________ E-mail: _________________________________________________________
Section 2. Vessel information
Vessel name: __________________________________ Vessel company: _________________________________________________ Embarkation port:______________________________ Length of voyage:____________________(days) Next US port: _________________________________ Arrival date/time: ___/____/_____ _________ mm dd yyyy (24 hr) hh:mm Duration of stay at next US port: ________ hours Number (#) on board: Crew:____________; Passengers:____________ List all port stops before arrival: ___________________________________________________________________________________ List all port stops after departure from next US port: ___________________________________________________________________
Section 3. General information on ill or deceased person
Surname/Last Name: ________________________________________________ Middle name: ______________________________ First/given name: __________________________________________________ Gender: □ Male □ Female □ Crew □ Passenger Occupation (if crew, list job title & duties):__________________________________________________________________________ Date of birth: ____/_____/________ Birth country: ______________________ Country of residence:__________________________ mm dd yyyy Passport Country/Number: ________________________ Date boarded vessel: ____/_____/______ Cabin Number: _____________ mm dd yyyy Home address (street/city): ________________________________________________ State/Province: ________________________ Zip/Postal Code: _______________________ Country: ___________________________Telephone: ____________________________ Duration of US stay: ____________________ Contact in US (hotel/address): _______________________________________________ US City/State: _______________________________________________US Telephone: _____________________________________
Section 4: Information on signs and symptoms of ill or deceased person
Signs/ Symptoms (check “yes” if present during illness)		No		Yes	If Yes, provide other information below:
Fever or recent history of fever		□		□	Onset date: ____/_____/________ mm dd yyyy Maximum measured temperature: °C/°F
Rash		□		□	Onset date: ____/_____/________ mm dd yyyy Where rash started: □ Head □ Trunk □ Extremities Distribution of rash: □ Head □ Trunk □ Extremities Appearance: □ Red/Flat □ Red/Raised □ Fluid-filled □ Pus-filled □ Other
Conjunctivitis (eye redness)		□		□
Coryza (runny nose)		□		□
Persistent cough		□		□	Onset date:____/_____/________ mm dd yyyy With blood: □ Yes □ No □ Don’t know
Sore throat		□		□
Difficulty breathing / Shortness of breath		□		□
Swollen glands		□		□	Onset date:____/_____/_________ mm dd yyyy Location: □ Head □ Neck □ Armpit □ Groin
Severe vomiting		□		□	Number of times in the last 24 hours: __________ Resulted in dehydration: □ Yes □ No □ Don’t know
Severe diarrhea (loose stools)		□		□	Onset date: _____/_____/________ mm dd yyyy Number of times in the last 24 hours:__________ With blood: □ Yes □ No Resulted in dehydration: □ Yes □ No □ Don’t know
Jaundice		□		□	Onset date: ____/_____/________ mm dd yyyy
Headache		□		□
Neck stiffness		□		□
Decreased consciousness (e.g. disoriented)		□		□
Recent onset of paralysis and / or focal weakness		□		□
Unusual bleeding		□		□	Site (explain):
Describe illness history (e.g., onset date, progression) :
Pre-existing medical conditions: □ No □ Yes (if yes, describe)
Section 5. Vaccination and disease history of ill or deceased person (Skip this section if the presumptive diagnosis is not a vaccine preventable disease)
Vaccination history (check box if he/she was vaccinated against the disease in the past and fill in number of doses received): # of doses # of doses # of doses □ Measles _______ □ Pertussis _______ □ Hepatitis A _______ □ Influenza, last received ____/______ □ Mumps _______ □ Diphtheria _______ □ Hepatitis B _______ mm yyyy □ Rubella _______ □ Varicella _______ □ Meningococcal _______ □ Other:________________________
Disease history (check box if he/she had the disease in the past): □ Measles □ Mumps □ Rubella □ Varicella □ Pertussis □ Diphtheria □ Hepatitis A □ Hepatitis B
Section 6. Information about deaths (skip to section 7 if not applicable)
Date of death: ____/____/_________ Time of death: _____ : _____ mm dd yyyy (24 hr) hh : mm Laboratory test results: __________________________________________________________________________________________ Presumptive cause of death: ______________________________________________________________________________________ Disposition of body (check one): □ Sent to Medical Examiner (city, country): ________________________________________________________________________ □ Other: _____________________________________________________________________________________________________ Determined cause of death (by medical examiner or other): _____________________________________________________________________________________________________________ Note: If deceased person did NOT have fever or the suspected cause of death is NOT a communicable disease, STOP and submit form. Otherwise complete rest of the form.
Section 7. Test results of ill or deceased person. (Skip to section 8 if no tests performed on ship or ashore)
Tests	Date performed (mm/dd/yyyy)				Results ( if unknown, provide name and number of lab which performed tests)
Chest x-ray (radiograph)
Rapid influenza test
Legionella urine antigen
Other Test 1: _______________________ Test 2: _______________________ Test 3: _______________________
Section 8. Treatment of ill or deceased person
Seen in ship infirmary: □ No □ Yes If yes, date of first visit: ____/_____/________ mm dd yyyy Check treatments/medications prescribed: □ Antibiotics/Antimicrobials: list_______________________ □ Fever-reducing medicines (e.g., aspirin, ibuprofen, acetaminophen) ____________________________________ □ Other: list __________________________________________________ Presumptive Diagnosis: __________________________________________________ Comments:________________________________________ __________________________________________________			Seen in health-care facility ashore: □ No □ Yes If yes, hospitalized □ No □ Yes If yes, dates: from: ____/_____/_____ to ____/_____/________ mm dd yyyy mm dd yyyy List name (s) and locating information of facility/health-care provider(s) and date(s) of visit: _________________________________________________________ _________________________________________________________ Treatment: ________________________________________________ Discharge Diagnosis: _______________________________________ Comments:_______________________________________________ _________________________________________________________
Section 9. Exposure history of ill or deceased person
During the three weeks before illness onset, did he/she have contact with: Other ill person(s)? □ No □ Yes If yes, ill persons’ diagnoses or description of illness: __________________________________________________________ Animals/poultry: □ No □ Yes If yes, explain:_________________________________________________________________ Other exposures (e.g., chemical): □ No □ Yes If yes, explain:_____________________________________________________ List places he/she traveled during 3 weeks before illness onset (include ship port stops if disembarked): _____________________________________________________________________________________________________________ Total # of persons (onboard ship or disembarked) with similar signs and symptoms during the past 3 weeks: (Please verify by a medical log review): Total # Crew:___________ ; Total # Passengers:___________
Section 10. Traveling companions and other contacts of ill or deceased person
Ill or deceased person isolated after illness onset?: □ No □ Yes If yes: Date isolated: ____/____/____ Place isolated: □ Cabin □ Infirmary □ Other: _______________________________________ mm dd yyyy Isolated alone: □ Yes □ No If no, explain: ___________________________________________________________________ Did he/she have contact other people after being placed in isolation?: □ No □ Yes If yes, identify them by titles or relationships with the ill/deceased person: _____________________________________________________________________
Answer if ill or deceased person is a crew member: Write number of : cabin mates:__________________ bathroom mates: ______________ work team mates: _____________ other contacts (e.g., intimate partners): _________ Do any of above persons have similar signs & symptoms?* □ No □ Yes If yes, explain:________________________ Does this crew member eat in passenger venues? □ No □ Yes Does this crew member have contact with passengers? □ No □ Yes If yes, describe extent/frequency:			Answer if ill or deceased person is a passenger: Write number of: cabin mates: _____________ travel companions: ________ other contacts (e.g., intimate partners): __________ Do any of above persons have similar signs & symptoms?* □ No □ Yes If yes, explain:________________________________ If passenger is a child, does he/she attend day care or youth program on ship? □ No □ Yes If yes, total # of children in day care or program: ______________ # of children with similar signs & symptoms: ________________
*Note: Submit a separate form for each ill or deceased person not previously reported to a CDC Quarantine Station.
To be completed by quarantine station staff only
Date Quarantine Station notified: ___/___/____ Time of initial notification: ________________ mm/dd/yyyy (24 hr) hh:mm Final Diagnosis ______________________________________________ QARS Unique ID # ________________ Comments:____________________________________________________________________________________________________ _____________________________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 7 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-xxxx.

Version: 11/18/08 OMB Control No 0929-XXXX

Expiration Date: XX/XX/XXXX