Form NPS Form 10-686 NPS Form 10-686 DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS) TOUR VE

NPS Form 10-686 (Rev. 06/2019) OMB Control No. 1024-####

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

DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS)

TOUR VEHICLE PASSENGER 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

Thank you for agreeing to help the National Park Service (NPS) Office of Public Health

This information is very important to the NPS Office of Public Health. These questions seek to identify the number of sick passengers on tour vehicle entering the park. The information is to help the [name of concession company] and the NPS Office of Public Health to detect, monitor, and track the spread of high-risk disease. The questions should take less than 5 minutes to complete. All of your answers are voluntary.

1. What concession company is filling out this report?

• [Concession Company A]

• [Concession Company B]

• [Concession Company C]

2. What is the NPS Park Unit?

• Yellowstone National Park

• Glacier National Park

• Grand Teton National Park

3. What is the date of tour group check in?

Click here to enter a date.

4. What lodging facility is the tour group checking in at?

• [Facility A]

• [Facility B]

• [Facility C]

5. What is the tour operator or company providing the report (company name)?

• [Tour operator A]

• [Tour operator B]

• [Tour operator C]

6. What is the company (owner) of the tour bus or vehicle company?

• [Vehicle operator A]

• [Vehicle operator B]

• [Vehicle operator C]

7. What is the type of tour vehicle?

• Bus

• Ship

• Train

• Other: Click here to enter text.

8. What is the [concessioner] tour group ID number?

• Click here to enter text.

• Not applicable

9. What city and state did the tour or trip originate from?

Click here to enter text.

10. Through which city did the tour group enter the National Park?

Click here to enter text.

11. What is the tour or trip type?

• Overnight

• Day tour

• Unsure

12. What are the total # passengers on tour vehicle?

Click here to enter text.

13. What are the number of passengers with [symptoms] in the past [xx] hours?

Click here to enter text.

14. What symptoms did tour vehicle passengers experience? 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.

15. 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: To enhance surveillance, estimate the burden of the illness, and determine where potential disease outbreaks may occur within a park. Information collected will document illnesses occurring on tour buses. 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 or any illness that are observed on tour buses.

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 30 minutes per response and is dependent upon the number of passengers reporting illness. The burden includes the time it takes to provide instructions, gather 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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