Air Travel Illness or Death Investigation

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

Attachment E Air Travel Illness or Death Form

Air Travel Illness or Death Investigation

OMB: 0920-0821

Document [docx]
Download: docx | pdf

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 (≥100F 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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSection 1
Authordlv8
File Modified0000-00-00
File Created2021-02-01

© 2024 OMB.report | Privacy Policy