Form No number No number Land Border Illness or Death Investigation

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Attachment K - Land Border Crossing of Travelers Form FINAL Burden State2

Land Border Illness or Death Investigation

OMB: 0920-0821

Document [doc]
Download: doc | pdf

I nternational Land Border Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention


QARS Unique ID #: __________________________


Section 1. Quarantine station notification

Type of notification:

Traveler illness

Traveler death

Date of initial notification:


_____/_____/_______

(mm / dd / yyyy)

Time of initial notification:

:

(hh : mm)

Detection of travelers illness or death:

Detected on conveyance or at POE Detected after departing POE Detected while exiting US

Port of Entry: (or city/region)


State:

Notified by: (name of person)

Notified by: (name of agency)

Phone:

Email:

Conveyance type:

Personal vehicle Commercial/Cargo vehicle Pedestrian/Bike Ambulance Train Bus/Van

Did illness occur en route?

No

Yes

Unknown

If illness occurred en route, was quarantine station notified prior to arrival?

No

Yes

If illness occurred en route, was illness reported to another agency prior to arrival?

No

Yes

Unknown

If yes, name of agency notified:

Section 2. Information on signs and symptoms of ill or deceased person

Brief history of present illness:


Signs, Symptoms, and Conditions (Check all that apply) :

Fever (≥100F or ≥37.8°C) OR recent history of fever


Onset date: ___/____/______

If measured, maximum temperature: __________ F/C

Sore throat

Decreased consciousness

Difficulty breathing / shortness of breath

Recent onset of focal weakness and/or paralysis

Rash


Onset date: ___/____/______


Where rash started:

Head Trunk Extremities


Current distribution:

Head Trunk Extremities


Appearance:

Red/flat Red/raised Fluid/Pus filled

Other: ___________________________


Contact with someone with a rash/chicken pox/rubella

in the last 3 weeks?

No Yes Don’t know


Swollen glands

Unusual bleeding


Onset date: ___/____/______

Severe vomiting

Obviously unwell

Severe diarrhea


Onset date: ___/____/______


With blood: NoYes


Number of times in past 24 hrs: _______


Asymptomatic

Other:

_____________________________

Jaundice


Onset date: ___/____/______

Cluster of illnesses §



Cluster number: ___________




§Each ill or deceased person in the cluster should have a separate illness or death report which QARS will link to other ill and/or deceased persons in the cluster

Conjunctivitis / eye redness

Headache

Persistent cough


Onset date: ___/____/______

With blood: NoYes

Neck stiffness

Presumptive Diagnosis:


Disease of public health importance

Condition of public health interest / Unknown, needs follow-up

OR

Condition not requiring public health follow-up:

Affected system: Gastrointestinal Cardiovascular Musculoskeletal Neurologic Psychiatric Respiratory Genitourinary Dermatologic


If disease of public health importance or condition of public health interest, proceed to next section.

If condition not requiring public health follow-up, stop here.

Section 3. General information about the ill or deceased person

Paternal/Last name:

Maternal name:

First name:

Middle name:

Married name:

Aliases:

Gender:

Male

Female

Race:


White American Indian/Alaskan Native Asian

Black Native Hawaiian/Pacific Islander Unknown

Other: _________________________

Ethnicity:


Hispanic

Non-Hispanic

Unknown

Type of traveler:


Crew

Passenger

N/A

Border commuter:

No

Yes

Unknown

Frequency of border crossing:

Passport #:

Alien #:

Passport country:

Legal status:


Immigrant Resident Alien Illegal Alien US Citizen

Foreign Citizen Refugee/Asylee Unknown

Visa type:

Student/Exchange Temporary worker: agriculture Business

Tourist (includes VFR) Humanitarian Parole Diplomatic

Temporary worker: skilled labor Witness/Informant N/A - no visa

Date of birth:


_____/_____/__________

(mm / dd / yyyy)

Age:


_______

Days Weeks

Months Years

Country of birth:

Home address:

City:

State/Province:

Country of residence:

ZIP/Postal code:

Home telephone number:

E-mail:


If visiting, total

duration of US stay:

_________

days months

weeks years

Contact in US - Address/hotel:



Same as above (home address)

Contact in US - City:

Contact in US -State/Province:

Contact phone in US:



Cell

Number of days reachable at contact phone:


______ days


Permanent number

Contact information:

None

Unknown

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Section 4. Border Crossing Information

Express lane?

No

Yes

Unknown

Attempted entry outside an official POE?

No

Yes

Unknown

Was the traveler coming from an airport?

No

Yes

Unknown

Make/Model/Year:

License plate #:

State issued:

Country issued:

Company owned?

No

Yes

If yes, specify:

Rental?

No

Yes

If yes, specify:

Did conveyance transport cargo?

No

Yes

If yes, specify:

Departure city & address:


Unknown

Departure date:


_____/_____/__________

(mm / dd / yyyy)

Departure time:

:


(hh : mm)

Destination city & address:


Unknown

Expected arrival date:


_____/_____/__________

(mm / dd / yyyy)

Expected arrival time:

:


(hh : mm)

Route information:


From (City/Country) To (City/Country) Duration Significant stops Name of commercial Flight/Bus/Train No.

of stay carrier, if applicable


Segment 1: _______________­­­__ _______________ ____________ _____________________ ______________________ _________________


Segment 2: _________________ _______________ ____________ _____________________ ______________________ _________________


Segment 3: _________________ _______________ ____________ _____________________ ______________________ _________________


Section 5. Traveling companions and other contacts of ill or deceased person

If traveling by conveyance, does anyone else on the conveyance have similar illness?

No

Yes

Unknown

Number of traveling companions:


_________

Are any traveling companions ill?

No Yes N/A

(no companions)

Number of driver(s):



___________

Name of driver(s):


  1. ________________________________________________________________


  1. ________________________________________________________________


  1. ________________________________________________________________


Driver’s license number(s):


  1. _________________


  1. _________________


  1. _________________

Section 6. Exposure history of ill or deceased person

Occupation:

During 3 WEEKS prior to date of illness onset, did traveler have contact with:

Other ill individuals?

No

Yes

Unknown

If Yes, ill persons’ diagnoses or description of illness:

Animals or birds?

(e.g., visits to zoo, animal market, poultry farm, etc.)

No

Yes

Unknown

If Yes, in which country did contact occur?

Describe nature of contact:

Other exposures?

(e.g., chemical, powder, radiation, etc.)

No

Yes

Unknown

If Yes, describe nature of contact:

Section 7. Vaccination, past illness, and treatment history of ill or deceased person

Does traveler have underlying conditions which may explain the symptoms:

No

Yes

Unknown

If yes, describe:

Vaccination history

(check all that apply):

Measles Varicella Rubella Pertussis Mumps Influenza, last received: ____/_______

Meningococcal Hepatitis A Hepatitis B (mm/yyyy)

Past illness history

(check all that apply):

Measles Varicella Rubella Pertussis Mumps

Currently taking medications?

No

Yes

Unknown


If Yes, indicate category(ies) of the medication(s) (check all that apply):


Antibiotic/antimicrobial

Fever reducing medication

Other



If Yes, indicate name of medication(s):


  1. ___________________________

  2. ___________________________

  3. ___________________________

  4. ___________________________


Treatment given prior to travel?

No

Yes

Unknown

If Yes, what was done and by whom?

Treatment given during travel, but before crossing the border?

No

Yes

Unknown

If Yes, what was done and by whom?

Treatment given at POE?

No

Yes

Unknown

If Yes, what was done and by whom?

Treatment given after crossing the border?

No

Yes

Unknown

If Yes, what was done and by whom?

Section 8. Disposition of ill or deceased person

Ill or deceased person was:

(check all that apply)

Advised to seek medical care Released to continue travel EMS called Refused entry

Transported to hospital MOA activated Isolated Deceased

Detained by ICE/CBP – Detained at: _______________________________________________________

Referred to: ___________________________________________________________________________


Section 9. Agencies contacted

(Agency type key: F = Federal, S = State, L = Local, P = Private, A = Airport, X = Foreign)

Contact name & title

Agency

Type

Phone

E-mail
















Additional comments or findings:


Investigation closed Date: _____________


Public reporting burden of this collection of information is estimated to average 6 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

File Typeapplication/msword
File TitleInternational Land Border Illness or Death Investigation Form
Authormdelea
Last Modified Bymga1
File Modified2008-11-18
File Created2008-11-17

© 2024 OMB.report | Privacy Policy