42 CFR 70.3 Applicant Traveler

FORM APPROVED

OMB No. 0920-0488

Exp xx/xx/200x

RESTRICTION ON TRAVEL OF PERSONS

Multipurpose Application Form Under the Provisions of 42 CFR Part 70

Name (applicant or ill passenger) ______________________________________________________________________

Date of Birth_______________SSN_____________________________Phone___________________________________

Address_________________________________ City, State, Zip _______________________________________

Physician’s Name ______________________________ Address___________________Phone_______________

• 1. Application for a permit to travel from one State or possession to another with a communicable disease in the communicable period (42 CFR 70.40)

To: Health Officer, State or Possession of _________________________________________________

I hereby apply for a permit to travel from _____________________ to __________________________

The route of travel (or airline/flight, etc.) will be ____________________________________________

The date of travel will be _______________________________________________________________

A physician’s statement including a detailed diagnosis must be attached.

• 2. Statement by the master of a vessel or person in charge of a conveyance engaged in interstate traffic about a suspected case of a communicable disease (42 CFR 70.45)

To: Health Officer, City/County of ___________________, State or Possession of____________________

In transit between _______________________________ and ____________________________________

Vessel or Conveyance___________________________________________________________________________

Suspected case of a communicable disease:

Observed symptoms ____________________________________________________________________

_____________________________________________________________________________________

• 3. Application for a permit to travel from one State or possession to another while in the communicable period of cholera, plague, smallpox, typhus or yellow fever, or, having been exposed to any such disease, in the incubation period thereof. (42 CFR 70.50)

To: Surgeon General or authorized representative ____________________________________________________

I hereby apply for a permit to travel from _____________________ to _____________________________

The route of travel (or airline/flight, etc.) will be ________________________________________________

The date of travel will be _________________________________________________________________

A physician’s statement including a detailed diagnosis must be attached.

Submitted by (signature) ____________________________________________ Date _______________________________

(Respondent indicates their consent by signature on the form)

Typed or Printed Name_________________________________________________________________________________

Address __________________________________ City, State, Zip______________________________________________

Phone ________________________ FAX _____________________________ Email_______________________________

Privacy Act Advisement: The Centers for Disease Control and Prevention (CDC), an agency of the Department of Health and Human Services (HHS), is authorized to collect this information, including the Social Security Number, under provisions of the Public Health Service Act, Section 301 (42 USC 241). Supplying the information is mandatory. The data will be used to track disease patterns. Data will become part of CDC Privacy Act System 09-20-0171, “Quarantine and Traveler-Related Activities , Including Records for Contact Tracing, Investigation, and Notification under 42 CFR Parts 70 and 71”, and may be disclosed to appropriate State or local public health departments and cooperating medical authorities to deal with conditions of public health significance; to private contractors assisting CDC in analyzing and reviewing records; to investigators under certain limited circumstances to conduct further investigations; to organizations to carry out audits and reviews on behalf of HHS; to the Department of Justice for litigation purposes; and to a congressional office assisting individuals in obtaining their records. An accounting of the disclosures that have been made by CDC will be made available to the subject individual upon request. Except for these and other permissible disclosures expressly authorized by the Privacy Act, no other disclosure may be made without the subject individual’s written consent.

Public reporting burden of this collection of information is estimated to average 15 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 0920-0488.