Form 0920-20HF Referral Slip

COVID-2019 REFERRAL SLIP

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) first 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.

Check all that apply. Provide to CDC screener who is escorting traveler from secondary to tertiary.

• Traveler from Hubei province in the last 14 days

• Had contact with a person known to be infected with the 2019 Novel Coronavirus

• Measured temperature: ____________ ___ (100.4° F / 38° C or higher)

• Self-reported fever

• Self-reported cough

• Self-reported difficulty breathing

• Screener visually observed signs and/or symptoms: ___________________________

Traveler Airline and Flight Number:____________________________

Name of screener: _________________________________________

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.