Form No number No number Air Travel Illness or Death Investigation

I nternational Air Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

Section 1. Quarantine station notification
Port of Entry:
Notified by: (name of person)					Phone:	Email:
Notified by: (name of agency)
Type of notification:	□ Traveler illness □ Traveler death	Date of initial notification:			_____/_____/_______ (mm / dd / yyyy)	Time of initial notification: (24 hours)		: (hh : mm)
For Illness Report, go to Section 2. For Death Report, go to Section 8.
Section 2. Information on signs and symptoms of ill or deceased person (passenger or crew)
Signs, Symptoms, and Conditions (Check all that apply) :
 FEVER (or recent history of) Temp: ______________0 F/C  rash  conjunctivitis/eye redness  persistent cough  sore throat  difficulty breathing / shortness of breath			 severe vomiting  severe diarrhea  headache  neck stiffness  decreased consciousness  recent onset of focal weakness and / or paralysis				 unusual bleeding  obviously unwell  asymptomatic  other (describe:____________________________
Brief history of present illness:
Are there other people on the plane with similar illness? Yes No
Does traveler have FEVER (or recent fever history) AND at least one other sign/symptom/condition listed above?  NO (STOP HERE)  NO (but you are concerned illness may be of public health significance (Proceed to next sections)  YES (Proceed to next sections)
Section 3. Pertinent medical history
Do you have underlying medical conditions that could explain your current symptoms?  No  Yes______________ Are you currently taking: (describe) a. Medications that could reduce a fever (e.g., aspirin, ibuprofen, Motrin, Aleve, acetaminophen, Tylenol)?  No  Yes Which one? __________________________________________________ b. Antibiotics/Antimicrobials?  No  Yes What?_____________________________ c. Medication that could be related to your current symptoms? ?  No  Yes..What?_____________________ During or prior to the flight did you take: a. Fever-reducing medications  No  Yes b. What did you take? _____________________ How long ago was your last dose? _______hrs Disease/Vaccination History (if applicable) Prior Disease? Prior Vaccination? Chickenpox  No  Yes  No  Yes Rubella (German Measles)  No  Yes  No  Yes Measles  No  Yes  No  Yes
Section 4. History of current illness
I. Fever History: Date of fever onset ___/___/___ If you measured your temperature during this illness, what was your maximum temperature? _______________ 0 F/C
II. Rash History: Date of rash onset ___/___/___ Where did the rash start?  Head  Trunk  Extremities  Other _______________________ Current distribution of rash:  Head  Trunk  Extremities  Other _______________________ Appearance of rash:  Red-raised  Red-flat  Fluid- or pus-filled  Other________________________ Passenger had contact with someone with a rash/known chickenpox/measles/rubella in the last 3 weeks?  No  Yes
III. Respiratory Illness History: Cough  No  Yes onset _____/_____/_____ with blood?  No  Yes (mm / dd / yyyy) Coryza*?  No  Yes (*runny nose)				IV. Gastrointestinal Illness History: Diarrhea: Date onset _____/_____/_______ With blood?  No  Yes Number of times in past 24 hrs? ____ Vomiting: Date onset _____/_____/_______ With blood?  No  Yes Number of times in past 24 hrs? ____

Section 5. Exposure history of ill or deceased person

* e.g., visits to zoo, animal market, poultry farms, family/friends with back yard poultry or pigs

Countries visited in the last 3 WEEKS	Visited Urban Areas?	Visited Rural Areas?	How long ago?	Activities (e.g. student, missionary, personal or business travel, etc. )	Exposure to animals?*	Exposure to ill persons?
	 Yes  No	 Yes  No			 Yes  No	 Yes  No
	 Yes  No	 Yes  No			 Yes  No	 Yes  No
	 Yes  No	 Yes  No			 Yes  No	 Yes  No
	 Yes  No	 Yes  No			 Yes  No	 Yes  No

If exposed to ill animals or birds, describe nature of contact:

If exposed to ill person, ill persons’ diagnoses or description of illness:

Other exposures (chemical, powder, radiation, etc)?  No  Yes

If yes, where?

If yes, when?

Occupation:

Section 6. Traveling companions & other contacts of ill or deceased person

Number of traveling companions:

Are any traveling companions ill? □ No □ Yes □ N/A (no companions)

If yes, use another illness screening and response worksheet for each.

Section 7. Flight information

Airline & Flight #	Departure Airport	Departure Date & Time	Arrival Airport	Arrival Date & Time	Seat #	Flight Duration
CURRENT FLIGHT:
PREVIOUS AND UPCOMING CONNECTING FLIGHTS:

Section 8. General information about the ill or deceased person

Paternal/Last name:

First name:

Type of traveler: □ Crew □ Passenger

Aliases:

Country of birth:

Gender:

□ Male

□ Female

Date of birth:

_____/_____/__________

(mm / dd / yyyy)

Age (if Date of Birth Unknown):

□ Days □ Weeks

□ Months □ Years

For deceased persons, go to Section 9. Otherwise, continue below:

Contact in US - Address/hotel:

□ 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?□ Yes □ No

If not permanent, home phone #:

Home address

Home City:

Home State/Province:

Home Zip/Postal Code

Home Country (Country of Residence):

If visiting, total

duration of US stay:

□ days □ months □ weeks □ years

Passport country:

Passport #:

Alien #:

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Section 9. General information about the deceased person onboard the flight

Date of death:

_____/_____/__________

(mm / dd / yyyy)

Time of death

(24 hours)

: (hh : mm)

Suspected cause of death:

If infectious disease is suspected as a contributing cause of death, then complete ALL sections of this form.

Medical examiner notified?

 Yes  No

Medical examiner name:

Medical examiner telephone:

Name of person body released to:

Title of person body released to:

Agency:

Office telephone:

Cell:

Email:

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.