International Maritime Illness or Death Report

OMB Control No 0929-XXXX

Expiration Date: XX/XX/XXXX

U.S. Centers for Disease Control and Prevention International Maritime Conveyance

Illness or Death Report

General information about reporting:

In accordance with public health law (42 CFR 71.21(a)), the U.S. Centers for Disease Control and Prevention (CDC) requires ships destined for a U.S. port, to report to the CDC quarantine station at or nearest the port of arrival, all deaths and certain illnesses among passengers or crew (including those who have disembarked), as soon as they occur and at least 24 hours before arrival. Illnesses reportable to CDC can be found at: http://wwwn.cdc.gov/travel/contentAirTravelCruiseShips.aspx

Directions for submitting this form:

This form may be used to report a death or illness to the CDC Quarantine Station.

• Please fax or e-mail the completed form to the CDC Quarantine Station at or closest to the next U.S. port of arrival. CDC

Quarantine Stations’ jurisdiction and contact information can be found online at www.cdc.gov/ncidod/dq/quarantine_stations.htm

• For urgent reports^† - in addition to filling out this form, please immediately call the CDC Quarantine Station at or closest to the next port of arrival.

• If you are unable to reach the CDC Quarantine Station, please call: 1-770-488-7100 or 1-877-764-5455 (at-sea use) for assistance.

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^† Urgent reports include suspected cases of cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fever, severe acute respiratory syndrome (SARS), novel influenza viruses, meningococcal disease, measles, mumps, rubella, pertussis, and unusual illness, cluster of illnesses or deaths due to a communicable disease.

Section 1. Vessel and agent information (use local dates and times)
Name and position of person reporting ­ ______________________________________________________________
Contact phone ___________________________		Contact email ____________________________________
Report date/time ___________ _________ mm / dd / yyyy (24 hr) hh : mm		Vessel company __________________________________
Vessel name ______________________________		Vessel type: Cargo Cruise Other:_________________
Embarkation port/code __________________________		Embarkation date/time ___________ ____________ mm / dd / yyyy (24 hr) hh : mm
Next U.S port _________________________________		Arrival date/time ___________ ____________ mm / dd / yyyy (24 hr) hh : mm
Section 2. Information on illness or death
Report type: illness crew member Initials of ill or (check appropriate boxes) death passenger deceased person ___________
Signs/Symptoms: Check ill or deceased person’s current or previous signs and symptoms
Fever (temperature 100° F or 38° C or higher) or recent history of fever Skin rash Difficulty breathing (Shortness of breath) Persistent cough	Decreased consciousness Unusual bleeding Jaundice Glandular swelling (Swollen glands)		Recent onset of paralysis (or focal weakness) Severe vomiting Severe diarrhea Other ___________________
Illness/death part of a cluster/outbreak? Yes No	Presumptive diagnosis or cause of death ____________________________________________

Public reporting burden of this collection of information is estimated to average 3 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. Revised 11/18/2008