International Maritime Illness or Death Report

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

Attachment I - Maritime Illness or Death Report revised 10809

International Maritime Illness or Death Report

OMB: 0920-0821

Document [doc]
Download: doc | pdf

OMB Control No 0929-XXXX

Expiration Date: XX/XX/XXXX

U.S. Centers for Disease Control and Prevention International Maritime Conveyance

Illness or Death Report




General information about reporting:

In accordance with public health law (42 CFR 71.21(a)), the U.S. Centers for Disease Control and Prevention (CDC) requires ships destined for a U.S. port, to report to the CDC quarantine station at or nearest the port of arrival, all deaths and certain illnesses among passengers or crew (including those who have disembarked), as soon as they occur and at least 24 hours before arrival. Illnesses reportable to CDC can be found at: http://wwwn.cdc.gov/travel/contentAirTravelCruiseShips.aspx


Directions for submitting this form:

This form may be used to report a death or illness to the CDC Quarantine Station.

  • Please fax or e-mail the completed form to the CDC Quarantine Station at or closest to the next U.S. port of arrival. CDC

Quarantine Stations’ jurisdiction and contact information can be found online at www.cdc.gov/ncidod/dq/quarantine_stations.htm

  • For urgent reports - in addition to filling out this form, please immediately call the CDC Quarantine Station at or closest to the next port of arrival.

  • If you are unable to reach the CDC Quarantine Station, please call: 1-770-488-7100 or 1-877-764-5455 (at-sea use) for assistance.

_________________________________________________________________________________

Urgent reports include suspected cases of cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, viral hemorrhagic fever, severe acute respiratory syndrome (SARS), novel influenza viruses, meningococcal disease, measles, mumps, rubella, pertussis, and unusual illness, cluster of illnesses or deaths due to a communicable disease.



Section 1. Vessel and agent information (use local dates and times)


Name and position of person reporting ­ ______________________________________________________________


Contact phone ___________________________


Contact email ____________________________________




Report date/time ___________ _________

mm / dd / yyyy (24 hr) hh : mm



Vessel company __________________________________


Vessel name ______________________________

Vessel type: Cargo Cruise Other:_________________

Embarkation port/code __________________________



Embarkation date/time ___________ ____________

mm / dd / yyyy (24 hr) hh : mm


Next U.S port _________________________________





Arrival date/time ___________ ____________

mm / dd / yyyy (24 hr) hh : mm







Section 2. Information on illness or death



Report type: illness crew member Initials of ill or

(check appropriate boxes) death passenger deceased person ___________


Signs/Symptoms: Check ill or deceased person’s current or previous signs and symptoms

Fever (temperature 100° F or 38° C or higher) or recent history of fever


Skin rash


Difficulty breathing

(Shortness of breath)


Persistent cough

Decreased consciousness


Unusual bleeding


Jaundice


Glandular swelling

(Swollen glands)

Recent onset of paralysis

(or focal weakness)


Severe vomiting


Severe diarrhea


Other ___________________


Illness/death part of

a cluster/outbreak? Yes No



Presumptive diagnosis

or cause of death ____________________________________________








Public reporting burden of this collection of information is estimated to average 3 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-xxxx. Revised 11/18/2008



File Typeapplication/msword
File TitleInternational Maritime Traveler Illness or Death Report
AuthorJeffrey Bethel
Last Modified Byhym3
File Modified2009-01-08
File Created2009-01-08

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