Form 0920-20HF Preboarding Health Screen

UNITED STATES
PRE-BOARDING PUBLIC HEALTH SCREENING FOR
US REPATRIATION FLIGHTS

Form Approved
OMB Control No.0920-XXXX
Exp XX/XX/XXXX

Providing the following information to the Centers for Disease Control and Prevention is required under Title 42
Code of Federal Regulations Section 71.20, and is being collected as part of the public health response to a new
coronavirus (COVID-2019) identified in China. 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.
Family name: ..…………….…………………………………………………. First (given) names:…………………..…………………………..…….
Birth date:

/

/

(Day/Month/Year)

Date of flight:

/

/

(Day/Month/Year)

TODAY OR IN THE PAST 72 HOURS (3 DAYS), 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 TWO WEEKS, have you been diagnosed with pneumonia?

BELOW TO BE COMPLETED BY HEALTH SCREENING STAFF

Measured temperature:
Visible signs of cough or difficulty breathing: Yes

Completed by:

No

_

This data collection is mandatory. Public reporting burden of this collection of information is estimated to average 5 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.