United States Traveler Health Declaration - English/Hard

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Temperature

ealth and Human Services, Centers for Disease Control and Prevention

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CARE ID #

MB approved 0920-0821
Exp XX/XX/XXXX

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CARE cell #

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 from outbreak country: ___ /___ / ___ (MM/DD/YY)

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

P assport country: Passport number: .……………………………………………………. ………

Birth date: ___ /___ / ___ (MM/DD/YY) Sex: Male Female Date of US arrival: ___ /___ / ___ (MM/DD/YY)

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

E -mail address: ………………………………...............Alternate e-mail address: ............................................................................

T elephone number (include country code or country name):.......................................................................................Mobile

Alternate telephone number (include country code or country name):.........................................................................Mobile

Address for next 21 days:......…………………………………………………………………………………………………………………

............................................................................. Dates at address: ___ /___ / ___ (MM/DD/YY) to ___ /___ / ___ (MM/DD/YY)

Additional address for next 21 days:....………………………………………………………………………………………………………

............................................................................. Dates at address: ___ /___ / ___ (MM/DD/YY) to ___ /___ / ___ (MM/DD/YY)

Home address: …………………………………………………………………………………………………………………………………

Name of a friend or relative in United States: …………………………...……………...………………………………………………….

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

DHS visual observation	Yes	No
For the CBP Officer: Observe ‎the traveler. Do you see signs of illness (vomiting, diarrhea, 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(s) Taken DHS Officer’s Name: ____________________________ Airport Code: ________

Gave tear sheet (if CARE Kit not available)

Gave CARE Kit

Referred to Tertiary 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 0920-0821.