Air Travel Form Changes

Air Form Changes and Justification

Section 1:

• Moved Port of Entry and State up to top line to consolidate space

• Moved Type of Traveler down below Type of Notification to consolidate space.

• Split the variable ‘When was the Quarantine Station notified?’ into two questions and added an ‘Unknown’ option for program purposes:

Type of notification: □ Illness □ Death	When was the Quarantine Station notified?: □ Before any travel was initiated □ During travel □ Prior to boarding conveyance □ While traveler was on a conveyance □ After disembarking conveyance □ After travel completed (reached final destination for that leg of trip) □ Unknown
Type of traveler: □ Passenger □ Crew
Where was the traveler when the QS was notified?: □ In U.S. jurisdiction / Inbound □ In foreign jurisdiction / Outbound □ Unknown

• Removed ‘Conveyance Type’ and ‘Was the travel domestic or international?’ from section 1 and incorporated into the Flight Information table in Section 4 shown below:

Type*	Domestic or Int’l?	Airline	Flight #	Departure Airport Code	Departure Date	Arrival Airport Code	Arrival Date	Seat #	Flight Duration
CURRENT FLIGHT:
PREVIOUS AND/OR UPCOMING FLIGHTS:
*C/FB = Commercial, foreign-based carrier C/US = Commercial, U.S.-based carrier P = Private CH = Charter CG = Cargo O = Other

• Moved ‘If ill/deceased person also traveled via □ Land and/or □ Maritime conveyances, please fill out the appropriate form’ to bottom of section to prioritize the fields.

Section 2:

• Renamed section title to ‘Pertinent medical history of ill or deceased person’ to clarify intent of section.

• Moved ‘Relevant history: present illness, other medical problems, vaccinations, etc.’ up from Section 3 and renamed it to ‘Relevant history: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:’ to keep relevant information together and clarify question intent.

• Moved ‘Traveler has taken:’ up from Section 3, changed format, added ‘antiparasitic(s)’ (option 1) and ‘related to current symptoms/illness’ (option 3) and removed ‘aspirin’ (option 2) to keep relevant information together and clarify question intent.

Traveler has taken (include those given on board):

□ Antibiotic/antiviral/antiparasitic(s) in the past week; list with dates started: ________________________________

□ Fever-reducing medications (e.g. acetaminophen, ibuprofen) in the past 12 hours; list with dates started: ________

□ Other (related to current symptoms/illness); list with date(s) started: ______________________________________

• Moved Exposure History questions up from Section 7, reformatted, added ‘Arrival date’ and removed ‘Visited rural areas?’ to keep relevant information together, clarify question intent, and reduce burden.

Relevant Exposures in the Past 3 Weeks:

Village/City/State	Province/Country	Arrival Date	Exposure to ill persons?	Exposure to animals?	Other exposures (chemical, drug ingestion, etc)?
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________

• Signs, Symptoms, and Conditions:

• Fever:

• Changed ‘…OR history of fever…’ to ‘…OR history of feeling feverish/having chills…’ to streamline question.

• Changed ‘Temperature’ to ‘Current temperature’ to clarify question intent.

• Removed ‘Maximum measured temperature’ to reduce burden.

• Removed ‘History of fever (not measured)’ to reduce burden.

• Removed ‘Feel warm to the touch’ to reduce to reduce burden.

• Rash:

• Removed ‘Where rash started’ and options to reduce burden.

• Removed ‘Current distribution’ and options to reduce burden.

• Changed options for ‘Appearance’ from ‘Red-flat, Red-raised, Fluid/pus-filled’ to ‘Maculopapular, Vesicular/Pustular, Pupuric/Petechial, Scabbed’ to clarify question intent.

• Removed ‘Severe’ from Vomiting and Diarrhea to clarify question intent.

• Added ‘Onset Date’ to Conjunctivitis/eye redness, Coryza/runny nose, Sore throat, Difficulty breathing/shortness of breath, Swollen glands, Headache, Neck stiffness, Decreased consciousness, Recent onset of focal weakness and/or paralysis, and Unusual bleeding for program purposes.

• Moved ‘Date of death’ and ‘Time of death’ for Deceased Persons up from Section 6 to keep relevant information together.

• Moved ‘Suspect cause of death before referral to medical examiner, if body released:’ up from section 6 and renamed to ‘Presumptive diagnosis/cause of death’ to keep relevant information together and clarify question intent.

• Reformatted ‘Are any traveling companions ill?’ to clarify question intent.

• ‘Presumptive Diagnosis’ field, for program purposes,:

• Reworded to ‘Response or Report’

• Removed ‘Disease of public health interest or any death’

• Changed ‘Condition of public health interest/unknown or cluster, needs follow-up’ to ‘Requires DGMQ Response & Follow-up’

• Changed ‘Condition not requiring public health follow-up‘ to ‘Information Report Only / No Follow-up Needed’

Section 3:

• Reworded ‘Passport country/issuing state’ to ‘Passport country/citizenship’ to clarify question intent.

• Added ‘Type of ID document’ for program purposes.

• Reworded ‘Passport/domestic ID document #’ to ‘ID document #’ to clarify question intent.

Passport country/citizenship:

Type of ID document:

ID document #:

Alien #:

Section 4:

• Reworded ‘Departure Airport’ and ‘Arrival Airport’ to ‘Departure Airport Code’ and ‘Arrival Airport Code’ to reduce burden.

• Changes as previously noted in Section 1 summary above.

Section 5:

• Renamed section title to ‘Disposition of ill/deceased person’

• Changed the order for program purposes and worded the ‘Ill person’ options:

• ‘Seen by EMS’ changed to ‘EMS responded’ to utilize proper terminology

• ‘Detained by ICE/CBP, location’ changed to ‘Detained by law enforcement, location:’ to utilize proper terminology.

• ‘Denied boarding’ changed to ‘Denied boarding by law enforcement’ to utilize proper terminology.

• Removed ‘Quarantine Order issued’ to reduce burden.

• Removed ‘Isolation Order issued’ to reduce burden.

• Moved ‘Body released to medical examiner?’, telephone, and ‘City/Country’ up from the former Section 6 to keep pertinent information together. Removed ‘Determined cause of death (by medical examiner or other) to reduce burden.

Section 5: Disposition of ill/deceased person
Ill person was (check all that apply):	Deceased Person:
□ Released to continue travel □ Advised to seek medical care □ EMS responded □ Recommended to not travel □ Transported to hospital (□ MOA activated): ___________________ □ Transported to non-hospital location: _________________________ □ Detained by law enforcement, location: _______________________ □ Denied entry by law enforcement □ Other: __________________________________________________	Body released to medical examiner?: □ Yes □ No Medical examiner telephone: ___________________ City/State/Country: __________________________