0920-1031 Attachment A1a DHS Form United States Traveler Health De

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Temperature

ealth and Human Services, Centers for Disease Control and Prevention

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CARE ID #

CARE cell #

MB approved 0920-1031
Exp 04/30/2015

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Language

NITED STATES

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RAVELER HEALTH DECLARATION

DHS should complete this form for EACH traveler. The information is being collected as part of the public health response to the outbreaks of Ebola. The information will be used by U.S. public health authorities and other international, federal, state, or local agencies for that purpose. The legal authorities for this collection are sections 311 and 361-368 of the Public Health Service Act.

NOTE: While cooperation with CDC during this proposed risk assessment is voluntary, if an individual refuses to provide the requested information, or is not truthful about the information provided during screening or an illness investigation, CDC may, if it is reasonably believed that the individual is infected with or has been exposed to Ebola, quarantine, isolate, or place the individual under surveillance under 42 CFR 71.32 and 71.33.

Traveler’s Information:

Ebola outbreak countries in last 21 days: ……………………………Departure date: ___ /___ / ___ (MM/DD/YY)

Last (family) name: First (given) name:

P assport country: Passport number:

Birth date: ___ /___ / ___ (MM/DD/YY) Sex: Male Female Arrival date: ___ /___ / ___ (MM/DD/YY)

Airline: …………………………………………….....Flight number: …………………Seat number(s): ……..…..…....

1^st e-mail address: ………………………………...2^nd e-mail address:

1^st telephone number (include country code or country name):

2^nd telephone number (include country code or country name):

Home address:

Address(es) for next 21 days (include dates):

…………………………………………………………………………………………………………………………………

Name of a friend or relative in United States (U.S.) ………...……………...…………………………………………...

U.S. friend/relative’s email:…………………………………Phone number:(……)……-……………………………….

DHS visual observation	Yes	No
Have you observed vomiting, diarrhea, or visible bleeding?

DHS Officer, ask traveler the following questions:

Today or in the past 48 hours, have you had any of the following symptoms?	Yes	No
A. Fever (100° F / 38° C or higher), feeling feverish, or having chills?
B. Vomiting or diarrhea?
In the last 21 days (3 weeks), have you done any of the following?	Yes	No
C. Lived in the same household or had contact with a person sick with Ebola or a person who was very sick or died?
D. Been in a health care facility or a laboratory in an Ebola outbreak country?
E. Been around or touched a dead body, or gone to a funeral, in an Ebola outbreak country?

DHS Action Taken DHS Officer’s Name: __________________________ Airport Code: ________

Gave tear sheet

Gave CARE Kit

Referred to CDC OR

Released

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 0920-1031.