Maritime Conveyance Illness or Death Investigation Form

Maritime Conveyance Illness or Death Investigation Form

Form Approved

OMB Control No.0920-0821

Exp XX/XX/XXXX

U.S. Centers for Disease Control and Prevention

If requested by Centers for Disease Control and Prevention (CDC) Quarantine Station, please use this form to submit additional information about the reported onboard illness or death, pursuant to 42 CFR 71.21(a).

• Complete and fax this form to the CDC Quarantine Station where the illness or death was reported. Quarantine Station jurisdictions and contact information can be found at http://www.cdc.gov/quarantine/QuarantineStationContactListFull.html

• If you are unable to reach a CDC Quarantine Station, call +1-770-488-7100. Alternate: +1-877-764-5455 (at-sea use).

• Reminder to cruise ships: Do not use this form for gastrointestinal (GI) illnesses, which are reportable to CDC Vessel Sanitation Program (VSP) per established protocol. More information about VSP can be found at: http://www.cdc.gov/nceh/vsp/default.htm or by calling +1-800-323-2132.

Section 1. Quarantine Station Notification

Person filling out form:

Phone:

E-mail:

Type of notification:

□ Illness

□ Death

Type of Traveler:

□ Crew

□ Passenger

Conveyance type:

□ Cruise Ship □ Cargo

□ Other _____________

Section 2: Vessel Information

Vessel company:

Vessel name:

Voyage Number:

Number on board:

Crew:

Passengers:

Country of departure:

Departure date & time (24 hr):

______/______/_______, _____ : _____

mm dd yyyy hh : mm

Arrival date & time (24hr) at final port:

______/______/_______, _____ : _____

mm dd yyyy hh : mm

Itinerary:

Next U.S. port:

Arrival date & time (24 hr) at next U.S. port : ______/______/_______, _____ : _____

mm dd yyyy hh : mm

Person info while onboard vessel:

Cabin number:

If crew, list job title & duties:

If crew member has contact with passengers, describe extent/frequency:

Embarkation port:

Embarkation date:

______/______/_______

mm dd yyyy

Disembarkation port:

Disembarkation date:

______/______/_______

mm dd yyyy

Section 3: Pertinent medical history of ill or deceased person

Relevant history: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:

Signs, Symptoms, and Conditions (Check all that apply) :

□ FEVER (≥100F or ≥38°C) OR history of

feeling feverish/ having chills in past 72 hrs

Onset date:_____/_____/______

Current temperature: _____⁰ F/C

□ Rash

Onset date: _____/_____/______

Appearance:

□ Maculopapular □Vesicular/Pustular

□ Purpuric/Petechial □ Scabbed □ Other ________­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

□ Conjunctivitis/eye redness

Onset date: ____/_____/____

□ Coryza/runny nose

Onset date: ____/_____/____

□ Persistent cough

Onset date: ___/____/___

□ With blood □ Without blood

□ Sore throat

Onset date: _____/_____/______

□ Difficulty breathing/shortness of breath

Onset date: _____/_____/______

□ Swollen glands

Onset date: ____/_____/____

Location: □ Head/neck □ Armpit □ Groin

□ Vomiting

Onset date: ___/___/__

# of times in past 24 hrs? _____

□ Diarrhea

Onset date: _____/_____/______

# of times in past 24 hrs?___

□ Jaundice

Onset date: _____/_____/______

□ Headache

Onset date: ____/_____/____

□ Neck stiffness

Onset date: ____/____/______

□ Decreased consciousness

Onset date: _____/_____/_____

□ Recent onset of focal weakness

and/or paralysis

Onset date: ____/____/____

□ Unusual bleeding

Onset date: _____/____/____

□ Obviously unwell

□ Chronic condition

□ Asymptomatic

□ Injury

□ Other Signs, Symptoms, Conditions: ______________________________________________________________________

Deceased Persons:

Date of death: ______/______/__________ Time of death (24 hours): ______:______

mm dd yyyy hh : mm

Presumptive diagnosis/cause of death:

During the past 3 weeks, has anyone (onboard ship or disembarked) had similar signs and symptoms? (Please verify by a medical log review):

*If yes, please fill in a new form for each person in the cluster

□ No

□ Yes*, total # ill of crew __________, passengers __________

□ Unknown

NOTE: STOP HERE IF THIS REPORT IS FOR A SIMPLE, UNCOMPLICATED CASE OF VARICELLA OR IS SUSPECTED.

Section 4. Evaluation of ill or deceased person

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: _________________________________________________________________

Countries visited in the past 3 weeks:	State/city/village	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, ____________

Number of potentially exposed contacts (e.g. cabin, work, bathroom mates): __________

Are any traveling companions ill?: □ No □ Yes*, how many are ill: __________ □ N/A (no companions)

If passenger is a child, does s/he attend day care/youth program on ship?:

□ No □ Yes, total # of children in day care/program: ___________, # of children with similar signs & symptoms*: ___________

*Note: Submit a separate form for each ill or deceased person not previously reported to a CDC Quarantine Station.

Seen in ship infirmary:

□ No

□ Yes, date of first visit: _____/_____/______

mm dd yyyy

□ No infirmary

Ill/deceased person isolated after illness onset?:

□ No

□ Yes, date isolated: _____/_____/_______

mm dd yyyy

Seen in health-care facility ashore:

□ No

□ Yes; facility/health care provider(s) information (name,

location, dates, telephone number, e-mail): ______________________________________________________________________________________________________________________________________________

­­­­­­­­­­­­­

Hospitalized?

□ No

□Yes, dates hospitalized: from ______/_____/______

to ______/_____/______

mm dd yyyy

Lab/Imaging Results

Tests	Date performed (mm/dd/yyyy)	Results (if unknown, provide name and phone number of lab/facility which performed tests/imaging): ______________________________________
Chest x-ray:	______/______/______	□ Normal □ Abnormal (□ Cavity □ No cavity)
Legionella urine antigen:	______/______/______	□ Positive □ Negative
Test 1: _______________________________ Test 2: _______________________________ Test 3: _______________________________	1. ______/______/______ 2. ______/______/______ 3. _____/______/_______	1. _____________________________ 2._____________________________ 3._____________________________

Deceased Persons:

Body released to medical examiner?: □ No □ Yes, telephone: ____________________ City/Country:_____________________

Discharge/final diagnosis/cause of death (determined by medical examiner or other):

Section 5. General information about 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/citizenship:

Type of ID document:

ID document #:

Alien #:

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 # of days reachable at contact phone: ____

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Comments: ___________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________
TO BE COMPLETED BY QUARANTINE STAFF ONLY
QARS Unique ID #:	CDC User ID:	Date Quarantine Station notified: _____/_____/______	Time Quarantine Station notified (24 hrs): ______:______
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		Ill person was (check all that apply): □ Released to continue travel □ Advised to seek medical care □ EMS responded □ Recommended to not continue travel □ Transported to hospital (□ MOA activated): ________________ □ Transported to non-hospital location: ______________________ □ Detained by law enforcement, location: ________________________ □ Denied boarding by law enforcement □ Other: _______________________________________________
Where was the traveler when the QS was notified?: □ In U.S. jurisdiction (within 3 nautical miles of U.S. coast or traveling between U.S. ports) □ Outside U.S. jurisdiction □ Unknown		Response or Report: □ Requires DGMQ Response & Follow-Up □ Information Report Only / No Follow-Up Needed
NOTE: If ill/deceased person also traveled via □ Land and/or □ Air conveyances, please fill out the appropriate form

Public reporting burden of this collection of information is estimated to average 7 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.