Attachment A referenced in the April 2020 change request adding the new COVID enhanced data collection form

Form Approved
OMB Control Number 0920-0134
Expiration date XX/XX/XXXX

Send Via Email

Maritime Conveyance Cumulative Influenza/Influenza-Like Illness (ILI) Form
U.S. Centers for Disease Control and Prevention
CDC does not require that cruise ships traveling to or within U.S. waterways report individual cases of suspected or confirmed influenza. CDC requests the
reporting of total influenza-like illness (ILI)/influenza cases (including zero) for each voyage by using this form. Cumulative ILI reporting is not requested
from cargo ships. Please review the CDC recommendations Guidance for Cruise Ships on the Management of Influenza-like Illness available at:
www.cdc.gov/quarantine/cruise/management/guidance-cruise-ships-influenza-updated.html.
Completing and submitting: Note that all fields with red text and an asterisk symbol (*) are required. These fields include: Person filling out form, E-mail,
Vessel company/name, Country of departure, Departure date, Next U.S. port and state, Arrival date at next U.S. port, Total number of passengers and crew
onboard, and Total number of ILI cases in passengers and crew during voyage (including zero).
Please complete all sections of this fillable form and submit to the CDC Quarantine Station with jurisdiction over the next U.S. seaport of arrival by:
1. Clicking on the gray “Send Via E-mail” button in the upper left-hand corner of the form (Note: In order to use this option, your e-mail
account must be set up to automatically generate an e-mail message from a PDF), or saving the form, then attaching to your e-mail and
sending it to [email protected], or
2. Looking up the contact information for the CDC Quarantine Station with jurisdiction over the next U.S. seaport of arrival at
www.cdc.gov/quarantine/QuarantineStationContactListFull.html and sending by fax, or
3. By telephone.
A confirmation e-mail will be sent to the e-mail address that was entered on the form within 1-2 business days. The quarantine station will contact you if
follow-up information is needed. If you don’t receive confirmation of your report or if you have any questions, please contact the CDC Quarantine Station
with jurisdiction over the next U.S. port of arrival, the CDC Emergency Operations Center at 770-488-7100, or the Maritime Activity Administrator
([email protected]).
Immediately report the following situations via the Maritime Conveyance Illness or Death Investigation Form available at:
www.cdc.gov/quarantine/conveyance-form.html.
 A death caused by or suspected to be associated with influenza/ILI onboard the vessel,
 Outbreaks of influenza or ILI (exceeding 1.380 cases per 1,000 traveler days) among passengers or crew members (for calculation, visit
www.cdc.gov/quarantine/calculate.html),
 Changes in clinical profile and severity of illnesses reported or severe complications in at least two epidemiologically linked influenza or ILI cases.
Reminder to cruise ships: Send gastrointestinal (GI) illness reports to CDC’s Vessel Sanitation Program (VSP). Visit: www.cdc.gov/nceh/vsp.
Do not use this form for GI illnesses, which are reportable to CDC VSP per established protocol. For more information call 800-323-2132.

Section 1. Quarantine Station Notification
Person filling out form (*):

Phone:

E-mail (*):

Section 2: Vessel Information
Voyage number:

Vessel company/name (*):
Country of departure (*):

Arrival date & time (24 hr) at final port:

Departure date (*) & time (24 hr):
mm /

dd

/

yyyy

hh : mm

mm /

dd

/

yyyy

hh : mm

Itinerary:
Next U.S. port (*):

Arrival date (*) & time (24 hr) at next U.S. port :
mm / dd /

yyyy

hh : mm

Section 3: Passenger and Crew Totals
Total number of persons onboard (*)

Total ILI cases during voyage (*) [including zero]

Passengers
Crew
Public reporting burden of this collection of information is estimated to average 2 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 0920-0134.