Attachment K - Land Border Crossing of Travelers Form FINAL Burden State - rev 4 24 09

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 (≥100F 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: □ No □ Yes 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: □ No □ Yes

□ Neck stiffness

Presumptive Diagnosis: □ Disease of public health interest □ 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): ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Driver’s license number(s): _________________ _________________ _________________

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): ___________________________ ___________________________ ___________________________ ___________________________

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