Air Travel Illness or Death Investigation

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Attachment G Air investigation Form 3_28_2012 FINAL

Air Travel Illness or Death Investigation

OMB: 0920-0821

Document [docx]
Download: docx | pdf

Air Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

Section 1. Quarantine station notification

QARS Unique ID #:

CDC User ID :


Port of Entry:


State:

Person notifying CDC:

Phone:

Email:

Agency notifying CDC:

Date of initial

notification to CDC:

_____/_____/______

mm dd yyyy

Time of initial notification to CDC (24 hrs):

_____ : _____

hh : mm

Type of notification: □ Illness □ Death


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

Type of traveler: □ Passenger □ Crew


Where was the traveler when the QS was notified?:

In U.S. jurisdiction / Inbound

In foreign jurisdiction / Outbound

Unknown

NOTE: If ill/deceased person also traveled via □ Land and/or □ Maritime conveyances, please fill out the appropriate form and attach

Section 2. Pertinent medical history of ill or deceased person

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





Traveler has taken:

Antibiotic/antiviral/antiparasitic(s) in the past week; list with date(s) started: _________________________________________________

Fever-reducing medications (e.g. acetaminophen, ibuprofen) in the past 12 hrs; list with time of last dose: _________________________

Other medications (related to current symptoms/illness); list with date(s) started: ______________________________________________


Relevant Exposures in the Past 3 Weeks:

Village/City/State

Province/Country

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, ____________




No

Yes, ____________

No

Yes, ____________

No

Yes, ____________


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


FEVER (≥100F or ≥38°C) OR

feeling feverish/having chills in past 72 hrs

Onset date: _____/_____/______

Current temperature: ______0 F/C


Rash

Onset date: _____/_____/______


Difficulty breathing/shortness of breath

Onset date: _____/_____/_______


Swollen glands

Onset date: _____/_____/_______

Location: □ Head/neck □ Armpit □ Groin


Decreased consciousness

Onset date: _____/_____/_______


Recent onset of focal weakness

and/or paralysis

Onset date: _____/_____/_______


Appearance:

Maculopapular Vesicular/Pustular

Purpuric/Petechial Scabbed Other­­­­­­­­­­­­­­­­­­­­­


Conjunctivitis/eye redness

Onset date: _____/_____/_______


Coryza/runny nose

Vomiting

Onset date: _____/_____/_______

Number of times in past 24 hrs? ______


Diarrhea

Onset date: _____/_____/_______

Number of times in past 24 hrs?: ______


Unusual bleeding

Onset date: _____/_____/_______


Obviously unwell

Injury


Onset date: _____/_____/_______


Persistent cough

Onset date: _____/_____/______

With blood Without blood

Jaundice

Onset date: _____/_____/_______


Headache

Onset date: _____/_____/_______

Chronic condition


Asymptomatic


Other: __________________________


Sore throat

Onset date: _____/_____/_______



Neck stiffness

Onset date: _____/_____/_______

________________________________

________________________________

Shape1

Form Approved

OMB Control No.0920-0821

Exp XX/XX/XXXX



Deceased Persons:

Date of Death:


______/______/__________

mm dd yyyy

Time of death (24 hours):

_____:_____

hh : mm

Presumptive Diagnosis or Cause of Death:




Does anyone else on the plane have similar illness?: No Yes* Unknown


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

Response or Info Only:

Requires DGMQ Response & Follow-up (Proceed to next section)

Information Report Only / No Follow-up needed (STOP HERE)

Section 3. General information about the 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:

ID document #:

Alien #:


For deceased persons, go to Section 5. Otherwise, continue below.

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:


Section 4. Flight information

Type*

Domestic or Int’l?

Airline

Flight #

Departure Airport

Code

Departure Date

Arrival Airport

Code

Arrival Date

Seat #

Flight Duration

CURRENT FLIGHT:











PREVIOUS AND/OR UPCOMING FLIGHTS:































*C/FB = Commercial, foreign-based carrier C/US = Commercial, U.S.-based carrier P = Private CH = Charter CG = Cargo O = Other

Section 5: Disposition of ill/deceased person

Ill person was (check all that apply):

Deceased Person:

Released to continue travel

Advised to seek medical care

EMS responded

Recommended to not travel

Transported to hospital (□ MOA activated): ______________________

Transported to non-hospital location: ____________________________

Detained by law enforcement, location: __________________________

Denied entry by law enforcement

Other: ____________________________________________________



Body released to medical examiner?: Yes No


Medical examiner telephone: ___________________


City/State/Country: __________________________

Public reporting burden of this collection of information is estimated to average 5 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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBuckley, Kirsten (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2021-01-25

© 2024 OMB.report | Privacy Policy