Form 0920-20HF US Traveler Health Declaration Repatriation from Ship

Form Approved

OMB Control No.0920-XXXX

Exp XX/XX/XXXX

UNITED STATES

TRAVELER HEALTH DECLARATION FOR REPATRIATION (SHIP)

Providing the following information to the Centers for Disease Control and Prevention is authorized under Title 42 Code of Federal Regulations Section 71.20, and is being collected as part of the public health response to 2019 Novel Coronavirus (COVID-2019). The information will be used by U.S. public health authorities and other international, federal, state, or local agencies for public health purposes.

Each traveler needs a separate form.

Flight 1: Number_______________ Seat number______________

Flight 2: Number_______________ Seat number______________ (if needed)

Flight 3: Number_______________ Seatnumber______________ (if needed)

Family name: ..…………….…………………………………………………. First (given) names: …………………..…………………………..……….……………………..

Citizenship:………………………………………………………………….. Country of residence: …………………………………………………………………………….

Birth date: ___ /___ / ___ (Day/Month/Year) Sex: Male Female Cabin number on ship:……..…………….……

Final destination address………………………….……………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………City: ……………………………………………………………

State/Province: ………………………... Country: ……………………………………………………………….E-mail address: ………………………………...............

Do you have a US mobile phone? Yes No US mobile number: ………………………………………………………………

Today or in the past 24 hours have you had any of the following symptoms?
	YES	NO
Fever (100.4° F / 38° C or higher), felt feverish, or had chills?
Cough?
Difficulty breathing?

IN THE PAST 14 DAYS, DID YOU HAVE CLOSE CONTACT (WITHIN 6 FEET/2 METERS) OF A PERSON WITH COVID-2019?

YES NO

If yes, date contact occurred: _____/_____/_____ (Day/Month/Year)

Was this person your cabin mate on ship? YES NO

TO BE COMPLETED BY CENTERS FOR DISEASE CONTROL AND PREVENTION STAFF

Destination 1: Arrival Temp Visible signs of illness: YES NO Screener:______________

Destination 2: Arrival Temp Visible signs of illness: YES NO Screener:______________(if needed)

Destination 3: Arrival Temp Visible signs of illness: YES NO Screener:______________(if needed)

This data collection is mandatory. 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. 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Cohen, Nicole (Nicky) (CDC/OID/NCEZID)
File Modified	0000-00-00
File Created	2021-01-14