Land Travel Illness or Death Investigation Form

Form Approved

OMB Control No.0920-0134

Exp XX/XX/XXXX

Land 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: □ Crew □ Passenger □ N/A

Where was the traveler when the QS was notified?:

□ In U.S. jurisdiction

□ In foreign jurisdiction

□ Unknown

NOTE: If ill/deceased person also traveled via □ Air 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, 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:

Countries visited in the past 3 weeks:	State/city/village	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, ____________

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

□ Sore throat

Onset date: _____/_____/______

□ Difficulty breathing/shortness of breath

Onset date: _____/_____/______

□ Neck stiffness

Onset date: _____/_____/______

□ Decreased consciousness

Onset date: _____/_____/______

□ Rash

Onset date: _____/_____/______

Appearance:

□ Maculopapular □ Vesicular/Pustular

□ Purpuric/Petechial □ Scabbed □ Other

□ Swollen glands

Onset date: _____/_____/______

Location: □ Head/neck □ Armpit □ Groin

□ Vomiting

Onset date: _____/_____/_______

Number of times in past 24 hrs? ______

□ Recent onset of focal weakness and/or

Paralysis

Onset date: _____/_____/______

□ Unusual bleeding

Onset date: _____/_____/______

□ Conjunctivitis/eye redness

Onset date: _____/_____/______

□ Coryza/runny nose

Onset date: _____/_____/______

□ Diarrhea

Onset date: _____/_____/_______

Number of times in past 24 hrs?: ______

□ Jaundice

Onset date: _____/_____/______

□ Obviously unwell

□ Injury

□ Chronic condition

□ Persistent cough

Onset date: _____/_____/______

□ With blood □ Without blood

□ Headache

Onset date: _____/_____/______

□ Asymptomatic

□ Other: ____________________________

____________________________________

Deceased Persons:

Date of Death: ______/______/__________

mm dd yyyy

Time of death (24 hours):

_____:_____

hh : mm

Presumptive Diagnosis or Cause of Death:

If traveling by conveyance, does anyone else have similar illness?: □ No □ Yes □ Unknown (If yes, please fill in a new form for each person in the cluster.)

Response or Report:

□ 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:

Frequency of

border crossing: ________ times/ □ Day □ Week □ Month □ year

Passport country/citizenship

Type of ID:

ID document #:

Visa?:

□ Yes □ No

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

Home address:

City:

State/province:

Zip/postal code:

Country of residence:

Home telephone:

If visiting, total duration of

U.S. stay: __________ □ Days □ Weeks □ Months □ 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

Number of days reachable at contact phone: _______

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Section 4. Border Crossing Information

License plate #:

State/province/country issued:

Attempted entry outside an official POE?:

□ Yes □ No □ Unknown

Contact information collected on conveyance passengers/driver(s)?:

□ Yes □ No □ Unknown

Crossing Type*	From (City/Country)	Departure date	To (City/Country)	Arrival date	Significant stops	Name of commercial carrier, if applicable	Bus/Train #	Seat #
Current Segment:
Past & Upcoming Segments:

*Crossing Type: V: Personal vehicle TC: Taxi cab M: Motorcycle P: Pedestrian/Bike B: Passenger bus CC: Commercial cargo vehicle A: Ambulance

T: Train 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 continue 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