Documentation of Interviews with AGE Crew Case Cabin Mat

Maritime Illness Database and Reporting System (MIDRS)

Att5d.Documentation of AGE Illness Status

71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times

OMB: 0920-1260

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Attachment 5d. Documentation of interviews to determine AGE illness status

Form approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/20XX

Documentation of Interviews with AGE Crew Case Cabin Mates and Immediate Contacts to Determine AGE Illness Status

Crewmember Name:


AGE Illness Status:


Immediate Contact:


AGE Illness Status of Immediate Contact:


Interview Date:


Interview Time:


Interviewer:




Crewmember Name:


AGE Illness Status:


Immediate Contact:


AGE Illness Status of Immediate Contact:


Interview Date:


Interview Time:


Interviewer:




Crewmember Name:


AGE Illness Status:


Immediate Contact:


AGE Illness Status of Immediate Contact:


Interview Date:


Interview Time:


Interviewer:




Crewmember Name:


AGE Illness Status:


Immediate Contact:


AGE Illness Status of Immediate Contact:


Interview Date:


Interview Time:


Interviewer:




CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorEtheredge, Alisha (CDC/DDNID/NCEH/OD)
File Modified0000-00-00
File Created2021-01-20

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