Land Travel Illness or Death Investigation

Land Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

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:

□ Crew □ Passenger □ N/A

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*:

□ Personal vehicle

□ Company owned

□ Rental

□ Public conveyance bus/van

□ Commercial cargo vehicle

□ Pedestrian/Bike

□ Ambulance

□ Train

□ Other

*If ill/deceased person also traveled via □ Air and/or □ Maritime

conveyances, please fill out the appropriate form and attach

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: _______________________

_______________________________

_______________________________

If traveling by conveyance, does anyone else 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)

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:

Border commuter:

□ Yes

□ No

□ Unknown

Frequency of border crossing: ________ times/ □ day □ week

□ month □ year

Passport country:

Passport country/issuing state:

Passport/domestic ID document #:

Visa?:

□ Yes

□ No

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

Home address:

City:

State/province:

Zip/postal code:

Country of residence:

Home telephone:

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

□ weeks □ years

□ days □ months

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. Border Crossing Information

Make/Model/Year:

License plate #:

State/country issued:

Attempted entry outside an official POE?:

□ No

□ Yes

□ Unknown

Contact information collected on conveyance passengers/driver(s)?:

□ No

□ Yes

From (City/Country)	Departure date	To (City/Country)	Arrival date	Significant stops	Name of commercial carrier, if applicable	Bus/Train #	Seat #
Current Segment:
Past & Upcoming Segments:

Section 6. General information about the 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

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

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

Describe relevant exposures:

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

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

If yes, how many 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 entry □ 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