Attachment A1b DHS Form United States Traveler Health Dec - electronic portal word ver

 

PUBLIC HEALTH
TRAVELER HEALTH DECLARATION

Health and Human Services, Centers for Disease Control and Prevention
OMB approved 0920-1031
Exp 04/30/2015

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.

Temperature Information

* Temperature (°F):

CARE ID #

CARE cell #

Language:

Ebola Outbreak Countries

* Ebola outbreak countries been in during last 21 days:

Guinea Liberia Sierra Leone Mali

Other:

 

Departure date: ___ /___ / ___ (MM/DD/YY)   

Traveler Information

* Last (Family) Name:

* First (Given) Name:

Passport Country:

Passport Number:

Date of Birth (mmddyyyy):

Gender:

Flight Information

* Arrival Airport Code:

* Arrival Date (mmddyyyy):

* Airline Carrier Code:

* Flight Number:

* Seat Number(s):

Contact Information

Email Address:

1st:

 

2nd:

Telephone Number (Include Country Code or Country Name):

1st:

 

2nd:

Home Address:

Address:

 

City:

 

State:

 

ZIP Code:

 

Country:

Address For Next 21 Days: Copy From Home Address

Address:

 

City:

 

State:

 

ZIP Code:

 

Country:

Name Of Friend/Relative In United States:

Friend/Relative Email Address:

Friend/Relative Telephone Number:

Health Information

DHS Officer Visual Observation

* Have you observed vomiting, diarrhea, or visible bleeding?

Yes No

Ask traveler the following questions:

Today or in the past 48 hours, have you had any of the following symptoms?

* Fever (100°F / 38°C or higher), feeling feverish, or having chills?

Yes No

* Vomiting or diarrhea?

Yes No

In the last 21 days, have you done any of the following?

* Lived in the same household or had contact with a person sick with Ebola or a person who was very sick or died?

Yes No

* Worked in a health care facility or laboratory in an Ebola outbreak country?

Yes No

* Been around or touched a dead body, or gone to a funeral, in an Ebola outbreak country?

Yes No

DHS Information

DHS Officer:

* DHS Action Taken:

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.