Form 0920-1031 Attachment A1c DHS Form United States Traveler Health De

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

Validate

Temperature

CARE ID #
CARE cell #

UNITED STATES
TRAVELER HEALTH DECLARATION

English

Language

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:

Guinea

Liberia

Mali

Sierra Leone Other:

Last (family) name:

First (given) name:

Passport country:

Passport number:

Birth date:

Sex:

Airline:

Departure date:

Arrival date:

Flight number:

1st e-mail address:

Seat number(s):
2nd e-mail address:

1st telephone number (include country code or country name):
2nd 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
Have you observed vomiting, diarrhea, or visible bleeding?

Yes

No

Today or in the past 48 hours, have you had any of the following symptoms?
A. Fever (100° F / 38° C or higher), feeling feverish, or having chills?
B. Vomiting or diarrhea?

Yes

No

In the last 21 days (3 weeks), have you done any of the following?
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?

Yes

No

DHS Officer, ask traveler the following questions:

DHS Action Taken
Gave tear sheet

DHS Officer’s Name:

Airport Code:
Referred to CDC

Gave CARE Kit

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.

Validate