Example Passenger Consent

Attachment J: Cruise Ship Outbreak Investigation (CSOI) Sample General Survey for Passenger Consent

Health Questionnaire

[Ship name, sail dates]

Dear Guest:

As you have been advised by the staff of the [ship name], there have been higher than expected number of people with vomiting and diarrhea on this cruise. The staff of the Vessel Sanitation Program, Centers for Disease Control and Prevention (CDC), in collaboration with [name of cruise line], has been investigating in order to determine the cause of the illnesses, to see how many people have been sick, and to find out how people may have become ill in order to prevent others from becoming sick.

To help with the investigation we ask that each guest complete the attached questionnaire. Please complete the entire questionnaire, even if you were not ill, so that we may be able to compare information from both ill and well guests. Please return your completed questionnaire to [ship location/point of contact] no later than [time and date]. If you are still ill, please have someone return the questionnaire for you.

Please use this itinerary to help you complete this questionnaire.

Day of week	Date	Port/Location
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]

An investigation summary will be posted to the CDC Vessel Sanitation Program website at: http://www.cdc.gov/nceh/vsp once available.

We appreciate your participation.

Sincerely,

CDC Vessel Sanitation Program and [cruise line name]

Please start on the back of this page

*PROTECTION OF PRIVACY INFORMATION

Public Law 93-579 entitled the Privacy Act of 1974 requires that individuals asked to furnish information such as that requested in this form be informed of the purpose for collecting such information and what the information will generally be used for. The following information is accordingly provided:

Authority: The Centers for Disease Control and Prevention, and agency of the Department of Health and Human Services, is authorized to solicit the information requested in this form under the authority of the Public Health Service Act, Section 301,361 (42 U.S.C. 241,264).

Purpose and Uses: The information requested will be used to implement appropriate control measures if any health problems are identified, and may be shared with federal, state and local health authorities. An accounting of such disclosures will be made available to you upon request.

Effects of Non-Disclosures: Your disclosure of the requested information is voluntary, and no penalty will be imposed if you choose not to respond. However, if you do not fill out the questionnaire, it will be more difficult for us to determine the health status of the persons on this cruise.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

CENTERS FOR DISEASE CONTROL AND PREVENTION

ATLANTA, GEORGIA 30333

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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance Officer: ATTN:PRA;Hubert H. Humphrey Bldg., Room. 721-B; 200 Independence Ave., SW; Washington, DC 20201, and to the Office of Management and Budget; Paperwork Reduction Project (0920-XXXX); Washington, DC 20503.

Attachment J: Cruise Ship Outbreak Investigation (CSOI) Sample General Survey for Crew Consent

Health Questionnaire

[Ship name, sail dates]

Dear Crew Member:

As you have been advised by the staff of the [ship name], there have been higher than expected number of people with vomiting and diarrhea on this cruise. The staff of the Vessel Sanitation Program, Centers for Disease Control and Prevention (CDC), in collaboration with [name of cruise line], has been investigating in order to determine the cause of the illnesses, to see how many people have been sick, and to find out how people may have become ill in order to prevent others from becoming sick.

To help with the investigation we ask that each crew member complete the attached questionnaire. Please complete the entire questionnaire, even if you were not ill, so that we may be able to compare information from both ill and well guests. Please return your completed questionnaire to [ship location/point of contact] no later than [time and date]. If you are still ill, please have someone return the questionnaire for you.

Please use this itinerary to help you complete this questionnaire.

Day of week	Date	Port/Location
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]
[day]	[date]	[port or sea]

An investigation summary will be posted to the CDC Vessel Sanitation Program website at: http://www.cdc.gov/nceh/vsp once available.

We appreciate your participation.

Sincerely,

CDC Vessel Sanitation Program and [cruise line name]

Please start on the back of this page

*PROTECTION OF PRIVACY INFORMATION

Public Law 93-579 entitled the Privacy Act of 1974 requires that individuals asked to furnish information such as that requested in this form be informed of the purpose for collecting such information and what the information will generally be used for. The following information is accordingly provided:

Authority: The Centers for Disease Control and Prevention, and agency of the Department of Health and Human Services, is authorized to solicit the information requested in this form under the authority of the Public Health Service Act, Section 301,361 (42 U.S.C. 241,264).

Purpose and Uses: The information requested will be used to implement appropriate control measures if any health problems are identified, and may be shared with federal, state and local health authorities. An accounting of such disclosures will be made available to you upon request.

Effects of Non-Disclosures: Your disclosure of the requested information is voluntary, and no penalty will be imposed if you choose not to respond. However, if you do not fill out the questionnaire, it will be more difficult for us to determine the health status of the persons on this cruise.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

CENTERS FOR DISEASE CONTROL AND PREVENTION

ATLANTA, GEORGIA 30333

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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to PHS Reports Clearance Officer: ATTN:PRA;Hubert H. Humphrey Bldg., Room. 721-B; 200 Independence Ave., SW; Washington, DC 20201, and to the Office of Management and Budget; Paperwork Reduction Project (0920-XXXX); Washington, DC 20503.

Attachment J: Cruise Ship Outbreak Investigation (CSOI) Sample General Interview for Passengers or Crew Consent

(For face to face interviews):

VSP (aka USPH) is helping your cruise line find out more about the illnesses that have happened on this voyage and we would like to talk with you about your experiences.

This interview will take approximately 15 minutes to complete. It will take place in a private setting. We will ask you questions about:

• any illness you may have had during the voyage,

• things you ate, drank, and did in the 48 hours before your illness (if you were sick),

• things you ate, drank, and did in the 48 hours before the start of the outbreak,

• any other information you think might be important for us to know about the outbreak.

There are no known risks from taking part in the survey. Some of the questions are personal and ask about sickness. There is no direct benefit from being in the survey. However, what you tell us will help us better learn how this outbreak occurred and how to prevent or control outbreaks in the future.

You can choose if you want to be interviewed. You can stop the interview at any time. You can also refuse to answer any question. If you refuse, it will not affect your job or future USPH inspections.

Your name or other identifying information will be added to the information we learn from other people, so it cannot be traced back to you. If you would like a copy of the report, one can be sent to you. Everything we learn will be kept private to the fullest extent of the law. Only project team members will be allowed to view this information.

If you have any questions about this investigation, you can call the person in VSP in charge of this investigation, XXXXX. XX’s number is (XXX) XXX-XXXX.

Participant unique ID: ________________________________

Are you willing to take part at this time?

Yes

No Thank respondent and end conversation

I verify that I have explained this survey to you. You have agreed to participate.

{No signature is requested as this is information that may be used to later identify the respondent and his or her responses}

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