Attachment F - Summary of Response Forms rev 4 24 09

Attachment F: Summary of Illness Response Forms

Air Travel Illness or Death Investigation Form

Form	Number of Respondents	Number of responses/ respondent	Average burden/ response (in hours)	Total burden hours
Air Travel Illness or Death Investigation Form	1320	1	0.1	132

The Air Travel Illness or Death Investigation Form is used by Quarantine Stations to gather all relevant clinical and epidemiologic data on reported cases of ill or deceased travelers on an airline. These data are used to determine if an illness or death is of public health interest and what (if any) public health action and further medical/epidemiologic expertise are needed. The form also allows for additional data collection that can help in passenger location. Information is collected from the individual. If the individual is not able to respond, quarantine staff solicits this information from relative or traveling companion. All of the information is entered into the Quarantine Activity Reporting System (QARS), a secure web-based system housed at DGMQ Headquarters, and used by all Quarantine Stations for surveillance and tracking.

The clinical portions of the form asks questions pertaining to symptoms that may be common to communicable (or quarantinable) diseases of public health interest such as fever, rash and diarrhea, and respiratory distress, some of which are reportable by airline operators under federal quarantine regulation. The epidemiological questions allow the Quarantine Station to assess the person’s travel history, occupation, contact with other ill individuals and other factors that may help determine the passenger’s suspected diagnosis. The epidemiologic questions also allow the person completing the form to assess the passenger for a history of high risk exposures during travel. Answers to these questions provide the necessary information to make a decision about the traveler’s suspected illness as well as their communicability. This in turn, helps the Quarantine official determine next steps. Completing the form also ensures that demographic and itinerary information for the passenger are collected. This information is used to locate the passenger if they are released or to determine the traveler’s contacts that might need to be notified of their exposure to a communicable disease or condition of public health interest.

International Maritime Traveler Illness or Death Report; Illness or Death Investigation Form

Form	Number of Respondents	Number of responses/ Respondent	Average burden/ response (in hours)	Total burden hours
International Maritime Conveyance Illness or Death Report Form	200	1	3/60= .05	10
International Maritime Conveyance Illness or Death Investigation Form	200	1	7/60=0.12	24

The International Maritime Conveyance Illness or Death Report Form will be utilized by international cruise and cargo ships bound for a U.S port, to report (to a CDC Quarantine Station) onboard deaths or illnesses suggestive of a communicable disease or condition, or which meet reporting requirements stated in the federal regulations (42 CFR Part 71). The form will be made available to ships both in paper and electronic format, and will not collect any personal identifying information of the ill or deceased person. This form will only collect data necessary to make an initial public health risk assessment and enable the Quarantine Station to contact the ship to carry out a more in-depth public health investigation. A ship can report up to three ill or deceased persons per form. After receiving the report form, the Quarantine Station having jurisdiction over the ship’s arrival port will investigate each ill or deceased person (listed on the form) using a separate tool called the International Maritime Conveyance Illness or Death Investigation Form.

The goal of the International Maritime Conveyance Illness or Death Investigation form is to systematically collect relevant clinical and epidemiologic data about an ill or deceased person and to facilitate timely and accurate public health assessment. This in turn will lead to a rapid implementation of appropriate public health measures, as necessary, to prevent the introduction and spread of communicable disease in the U.S. and communities worldwide. The form will be completed either by the Quarantine Station staff or by the ship line staff (for cruise ships, this is usually the medical clinic personnel). To minimize the burden of reporting, the form has skip patterns to avoid collection of information which may not be pertinent to the signs and symptoms of the ill or deceased person. The information collected on this form is similar to that of the Air Travel Illness or Death Investigation Form.

The clinical portion of this form asks questions about presence of signs and symptoms which are common manifestations of communicable (e.g. quarantinable) disease or condition of public health interest. Examples of some of these signs and symptoms include fever, rash, swollen lymph gland, jaundice, diarrhea, vomiting, headache with neck stiffness, and respiratory distress. Given that most ships have access to a medical facility during the voyage, either offshore at port stops or onboard (as in most cruise ships) the form contains questions regarding treatment and diagnostics. The epidemiologic information such as ship itinerary, travel history, occupation, contact with other ill individuals, help Quarantine Station staff gain knowledge about possible exposures to public health threats. This directs appropriate public health actions and follow-up. The form collects demographic and contact information of the ill or deceased person for surveillance and follow-up purposes. In addition, depending on the suspect diagnosis, the Quarantine Station may also request ships to submit contact and pertinent medical information about passengers and crew who were in contact with the ill or deceased person. This is done so that Quarantine staff can ensure that appropriate prevention measures (such as post exposure prophylaxis) are provided and can track the spread of disease to these individuals.

Land Border Illness or Death Investigation Form

Respondents	Number of Respondents	Number of responses/ respondent	Average burden/ response (in hours)	Total burden hours
Land Border Illness or Death Investigation Form	48	1	5/60	4

The information collected on the Land Border Illness or Death Investigation Form is very similar to that of the Air Travel Illness or Death Investigation Form. The clinical portion of the form asks questions pertaining to symptoms that may be common to communicable (or quarantinable) disease or condition of public health interest such as fever, rash and diarrhea, and respiratory distress. The epidemiological questions allow the Quarantine Station to assess the person’s travel history, occupation, contact with other ill individuals and other factors that may help determine the traveler’s suspected diagnosis. It also allows staff to assess the traveler for a history of high risk exposures during travel.

At land-border crossings, CDC works with its partners in the Department of Homeland Security, specifically CBP, to identify ill travelers when they are crossing into the U.S. Under Part 71, Subpart D-Health Measures at US Ports: Communicable Diseases, CDC can detain and assess a carrier (defined as a ship, aircraft, train, road vehicle, or other means of transport, including military) if it is determined that failure to inspect will present a threat of introduction of communicable diseases into the United States. A report of an ill traveler to CDC by CBP or Border Patrol at a land-border port of entry precipitates a public health response.

Quarantine Stations have not traditionally had staff at land border crossings; therefore Quarantine staff at these locations are focusing considerable effort on building relationships and training partners, such as CBP/Department of Homeland Security (DHS) officials, to alert Quarantine officials about situations of public health interest. Initial efforts at partnership and training have already resulted in increased reporting.