0920-1180 Informal Manifest Request TB Template

Form Approved

OMB Control No. 0920-1180

Expiration date: 05/31/2020

Date

POC

Airline

Address

Fax number

Tel Number

Dear [INSERT Name of POC]:

A state public health authority notified the Centers for Disease Control and Prevention (CDC) of a passenger diagnosed with who is believed to have been infectious during travel., [INSERT name of disease]

On [INSERT Departure Date], the passenger departed [INSERT Departure Airport Code, City, State, Country] on [INSERT Airline and Flight Number] arriving into [INSERT Arrival Airport Code, City, State, Country] on [INSERT Arrival Date if different from departure date].

The CDC considers passengers seated in close proximity to this passenger to be at a significant risk for infection and is conducting a public health investigation. To expedite our ability to identify, inform, and begin interventions on exposed individuals, we are asking that you provide us with the name, seat number, and locator information for the following passengers on the flight(s) indicated below as soon as possible:

[INSERT THE SEATS/ROWS NEEDED ACCORDING TO THE DISEASE-SPECIFIC SOP IN CDC QS OPS MANUAL]

• The ill passenger, [INSERT index case name] seated in [INSERT seat# DELETE if no seat number could be obtained] and the passengers seated in the same row, two rows in front, and two rows behind the ill passenger aboard [INSERT Airline and Flight Number]

• [REPEAT FOR EACH ADDITIONAL FLIGHT WITH SAME AIRLINE OR DELETE THIS BULLET IF ONLY ONE FLIGHT INVOLVED]

This information may be provided to the X YZQuarantine Station staff in person on a disk or hard copy, by fax at xxx-xxx-xxxx, or by telephone at xxx-xxx-xxxx.

If you have any questions concerning how the requested information will be used by CDC, please do not hesitate to contact me. I can be reached by phone at xxx-xxx-xxxx or by e-mail at the xxxxxxxxx@cdc.gov.

Thank you very much for your assistance in this investigation.

Sincerely,

INSERT NAME

Officer-in-Charge or Quarantine Medical Officer

CDC [INSERT Name] Quarantine Station

Telephone: [INSERT]

FAX: [INSERT]

Public reporting burden of this collection of information is estimated to average 6 hours 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 0920-1180.