Traveler with Non-Compliant Test or Documentation of Recovery

Form

OMB Control No.: 0920-1318

Expiration date: 05/31/2021

Data Collection Points from Air Passengers that are COVID Positive or Invalid Test Result

• Name

• DOB

• Home Address

• Home Phone Number

• Destination Address Destination

• Phone Number

• Cell Phone Number

• Passport Number (international)

• Test Type

• Test Location COVID-19 Test Date

• COVID-19 Test Date Reported

• COVID-19 Test Result (Positive/Negative/Inconclusive)

• Country Originating from

• Airline/ Flight Number

• Any other information pertinent to the situation to protect public health

Data Collection Points from Airlines when a Traveler is Denied Entry to a Foreign Country and Must Return to the United States without being Tested

• Passenger Info

  • Name

  • Destination Address

  • Email

  • Cell Phone #

  • Passport Info such as Nationality and Passport #

• Passenger Return Flight info such as departure date to US, Flight #, transfer or destination airport, etc.

• Information about why passenger was inadmissible to the foreign country where they flew

• Any other information pertinent to the situation to protect public health

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 0920-1318