Form 42CFR 71.21(a) 42CFR 71.21(a) Maritime Conveyance Illness or Death Investigation Form

Instructions for the Maritime Conveyance Illness or Death Investigation Form
Please download this form, type the vessel name at the top of the form, and save it for future use.
Completing and submitting
 Complete this form as specified by www.cdc.gov/quarantine/cruise-reporting-guidance.html or www.cdc.gov/quarantine/cargoreporting-guidance.html.
 Remember to use a separate form for each ill or deceased person.
 Note that all fields with red text and an asterisk symbol (*) are required. These fields include: Person filling out form, E-mail, Type
of notification, Type of traveler, Conveyance type, Vessel company/name, Country of departure, Departure date, Next U.S. port
and state, Arrival date at next U.S. port, Embarkation port, Embarkation date, at least one Sign, Symptom, or Condition, and
Presumptive diagnosis/cause of death.
 Please note that for some questions (temperature unit, rash type, cough type, chest x-ray result, and presence of cavity) you won’t
be able to clear your selection by unclicking the box. To clear your selection you should click on the green default circle located to
the right of the main selections. For example, if ‘cavity’ is checked in error, you may clear the selection by clicking the green
default circle to the right of ‘no cavity.’ See images below.
 For more information about the fields on this form, visit: www.cdc.gov/quarantine/key-fields.html.
 Submit to the CDC Quarantine Station with jurisdiction over the next U.S. seaport of arrival by one of the methods described
below.
Instructions by section
Sections 1–4 (Quarantine Station Notification, Vessel Information, Medical History, and Evaluation of Ill or Deceased Person)
o To complete Sections 1–4, you may type directly into the form, or print and fill out by hand.
o To submit the form, choose from the following options:
1. Click on the gray “Send Via E-mail” button in the upper left-hand corner of the form (Note: In order to use this
option, your e-mail account must be set up to automatically generate an e-mail message from a PDF), or save the
form, then attach to your e-mail and send it to [email protected], or
2. Look up the contact information for the CDC Quarantine Station with jurisdiction over the next U.S. seaport of
arrival at www.cdc.gov/quarantine/QuarantineStationContactListFull.html and send by fax, or
3. By telephone.
o A confirmation e-mail will be sent to the e-mail address that was entered on the form within 1-2 business days. The quarantine
station will contact you if follow-up information is needed.
o If you don’t receive confirmation of your report, or if you have any questions, please contact the CDC Quarantine Station with
jurisdiction over the next U.S. port of arrival, the CDC Emergency Operations Center at 770-488-7100, or the Maritime
Activity Administrator ([email protected]).
Section 5 (General Information About Ill or Deceased Person)
o Please DON’T submit Section 5 unless the quarantine station asks you to do so.
o To complete Section 5, print out the form and fill in by hand. This section contains personally identifiable information (PII),
so you won’t be able to type into the fillable PDF form.
o Submit by fax or telephone.
o Do not submit any forms with PII to CDC through e-mail.
PII is any information that can be used alone or in combination to identify an individual. This includes names, addresses, phone
numbers, dates (birth, hospital admission, travel), identifying numbers (passport, social security, driver’s license, alien), medical
records, photographs, and for rare diseases, geographic locations.
Reminder to cruise ships

1. Report cumulative influenza and influenza-like illness (ILI) cases (including zero) for each voyage with the Maritime Conveyance
Cumulative Influenza/ Influenza-Like Illness (ILI) Form: www.cdc.gov/quarantine/cumulative-form.html. Influenza and ILI are defined
as fever (temperature of 100°F [37.8°C] or greater) and a cough and/or a sore throat without a KNOWN cause other than influenza.

2. Send gastrointestinal (GI) illness reports to CDC’s Vessel Sanitation Program (VSP). For more information call 800-323-2132 or visit
http://www.cdc.gov/nceh/vsp/.

3. Report a case of Legionnaires’ disease by sending an e-mail to [email protected].

Form Approved
OMB Control No.0920-0134 (Section 1-3), Exp 9/30/2017
OMB Control No. 0920-0821 (Section 4-5), Exp 4/30/2016

Send Via Email

Maritime Conveyance Illness or Death Investigation Form
U.S. Centers for Disease Control and Prevention
Section 1. Quarantine Station Notification
Person filling out form (*):
Type of notification (*):

E-mail (*):

Phone:
Type of traveler (*):

Illness
Death

Crew
Passenger

Conveyance type (*):

Cruise ship
Other

Cargo

Section 2: Vessel Information
Vessel company/name (*):

Voyage number:
Crew:

Country of departure (*):

Departure date (*) & time (24 hr):
mm / dd / yyyy

Number on board:
Passengers:

Arrival date & time (24 hr) at final port:
mm / dd / yyyy

hh : mm

hh : mm

Itinerary:
Next U.S. port (*):

Arrival date (*) & time (24 hr) at next U.S. port :
mm / dd / yyyy

Person information while onboard vessel:
Cabin number:
If crew, list job title & duties:
Embarkation port (*):

Embarkation date (*):

Disembarkation port:

hh : mm

If crew member has contact with passengers, describe
extent/frequency:
Disembarkation date:
mm / dd / yyyy

mm / dd / yyyy

Section 3: Medical History
Include relevant medical history of ill or deceased person (present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.):

Signs, Symptoms, and Conditions (*) [Check all that apply] :
Difficulty breathing/shortness of breath
Decreased consciousness
FEVER (≥100F or ≥38°C) OR history of
Onset date:
Onset date:
feeling feverish/ having chills in past 72 hrs
Onset date:
0
Swollen glands
Recent onset of focal weakness
Current temperature:
F/C
Onset date:
and/or paralysis
Location: Head/neck Armpit
Groin
Rash
Onset date:
Onset date:
Vomiting
Appearance:
Unusual bleeding
Onset date:
Maculopapular Vesicular/Pustular
Onset date:
# of times in past 24 hrs:
Purpuric/Petechial Scabbed Other
Obviously unwell
Diarrhea
Conjunctivitis/eye redness
Onset date:
Onset date:
Chronic condition
# of times in past 24 hrs:
Coryza/runny nose
Asymptomatic
Jaundice
Onset date:
Onset date:
Injury
Persistent cough
Headache
Onset date:
Other signs, symptoms, conditions:
Onset date:
With blood
Without blood
Sore throat
Onset date:
Deceased persons:

Neck stiffness
Onset date:
Date of death:

Time of death (24 hours):
mm / dd / yyyy

hh : mm

Presumptive diagnosis/cause of death (*):

During the past 3 weeks, has anyone (onboard ship or disembarked) had similar
signs and symptoms? (Please verify by a medical log review):
*If yes, please fill in a new form for each person in the cluster

No
Yes*, total # ill of crew:
Unknown

total # ill of passengers:

Form Approved
OMB Control No.0920-0134 (Section 1-3), Exp 9/30/2017
OMB Control No. 0920-0821 (Section 4-5), Exp 4/30/2016

Section 4. Evaluation of Ill or Deceased Person
Traveler has taken (include those given on board):
Antibiotic/antiviral/antiparasitic(s) in the past week; list with dates started:
Fever-reducing medications (e.g., acetaminophen, ibuprofen) in the past 12 hours; list with dates started:
Other (related to current symptoms/illness); list with date(s) started:
Countries visited in
the past 3 weeks

State/city/village

Arrival
date

Exposure to ill persons

Exposure to animals

No
Yes
No
Yes
No
Yes

No
Yes
No
Yes
No
Yes

Other exposures (chemical, drug
ingestion, etc.)
No
Yes
No
Yes
No
Yes

Number of potentially exposed contacts (e.g., cabin, work, bathroom mates):
Are any traveling companions ill?

No

Yes*, how many are ill:

N/A (no companions)

If passenger is a child, does s/he attend day care/youth program on ship?
No Yes, total # of children in day care/program:
# of children with similar signs & symptoms*:

*Note: Submit a separate form for each ill or deceased person not previously reported to a CDC Quarantine Station.
Ill/deceased person isolated after illness onset?
No
Yes, date isolated:

Seen in ship infirmary?
No
Yes, date of first visit:

mm / dd / yyyy

mm / dd / yyyy

No infirmary
Seen in health-care facility ashore?
No
Yes; facility/health care provider(s) information (name,
location, dates, telephone number, e-mail):

Hospitalized?
No
Yes,
dates hospitalized: from
to
mm / dd / yyyy

Lab/Imaging Results
Date performed

Tests

(mm/dd/yyyy)

Results (if unknown, provide name and
phone number of lab/facility which
performed tests/imaging)
Normal

Chest x-ray:

(
Positive
Negative

Legionella urine antigen:
1.

Test 1:

1.

2.

Test 2:

2.

3.

Test 3:

Abnormal
Cavity No cavity)

3.

Deceased persons:
Body released to medical examiner?:

No

Yes

Telephone:

Discharge/final diagnosis/cause of death (determined by medical examiner or other):

City/Country:

Form Approved
OMB Control No.0920-0134 (Section 1-3), Exp 9/30/2017
OMB Control No. 0920-0821 (Section 4-5), Exp 4/30/2016

Section 5. General information about ill or deceased person
Last/paternal name:

First/given name

Middle name:

Maternal name (if applicable):

Gender:

Date of
birth:

□ Male □ Female
Country of birth:

Other names used (e.g., former name, alias):

________/_________/_______
mm

Passport country/citizenship:

dd

yyyy

Type of ID document:

Age (if date of birth
unknown):
ID document #:

Days
Months
Alien #:

Weeks
Years

Home address:

City:

State/province:

Zip/postal code:

Country of residence:

Home phone:

If visiting, total duration
of U.S. stay:

Days
Weeks

Contact in U.S. – Address/hotel:

Months
Years

E-mail:
Same as home address above

Contact in U.S. - City:

Contact in U.S.-State/territory:

Contact phone in U.S.:

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Cell

# of days reachable at contact phone: ____

Comments:

TO BE COMPLETED BY QUARANTINE STAFF ONLY
QARS Unique ID #:

CDC User ID:

Date Quarantine Station notified:
_____/_____/______

Time Quarantine Station notified (24 hrs):
______:______

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

Ill person was (check all that apply):
Released to continue travel
Advised to seek medical care
EMS responded
Recommended to not continue travel
Transported to hospital (□ MOA activated): ________________
Transported to non-hospital location: ______________________
Detained by law enforcement, location: ________________________
Denied boarding by law enforcement
Other: _______________________________________________

Where was the traveler when the QS was notified?:
In U.S. jurisdiction (within 3 nautical miles of U.S. coast or traveling
between U.S. ports)
Outside U.S. jurisdiction
Unknown

Response or Info Only:
Requires DGMQ Response & Follow-Up
Information Report Only / No Follow-Up Needed

NOTE: If ill/deceased person also traveled via Land and/or Air conveyances, please fill out the appropriate form
Sections 1-3: 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.
Sections 4-5: 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.

Vessel Company/Name:

Country of departure:

Departure date:

Presumptive Diagnosis: