72-hr Food/Activity History Template

Form approved

OMB No: 0920-XXXX

Expiration Date: XX/XX/20XX

Gastrointestinal Illness Surveillance System Questionnaire

(To be completed if you experienced gastrointestinal illness)

Vessel Name:		Voyage No. :		Date:
Last Name:		First Name:
Date of Birth:	(mm/dd/yyyy)	Age:	(in years)	Sex M / F
Cabin Number:		Total Number of People in Cabin:
Dining Seating:		Dining Table Number:
Symptoms Started Date:	(mm/dd/yyyy)	Time:	(hh:mm)	AM / PM

Do you know other people ill with the same symptoms?									Yes / No
If yes, please list their names:
Did you stay overnight or longer in a boarding city before you joined the vessel?									Yes / No
If yes, where?			City:			State:	Country:
Was the overnight stay in a hotel/motel/commercial residence?									Yes / No
If yes, what was the name and address of the hotel, motel/commercial residence
Name:
Address:
City:					State:		Country:
How did you travel to the city where you boarded the ship for this cruise? Select all that apply.
	[ ]	Airplane		Airlines:				Flight No.:
	[ ]	Automobile
	[ ]	Bus/Motorcoach
	[ ]	Train
	[ ]	Other		Please specify:
Are you a member of a tour group?									Yes / No
Prior to boarding the ship, did you participate in a pre-embarkation tour/package?									Yes / No
If yes, which tour(s)/package(s) did you participate in? (list all)
Prior you your illness, did you go ashore at any of the ports of call?									Yes / No
If yes, please list the ports of call where you went ashore
Did participate in any shore excursions at any port of call?									Yes / No
If yes, which shore excursions did you participate in? (list all)
Did you eat anything while you were ashore at any port of call?									Yes / No
Did you drink anything (including drinks with ice) while ashore at any port of call?									Yes / No
What did you think is the cause of your illness?:

CDC estimates the average public reporting burden for this collection of information as 10 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; ATN: PRA (0920-XXXX)

PLEASE TURN THIS FORM OVER TO PROVIDE FOOD AND SHIPBOARD ACTIVITIES HISTORY

Last Name ______________________________________

First Name ______________________

Meals and Activities Aboard Vessel Prior to Illness

Please list the specific vessel locations of the meals you consumed and the vessel activities you participated in before you became ill

Day of illness onset Give Date:__________		Day before illness onset		Two days before illness onset		Three days before illness onset
Breakfast Place: _______________ Time: _________ Items eaten/drank		Breakfast Place: _______________ Time: _________ Items eaten/drank		Breakfast Place: _______________ Time: _________ Items eaten/drank		Breakfast Place: _______________ Time: _________ Items eaten/drank
Lunch Place: _______________ Time: _________ Items eaten/drank		Lunch Place: _______________ Time: _________ Items eaten/drank		Lunch Place: _______________ Time: _________ Items eaten/drank		Lunch Place: _______________ Time: _________ Items eaten/drank
Dinner Place: _______________ Time: _________ Items eaten/drank		Dinner Place: _______________ Time: _________ Items eaten/drank		Dinner Place: _______________ Time: _________ Items eaten/drank		Dinner Place: _______________ Time: _________ Items eaten/drank
Snack Place: _______________ Time: _________ Items eaten/drank		Snack Place: _______________ Time: _________ Items eaten/drank		Snack Place: _______________ Time: _________ Items eaten/drank		Snack Place: _______________ Time: _________ Items eaten/drank
Activities		Activities		Activities		Activities
AM	PM	AM	PM	AM	PM	AM	PM