Maritime Conveyance Illness or Death Investigation

M aritime Conveyance Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

If requested by Centers for Disease Control and Prevention (CDC) Quarantine Station, please use this form to submit additional information about the reported onboard illness or death, pursuant to 42 CFR 71.21(a).

• Complete and fax this form to the CDC Quarantine Station to which the illness or death was reported. Quarantine Station jurisdictions and contact information can be found at www.cdc.gov/ncidod/dq/quarantine_stations.htm

• Contact the CDC Quarantine Station to confirm receipt of the faxed report or if you have any questions.

• If you are unable to reach a CDC Quarantine Station, call +1-770-488-7100. Alternate: +1-877-764-5455 (at-sea use).

• Reminder to cruise ships: do not use this form for gastrointestinal (GI) illnesses, which are reportable to CDC Vessel Sanitation Program (VSP) per established protocol. More information about VSP can be found at: http://www.cdc.gov/nceh/vsp/default.htm or by calling +1-800-323-2132.

Section 1. Quarantine Station Notification

Person filling out form:

Phone:

E-mail:

Date form completed:

______/_______/_______

mm dd yyyy

Time form completed (24 hrs):

_____ : _____

hh : mm

Type of notification:

□ Traveler illness

□ Traveler death

Type of Traveler:

□ Crew

□ Passenger

Conveyance type: □ Cruise Ship □ Cargo □ Other

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: _________________________

________________________________

________________________________

During the past 3 weeks, has anyone (onboard ship or disembarked) had similar signs and symptoms? (Please verify by a medical log review):

*If yes, please fill in a new form for each person in the cluster

□ No

□ Yes*

□ Unknown

If yes, total # of ill:

Crew:

___________

Passengers:

___________

Section 3. Pertinent medical history of ill or deceased person

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

Traveler has taken:

(include those given on board):

□ 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. ____/____/______

Seen in ship infirmary:

□ No □ Yes

If yes, date of first visit:

_____/_____/________

mm dd yyyy

Ill or deceased person isolated after illness onset?:

□ No □ Yes

If yes, date isolated:

_____/_____/_______

mm dd yyyy

Suspect Diagnosis:

Seen in health-care facility ashore:

□ No □ Yes

Hospitalized? □ No □Yes

Dates hospitalized: from _____/_____/______ to ______/_____/_______

mm dd yyyy mm dd yyyy

Facility/health care provider(s) info (name, location, dates, telephone number, e-mail):

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

Discharge Diagnosis:

Tests	Date performed (mm/dd/yyyy)	Results ( if unknown, provide name and phone number of lab which performed tests): ______________________________________
Chest x-ray:	______/______/______	□ Normal □ Abnormal (□ Cavitation □ No Cavitation)
Legionella urine antigen:	______/______/______	□ Positive □ Negative
Other: Test 1: _______________________________ Test 2: _______________________________ Test 3: _______________________________	1. ______/______/______ 2. ______/______/______ 3. _____/______/_______	1._____________________________ 2._____________________________ 3._____________________________

Section 4. General information about 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 #:

If crew, list job title & duties:

Date boarded vessel:

_______/_______/_______

mm dd yyyy

Cabin Number:

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. Vessel information

Vessel name:

Vessel company:

Voyage Number:

Number on board:

Crew:

Passengers:

Embarkation port:

Embarkation Date:

______/______/_______

mm dd yyyy

Disembarkation port:

Disembarkation date:

______/______/_______

mm dd yyyy

Next U.S. port:

Arrival date: ______/______/_______

mm dd yyyy

Arrival time:

(24 hr) _____ : _____

hh : mm

Duration of stay at next U.S. port:

____________hrs

Itinerary:

Section 6. Additional information about deceased person

Date of death:

_____/_____/_______

mm dd yyyy

Time of death (24 hr):

_____ : ______

hh : mm

Suspected cause of death before referral to a 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):

Note: 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
Cities/states/countries visited in the last 3 WEEKS (include ship port stops if disembarked)			1.		2.			3.			4.
Exposures:	Exposure to ill persons? □ No □ Yes			Exposure to animals?* □ No □ Yes			Visited rural areas? □ No □ Yes		Other exposures (chemical, drug ingestion, etc)?: □ No □ Yes
*zoos, bush meat, poultry markets, farms, backyard animals
Describe relevant exposures:
Are any traveling companions ill?: □ No □ Yes* □ N/A (no companions) If yes, how many are ill: __________ *Note: Submit a separate form for each ill or deceased person not previously reported to a CDC Quarantine Station.
Answer if ill or deceased person is a crew member: Number of : Cabin mates:_______________ Bathroom mates: ____________ Work team mates: ___________ Other contacts (e.g., intimate partners): _______					Does crew member have contact with passengers?: □ No □ Yes If yes, describe extent/frequency: _______________________________________________________________ _______________________________________________________________
Answer if ill or deceased person is a passenger: Number of: Cabin mates: _____________ Other contacts (e.g., intimate partners):_______					If passenger is a child, does s/he attend day care/youth program on ship?: □ No □ Yes If yes, total # of children in day care/program: ______________ # of children with similar signs & symptoms: ______________
Comments: _________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
TO BE COMPLETED BY QUARANTINE STAFF ONLY
QARS Unique ID #:		CDC User ID:				Date Quarantine Station received: _____/_____/______ mm dd yyyy				Time Quarantine Station received (24 hrs): ______:______ hh:mm
If ill/deceased person also traveled via □ Land and/or □ Air conveyances, please fill out the appropriate form
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						Presumptive Diagnosis: □ Disease of public health interest □ Condition of public health interest/unknown or cluster, needs follow-up □ Condition not requiring public health follow-up
						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 7 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