Form NPS Form 10-685 NPS Form 10-685 DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS) CONCESS

NPS Form 10-685 (Rev. 06/2019) OMB Control No. 1024-####

National Park Service Expiration Date ##/##/####

DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS)

CONCESSION/PARTNER EMPLOYEE ILLNESS REPORT

PARK NAME

Park Address Line 1

Park Address Line 2

Telephone: (###) ###-#### Fax: [(###) ###-#### - optional]

Email: [Insert Email Address - Optional]

Website: [Insert Website- Optional]

THIS FORM IS ONLY AUTHORIZED FOR USE IN YELLOWSTONE NATIONAL PARK, GLACIER NATIONAL PARK, AND GRAND TETON NATIONAL PARK

This information is very important to the NPS Office of Public Health. These questions seek to identify the number of sick employees; and where they work. The information will help both the [concession company] and the NPS Office of Public Health detect, monitor, and track high-risk disease. The questions should take less than 10 minutes to complete. All answers are voluntary.

1. What is your NPS Park Unit?

• Yellowstone National Park

• Glacier National Park

• Grand Teton National Park

2. What was the date the employee reported the illness?

Click here to enter a date.

2. What was the date of the employee’s symptom onset?

Click here to enter a date.

2. What was the approximate time of the employee’s symptom onset?

• The time was: Click here to enter text.

• Time unknown

2. During the employee’s illness, did they experience any of the following symptoms listed below? Please mark all that apply.

• Nausea

• Vomiting

• Abdominal Pain/Cramps

• Diarrhea

• Bloody Diarrhea

• Fever

• Shortness of breath

• Rash

• Pink eye or eye irritation

• Unsure

• Other: Click here to enter text.

2. Which company/organization does the sick employee work for? (Please select one response.)

• [Company A]

• [Company B]

• [Company C]

2. What is the sick employee’s employment location? (Please select one response.)

• [Location A]

• [Location B]

• [Location C]

2. What is the sick employee’s facility of employment? (Please select one response.)

• [Facility A]

• [Facility B]

• [Facility C]

2. What type of position does the sick employee have? (Please select one response.)

• [Position A]

• [Position B]

• [Position C]

• Other (Please specific.) Click here to enter text.

2. Which residence does the sick employee live in? (Please select one response.)

• [Residence A]

• [Residence B]

• [Residence C]

• Other (Please specific.) Click here to enter text.

2. Did this employee visit a health care provider?

• Yes

• No

• Unsure

2. As a result of this sickness, has this employee been quarantined?

• Yes

• No

• Unsure

2. If the employee has been placed on sick leave, for how long?

• Click here to enter text.

• Not applicable or unsure

2. Do you have any other comments? Please be specific.

NOTICES

Privacy Act Statement

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this form.

Authority: 54 U.S.C. §100101, NPS Organic Act; 42 U.S. Code Chapter 6A Public Health Service Act; NPS Management Policy 2006, 8.2.5.5.

Purposes and Uses: Information collected will be used to document concessionaire employees’ illnesses. Concession management, the park, and the Office of Public Health will use the Disease Reporting and Surveillance System (DRSS) to detect an increase in illness reports. The NPS may use the information to apprise the Centers for Disease Control and Prevention of potential disease outbreaks in the park. The Office of Public Health will use epidemiologic statistics, maps, and graphs to provide summaries of relevant data to the concession staff in an effort to reduce outbreaks within the park.

Effects of Nondisclosure: It is in your best interest to answer all of the questions. Given the nature of illness and outbreaks, respondents are requested to report any illnesses that have caused concession employees to miss work.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number is not needed to complete this form.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to assist park superintendents in protecting and promoting visitor health through disease surveillance and response, on-site evaluation/hazard analysis, consultation, policy guidance, and coordination with local, state and other federal health jurisdictions. Your response is voluntary and results will not be shared publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1024-­###, which expires ##/##/####.

Estimated Burden Statement

Public Reporting burden for this form is estimated to average 10 minutes per response, including the time it takes for providing instructions, gathering data, and completing the form. Comments regarding this burden estimate or any aspect of this form should be sent to the Information Collection Clearance Officer, National Park Service, 1201 Oakridge Drive, Fort Collins, CO 80525.

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