Restriction on Travel of Persons

FORM APPROVED

OMB No. 0920-0488

Exp xx/xx/20xx

RESTRICTION ON TRAVEL OF PERSONS

Report of Illness from Master of Vessel or Person in Charge of a Conveyance

Statement by the master of a vessel or person in charge of a conveyance engaged in interstate traffic about a suspected case of a communicable disease (42 CFR 70.4)

Name (Master of Vessel or Person in Charge of the Conveyance):

______________________________________________________________________________________

To whom is the report being made (Check One)

To: Health Officer, City/County of ___________________, State or Possession of____________________

OR

To: Quarantine Station Located in______________________

OR

To: Centers for Disease Control and Prevention Emergency Operations Center

Vessel or Conveyance Identification:__________________________________________________________

Departure from___________________________ Arrival at ____________________________________

Date___________________________________

Other countries visited during trip:________________________________________________________________

Name of Traveler (Passenger or Crew):___________________________________________________________

Seat/cabin number or work area:______________________________________________________________________

Approximate age:________________

Persons on board observed to be suffering from physical conditions other than airsickness/motion sickness or the effects of accidents, as well as those cases of illness disembarked during the travel period:

_________________________________________________________________________________________

Any physical condition on board which may lead to the spread of disease: ______________________________________________________________________________________

______________________________________________________________________________________

Submitted by (signature) ____________________________________________ Date _______________________________

Typed or Printed Name_________________________________________________________________________________

Address __________________________________ City, State, Zip______________________________________________

Phone ________________________ FAX _____________________________ Email_______________________________

Privacy Act Advisement: The Centers for Disease Control and Prevention (CDC), an agency of the Department of Health and Human Services (HHS), is authorized to collect this information, including the Social Security Number, under provisions of the Public Health Service Act, Section 301 (42 USC 241). Supplying the information is mandatory. The data will be used to track disease patterns. Data will become part of CDC Privacy Act System 09-20-0171, “Quarantine and Traveler-Related Activities , Including Records for Contact Tracing, Investigation, and Notification under 42 CFR Parts 70 and 71”, and may be disclosed to appropriate State or local public health departments and cooperating medical authorities to deal with conditions of public health significance; to private contractors assisting CDC in analyzing and reviewing records; to investigators under certain limited circumstances to conduct further investigations; to organizations to carry out audits and reviews on behalf of HHS; to the Department of Justice for litigation purposes; and to a congressional office assisting individuals in obtaining their records. An accounting of the disclosures that have been made by CDC will be made available to the subject individual upon request. Except for these and other permissible disclosures expressly authorized by the Privacy Act, no other disclosure may be made without the subject individual’s written consent.

Public reporting burden of this collection of information is estimated to average 15 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 0920-0488.