International Maritime Illness or Death Report

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0821 can be found here:

Documents and Forms

Document Name Document Type
International Maritime Illness or Death Report Form
International Maritime Illness or Death Report Attachment I - Maritime Illness or Death Report revised 10809.doc Form

Information Collection (IC) Details

IC Title:	International Maritime Illness or Death Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	International Maritime Illness or Death Report	Attachment I - Maritime Illness or Death Report revised 10809.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Quarantine and Traveler Related Activities, including Records for Contact Tracing Investigation and Notification	FR Citation: 72 FR 70867

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.