Air Trvael Illness or Death Investigation

Section 1. Quarantine station notification
QARS Unique ID #:				CDC User ID :
Port of Entry:						State:
Person notifying CDC:				Phone:		Email:
Agency notifying CDC:		Date of initial notification to CDC:			_____/_____/______ mm dd yyyy	Time of initial notification to CDC (24 hrs):		_____ : _____ hh : mm
Type of notification:	□ Traveler illness □ Traveler death			Type of traveler:		□ Passenger □ Crew
When was the QS notified?: □ Before any travel was initiated □ In U.S. jurisdiction □ In foreign jurisdiction □ During travel □ Prior to boarding conveyance □ While traveler was on a conveyance □ Inbound to or within U.S. states and territories □ Outbound from U.S. states and territories □ After disembarking conveyance □ After travel completed (reached final destination for that leg of trip) □ In U.S. jurisdiction □ In foreign jurisdiction				Conveyance type*: □ Commercial □ foreign-based carrier □ U.S.-based carrier □ Private □ Charter □ Cargo □ Other *If ill/deceased person also traveled via □ Land and/or □ Maritime conveyances, please fill out the appropriate form and attach
				Was the travel domestic or international?: □ U.S. domestic travel only (U.S. states and territories) □ International travel (could include domestic portion) □ No travel done
Section 2. Information on signs and symptoms of ill or deceased person
Signs, Symptoms, and Conditions (check all that apply):
□ FEVER (≥100F or ≥38°C) OR history of fever in the past 72 hours Temperature: ____________0 F/C Onset date: _____/_____/______ Maximum measured temperature: __________ 0 F/C □ History of fever (not measured) □ Feel warm to the touch □ Rash Onset date: _____/_____/______ Where rash started: □ Head/neck □ Trunk □ Extremities Current distribution: □ Head/neck □ Trunk □ Extremities Appearance: □ Red-flat □ Red-raised □ Fluid/pus-filled □ Other ________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________ □ Conjunctivitis/eye redness □ Coryza/runny nose			□ Persistent cough Onset date: _____/_____/______ □ With blood □ Without blood □ Sore throat □ Difficulty breathing/shortness of breath □ Swollen glands Location: □ Head/neck □ Armpit □ Groin □ Severe vomiting Onset date: _____/_____/_______ Number of times in past 24 hrs? ______ □ Severe diarrhea Onset date: _____/_____/_______ Number of times in past 24 hrs?: ______ □ Jaundice Onset date: _____/_____/_______ □ Headache				□ Neck stiffness □ Decreased consciousness □ Recent onset of focal weakness and/or paralysis □ Unusual bleeding □ Obviously unwell □ Injury □ Chronic condition □ Asymptomatic □ Other: _____________________________ _____________________________ ______________________________
Does anyone else on the plane have similar illness?: □ No □ Yes □ Unknown (If yes, please fill in a new form for each person in the cluster.)
Presumptive Diagnosis: □ Disease of public health interest or any death (Proceed to next section) □ Condition of public health interest/unknown or cluster, needs follow-up (Proceed to next section) □ Condition not requiring public health follow-up (STOP HERE)

Air Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

Section 3. Pertinent medical history of ill person

Relevant history: present illness, other medical problems, vaccinations, etc.:

Traveler has taken:

□ Antibiotic/antiviral in the past week

□ Fever reducing medications in the past 12 hours

(e.g. acetaminophen, ibuprofen, aspirin)

□ Other

Medication(s) taken:

1. _____________________________

2. _____________________________

3. _____________________________

Date(s) started:

1. ____/____/______

2. ____/____/______

3. ____/____/______

Section 4. General information about the ill or deceased person

Last/paternal name:

First/given name:

Middle name:

Maternal name (if applicable):

Other names used (e.g., former name, alias):

Gender:

□ Male

□ Female

Date of birth:

_____/_____/______

mm dd yyyy

Age (if date of birth unknown):

□ Days □ Weeks

□ Months □ Years

Country of birth:

Passport country/issuing state:

Passport/domestic ID document #:

Alien #:

For deceased persons, go to Section 5. Otherwise, continue below.

Home address:

City:

State/province:

Zip/postal code:

Country of residence:

Home phone:

If visiting, total duration of U.S. stay:

□ days □ months

□ weeks □ years

Contact in U.S. - Address/hotel:

□ Same as home address above

E-mail:

Contact in U.S. - City:

Contact in U.S. - State/territory:

Contact phone in U.S.:

□ Cell

Number of days reachable at contact phone:

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Section 5. Flight information

Airline & Flight #

Departure Airport

Departure Date

Arrival Airport

Arrival Date

Seat #

Flight Duration

CURRENT FLIGHT:

PREVIOUS AND UPCOMING CONNECTING FLIGHTS:

Section 6. Additional information about deceased person

Date of death:	______/______/__________ mm dd yyyy		Time of death (24 hours):		_____:_____ hh : mm
Suspected cause of death before referral to medical examiner, if body released:
Body released to medical examiner?: □ Yes □ No		Medical examiner telephone:		City/Country:
Determined cause of death (by medical examiner or other): For deceased persons for whom the suspected cause of death is NOT a communicable disease, stop here. Otherwise, continue to Section 7.

Section 7. Exposure and contact history of ill or deceased person

*zoos, bush meat, poultry markets, farms, backyard animals

Cities/states/countries visited in the last 3 WEEKS	1.		2.		3.		4.
Exposures	Exposure to ill persons? □ Yes □ No	Exposure to animals?* □ Yes □ No		Visited rural areas? □ Yes □ No		Other exposures (chemical, drug ingestion, etc): □ Yes □ No

Describe relevant exposures:

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

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

If yes, how many are ill: _________

Section 8: Disposition of ill person

Ill person was

(check all that apply):

□ Released to continue travel □ Advised to seek medical care □ Recommended to not continue travel

□ Seen by EMS □ Denied boarding □ Quarantine Order issued □ Isolation Order issued

□ Detained by ICE/CBP, location: __________________________________________________________

□ Transported to hospital (□ MOA activated): ________________________________________________

□ Transported to non-hospital location: ______________________________________________________

□ Other: _______________________________________________________________________________

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 0920-0821

OMB Control No. 0920-0821

Expiration Date: 09/30/2012