Form 0920-0134 Air Travel Illness or Death Investigation Form

Air Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

Section 1. Quarantine station notification

QARS Unique ID #:

CDC User ID :

Port of Entry:

State:

Person notifying CDC:

Phone:

Email:

Agency notifying CDC:

Date of initial

notification to CDC:

_____/_____/______

mm dd yyyy

Time of initial notification to CDC (24 hrs):

_____ : _____

hh : mm

Type of notification: □ Illness □ Death

When was the Quarantine Station notified?:

□ Before any travel was initiated

□ During travel

□ Prior to boarding conveyance

□ While traveler was on a conveyance

□ After disembarking conveyance

□ After travel completed (reached final destination for that leg of trip)

□ Unknown

Type of traveler: □ Passenger □ Crew

Where was the traveler when the QS was notified?:

□ In U.S. jurisdiction / Inbound

□ In foreign jurisdiction / Outbound

□ Unknown

NOTE: If ill/deceased person also traveled via □ Land and/or □ Maritime conveyances, please fill out the appropriate form and attach

Section 2. Pertinent medical history of ill or deceased person

Relevant history: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:

Traveler has taken:

□ Antibiotic/antiviral/antiparasitic(s) in the past week; list with date(s) started: _________________________________________________

□ Fever-reducing medications (e.g. acetaminophen, ibuprofen) in the past 12 hrs; list with time of last dose: _________________________

□ Other medications (related to current symptoms/illness); list with date(s) started: ______________________________________________

Relevant Exposures in the Past 3 Weeks:

Village/City/State	Province/Country	Arrival Date	Exposure to ill persons?	Exposure to animals?	Other exposures (chemical, drug ingestion, etc)?
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________
			□ No □Yes, ____________	□ No □Yes, ____________	□ No □Yes, ____________

Signs, Symptoms, and Conditions (check all that apply):

□ FEVER (≥100F or ≥38°C) OR

feeling feverish/having chills in past 72 hrs

Onset date: _____/_____/______

Current temperature: ______⁰ F/C

□ Rash

Onset date: _____/_____/______

□ Difficulty breathing/shortness of breath

Onset date: _____/_____/_______

□ Swollen glands

Onset date: _____/_____/_______

Location: □ Head/neck □ Armpit □ Groin

□ Decreased consciousness

Onset date: _____/_____/_______

□ Recent onset of focal weakness

and/or paralysis

Onset date: _____/_____/_______

Appearance:

□ Maculopapular □ Vesicular/Pustular

□ Purpuric/Petechial □ Scabbed □ Other­­­­­­­­­­­­­­­­­­­­­

□ Conjunctivitis/eye redness

Onset date: _____/_____/_______

□ Coryza/runny nose

□ Vomiting

Onset date: _____/_____/_______

Number of times in past 24 hrs? ______

□ Diarrhea

Onset date: _____/_____/_______

Number of times in past 24 hrs?: ______

□ Unusual bleeding

Onset date: _____/_____/_______

□ Obviously unwell

□ Injury

Onset date: _____/_____/_______

□ Persistent cough

Onset date: _____/_____/______

□ With blood □ Without blood

□ Jaundice

Onset date: _____/_____/_______

□ Headache

Onset date: _____/_____/_______

□ Chronic condition

□ Asymptomatic

□ Other: __________________________

□ Sore throat

Onset date: _____/_____/_______

□ Neck stiffness

Onset date: _____/_____/_______

________________________________

________________________________

Form Approved

OMB Control No.0920-0134

Exp XX/XX/XXXX

Deceased Persons:

Date of Death:

______/______/__________ mm dd yyyy

Time of death (24 hours):

_____:_____ hh : mm

Presumptive Diagnosis or Cause of Death:

Does anyone else on the plane have similar illness?: □ No □ Yes* □ Unknown *If yes, please fill in a new form for each person in the cluster

Response or Info Only: □ Requires DGMQ Response & Follow-up (Proceed to next section) □ Information Report Only / No Follow-up needed (STOP HERE)

Section 3. General information about the ill or deceased person

Last/paternal name:

First/given name:

Middle name:

Maternal name (if applicable):

Other names used (e.g., former name, alias):

Gender:

□ Male □ Female

Date of birth:

_____/_____/______ mm dd yyyy

Age (if date of birth unknown):

□ Days □ Weeks □ Months □ Years

Country of birth:

Passport country/citizenship:

Type of ID:

ID document #:

Alien #:

For deceased persons, go to Section 5. Otherwise, continue below.

Home address:

City:

State/province:

Zip/postal code:

Country of residence:

Home phone:

If visiting, total duration of U.S. stay:

□ Days □ Months □ Weeks □ Years

Contact in U.S. - Address/hotel: □ Same as home address above

E-mail:

Contact in U.S. - City:

Contact in U.S. - State/territory:

Contact phone in U.S.:

□ Cell # of days reachable at contact phone: _____

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Section 4. Flight information

Type*

Domestic or Int’l?

Airline

Flight #

Departure Airport Code

Departure Date

Arrival Airport Code

Arrival Date

Seat #

Flight Duration

CURRENT FLIGHT:

PREVIOUS AND/OR UPCOMING FLIGHTS:

*C/FB = Commercial, foreign-based carrier C/US = Commercial, U.S.-based carrier P = Private CH = Charter CG = Cargo O = Other

Section 5: Disposition of ill/deceased person

Ill person was (check all that apply):

Deceased Person:

□ Released to continue travel □ Advised to seek medical care □ EMS responded □ Recommended to not travel □ Transported to hospital (□ MOA activated): ______________________ □ Transported to non-hospital location: ____________________________ □ Detained by law enforcement, location: __________________________ □ Denied entry by law enforcement □ Other: ____________________________________________________

Body released to medical examiner?: □ Yes □ No Medical examiner telephone: ___________________ City/State/Country: __________________________

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 0920-0821.