Land Travel Illness or Death Investigation Form

Foreign Quarantine Regulations (42CFR71)

Attachment E Land Travel Illness or Death Investigation Form final

Land Travel Illness or Death Investigation Form

OMB: 0920-0134

Document [docx]
Download: docx | pdf

Shape1

Form Approved

OMB Control No.0920-0134

Exp XX/XX/XXXX

Land 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: □ Crew □ Passenger □ N/A


Where was the traveler when the QS was notified?:

In U.S. jurisdiction

In foreign jurisdiction

Unknown

NOTE: If ill/deceased person also traveled via □ Air 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, 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:

Countries visited in the past 3 weeks:

State/city/village

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, ____________


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



Sore throat

Onset date: _____/_____/______


Difficulty breathing/shortness of breath

Onset date: _____/_____/______


Neck stiffness

Onset date: _____/_____/______


Decreased consciousness

Onset date: _____/_____/______

Rash

Onset date: _____/_____/______

Appearance:

Maculopapular Vesicular/Pustular

Purpuric/Petechial Scabbed Other

Swollen glands

Onset date: _____/_____/______

Location: □ Head/neck □ Armpit □ Groin


Vomiting

Onset date: _____/_____/_______

Number of times in past 24 hrs? ______


Recent onset of focal weakness and/or

Paralysis

Onset date: _____/_____/______


Unusual bleeding

Onset date: _____/_____/______

Conjunctivitis/eye redness

Onset date: _____/_____/______


Coryza/runny nose

Onset date: _____/_____/______

Diarrhea

Onset date: _____/_____/_______

Number of times in past 24 hrs?: ______


Jaundice

Onset date: _____/_____/______

Obviously unwell


Injury


Chronic condition


Persistent cough

Onset date: _____/_____/______

With blood Without blood


Headache

Onset date: _____/_____/______

Asymptomatic


Other: ____________________________

____________________________________

Deceased Persons:

Date of Death: ______/______/__________

mm dd yyyy

Time of death (24 hours):

_____:_____

hh : mm

Presumptive Diagnosis or Cause of Death:



If traveling by conveyance, does anyone else have similar illness?: No Yes Unknown (If yes, please fill in a new form for each person in the cluster.)


Response or Report:

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:

Frequency of

border crossing: ________ times/ Day Week Month □ year

Passport country/citizenship



Type of ID:

ID document #:

Visa?:

Yes □ No

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

Home address:

City:

State/province:


Zip/postal code:

Country of residence:

Home telephone:

If visiting, total duration of

U.S. stay: __________ □ Days □ Weeks □ Months □ 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

Number of days reachable at contact phone: _______

Emergency contact name:

Emergency contact relationship:


Emergency contact phone:



Section 4. Border Crossing Information

License plate #:


State/province/country issued:

Attempted entry outside an official POE?:

Yes No □ Unknown

Contact information collected on conveyance passengers/driver(s)?:

Yes No □ Unknown


Crossing Type*


From

(City/Country)


Departure date

To (City/Country)

Arrival date

Significant stops

Name of commercial carrier, if applicable

Bus/Train #

Seat #

Current Segment:













Past & Upcoming Segments:























*Crossing Type: V: Personal vehicle TC: Taxi cab M: Motorcycle P: Pedestrian/Bike B: Passenger bus CC: Commercial cargo vehicle A: Ambulance

T: Train 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 continue 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
File TitleInternational Land Border Illness or Death Investigation Form
Authormdelea
File Modified0000-00-00
File Created2021-01-20

© 2024 OMB.report | Privacy Policy