Traveler Contact Information Form

Traveler Contact Information Form
Form Approved
OMB No.: xxxx-xxxx
Exp. Date: xx/xx/xxxx

Note to CBP: Please ask traveler to complete this form in its entirety to ensure that CDC can conduct follow up.
If traveler is unable to complete the form, please assist the traveler in completing the form.
Please print clearly.

Name_____________________________________________________________________________________
Name of parent/guardian if individual is under 18________________________________________________

Permanent Address
Address_____________________________________________________________________________________________
City______________________________ State__________ Zip Code _________ Country_______________________
Work Telephone_____________________ Work Email_____________________________________________________
Home Telephone____________________ Home Email____________________________________________________
Mobile Telephone___________________

Address where you may be contacted in US (if different from permanent address)
Address_____________________________________________________________________________________________
City______________________________ State__________ Zip Code _________ Country_______________________
Work Telephone_____________________ Work Email____________________________________________________
Home Telephone____________________ Home Email____________________________________________________
Mobile Telephone___________________

For Customs and Border Protection use
Dose/dose-rate (include units)________________________________________________________________________
Isotope_____________________________________________________________________________________________
CBP, please transmit via secure password-protected email from NOC to SOC to CDC EOC to [email protected].
Public reporting burden of this collection of information is estimated to average 10 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
Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (xxxx-xxxx).

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
March 24, 2011
CS222404-C