Domestic non-TB Manifest Template and Informal Manifest Request

ORDER OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION,

DEPARTMENT OF HEALTH AND HUMAN SERVICES

[INSERT Airline Name]

Attn: [INSERT Name and Title of Airline Representative/POC]

[INSERT Airline Address]

[INSERT Airline POC Telephone Number]

[INSERT Airline POC Fax Number]

On [INSERT Departure Date], a passenger with [INSERT disease] 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 passenger is believed to have been contagious and in contact with other passengers and crew during the flight(s). The Centers for Disease Control and Prevention (CDC) considers passengers seated in close proximity to an individual with [INSERT disease] [INSERT on flights that exceed X hours (if length of flight is to be specified)] to be at risk for exposure and infection.

In accordance with 42 CFR § 70.10 as authorized by 42 U.S.C. § 264, [INSERT Airline Name] is hereby ordered to produce to the Director of the Division of Global Migration and Quarantine, CDC, or his representative, on or before 5:00 P.M. Eastern Standard Time, [HQ INSERT Date of deadline – typically 24 hours] a record, electronic (preferred) or written (address will be provided upon request), for the following passengers and crew:

• The ill passenger seated in [INSERT seat#] and the passengers in [INSERT SEAT# AND ROWS –use QS OPS Manual] aboard [INSERT Airline and Flight Number]

• REPEAT FOR EACH ADDITIONAL DOMESTIC FLIGHT WITH SAME AIRLINE ( delete if only one domestic flight)

• All babes in arms seated anywhere on the plane (delete if disease is NOT measles or rubella AND plane is not ≤ 30 passenger capacity)

• [INSERT – AIRLINE NAME has agreed to notify the crew serving these passengers on this flight] (you must ask the airline about this)-delete if not applicable

OR

• [INSERT- The cabin crew serving these passengers on this flight] –delete if not applicable

This record should contain the information listed below, as available:

• Full name (first, middle initial, last)

• Seat number

• Date of birth

• Sex

• Primary phone number

• Secondary phone number

• Address

• Email address

• Passport number and issuing country

CDC also requests seat configuration for the requested contact area (example: AB/aisle/CDE/aisle/FG, bulkhead in front of row 9).

If this information is not available, it should be noted as part of the response to CDC. Information provided to CDC will be used in the public health investigation and to notify potentially exposed passengers and crew, so that they may receive timely medical intervention.

CDC is issuing this order to prevent the importation and spread of a communicable disease of public health importance. Failure to comply with this order may result in the imposition of fines or other penalties as provided in 42 USC § 271, or as otherwise provided by law. CDC maintains information retrieved by personal identifier in accordance with federal law, including the Privacy Act of 1974 (5 USC 552a). Identifiable information may be shared with authorized personnel of the U.S. Department of Health and Human Services, state and/or local public health departments, and other cooperating authorities.

In testimony whereof, the Chief, Quarantine and Border Health Services Branch, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, has hereunto set his hand at Atlanta, Georgia, this [HQ INSERT Today’s Date (e.g., 1^st day of January, 2014)].

____________________________________________________

Clive M. Brown, MBBS, MPH, MSc, DTM&H (London)

Chief, Quarantine and Border Health Services