71.21 (a) Radio Report of Death/Illness Report from Ship

Maritime Conveyance Cumulative Influenza-Like Illness (ILI) Form
U.S. Centers for Disease Control and Prevention
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CDC does not require that cruise ships traveling to or within U.S. waterways report individual cases of suspected or confirmed
influenza. CDC requests the reporting of total influenza-like illness (ILI)/influenza cases (including zero) for each voyage by using
this form.
Complete this form and submit via email or fax to the CDC Quarantine Station with jurisdiction over the expected U.S. seaport of
arrival.
 The following situations should be immediately reported via the Maritime Illness and Death Investigation form, by phone, email,
or fax, to the CDC Quarantine Station in the jurisdiction of the arrival port: Outbreaks of influenza or ILI among passengers or
crew members,
 A death caused by or suspected to be associated with ILI/influenza onboard the vessel,
 Changes in the clinical profile and severity of illnesses or severe complications among at least two epidemiologically linked
influenza or ILI cases.
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).
Do not use this form for gastrointestinal (GI) illnesses, which are reportable to CDC Vessel Sanitation Program (VSP) per
established protocol. For more information about VSP, please see: http://www.cdc.gov/nceh/vsp/default.htm or call +1-800-3232132.

Section 1. Quarantine Station Notification
Person filling out form:

Phone:

E-mail:

Section 2: Vessel Information
Vessel company:

Vessel name:

Country of departure:

Voyage Number:

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

Section 3:
Total number of persons onboard:

Total ILI cases during voyage (including zero)

Passengers
Crew
Public reporting burden of this collection of information is estimated to average 2 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 0920-0134.

OMB Control No. 0920-0134
Expiration Date: xx/xx/xxxx