Example Questionnaire Undetermined Agent

Attachment E3. Example Questionnaire for Undetermined Agent

Crown Princess

Form Approved
OMB No. 0920-1255
Exp. Date 03/31/2022

Voyage No. 3278

Guest Health Questionnaire
Status

W ........
S .........
CDC Use Only

CDC ID

U.........

CDC Use Only
Part I. Respondent Information

Q3

Stateroom

Q4

Sex

Male ..........................................................
Female .....................................................

Q5

What is your age (in years)?

Q6

During this voyage, did you have any of the following symptoms? (Please select "Yes" or "No" for each
symptom)
Yes
No
Diarrhea (loose stools/motions)
Vomiting (not associated with
seasickness)
Blood in stool
Fever (feeling warm/hot)
Stomach cramps/pain
Muscle aches
Headaches

Q7

If you were ill with DIARRHEA, please indicate the maximum number of diarrhea episodes you
had in a 24-hour period.

Q8

During this voyage, did you experience any other symptoms not
listed above?

Q9

Yes ............................................
No..............................................

If you responded "Yes" to Q8, please list the additional symptoms below.

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching
existing data/information sources, gathering and maintaining the data/information 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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1255)

Page:1

Q10 If you were ill with Diarrhea or Vomiting, please indicate the day that your symptoms started. The
ship location for each day is provided to assist selecting the appropriate day. If you did not have
diarrhea or vomiting, please select "I was not ill with diarrhea or vomiting".
26 October (Embarkation Day)..........................................

03 November (Newport, RI) ..............................................

27 October (Saguenay, Quebec) ......................................

04 November (New York, NY) ...........................................

28 October (At sea) ...........................................................

05 November (Norfolk, VA) ...............................................

29 October (Sydney, Nova Scotia)....................................

06 November (At sea) .......................................................

30 October (Halifax, Nova Scotia).....................................

07 November (At sea) .......................................................

31 October (Halifax, Nova Scotia).....................................

08 November (Ft Lauderdale, FL) .....................................

01 November (Bar Harbor, ME).........................................

I was not ill with diarrhera or vomiting ..............................

Q11 If you were ill with Diarrhea or Vomiting, please indicate the time period that your symptoms started.
If you did not have diarrhea or vomiting, please select "I was not ill with diarrhea or vomiting".
Midnight - 05:59 am...........................................................

06:00 pm - 11:59pm ..........................................................

06:00 am - 11:59 am .........................................................

I was not ill with diarrhea or vomiting. ..............................

12:00 (noon) - 05:59 pm....................................................

Part II. Food and Beverage Locations
Q12 On 27 October (Port: Saguenay), please indicate if you ate or drank in any of the Restaurants and
Buffets listed below. Please indicate "Yes", "No", or "Unsure" for each location.
Yes

No

Unsure

Cafe Caribe (Deck 15 aft)
Horizon Court (Deck 15)
Da Vinci Dining Room (Deck 6 midship)
Botticelli Dining Room (Deck 6 aft)
Michelangelo Dining Room (Deck 5 midship)
Crown Grill Steakhouse (Deck 7 aft)
Pizzeria/Ice Cream Bar (Deck 15 midship)
Sabatini's (Deck 16 aft)
Trident Grill (Deck 15 forward)
Other, please specify

Page:2

Q13 On 28 October (Port: At sea), please indicate if you ate or drank in any of the Restaurants and
Buffets listed below. Please indicate "Yes", "No", or "Unsure" for each location.
Yes

No

Unsure

Cafe Caribe (Deck 15 aft)

Horizon Court (Deck 15)
Da Vinci Dining Room (Deck 6 midship)
Botticelli Dining Room (Deck 6 aft)
Michelangelo Dining Room (Deck 5 midship)
Crown Grill Steakhouse (Deck 7 aft)
Pizzeria/Ice Cream Bar (Deck 15 midship)
Sabitini's (Deck 16 aft)
Trident Grill (Deck 15 forward)
Other, please specify

Q14 On 27 October (Port: Saguenay), please indicate if you ate or drank in any of the Bars and Cafes
listed below. Please indicate "Yes", "No", or "Unsure" for each location.
Yes

No

Unsure

International Cafe (Deck 5 midship)
Vines Bar (Deck 5 midship)
Speakeasy Lounge (Deck 6 midship)
Casino Bar (Deck 6 forward)
Tradewinds Bar (Deck 16 forward)
Crooners Bar (Deck 7 midship)
Explorer's Bar (Deck 7 midship)
Adagio Bar (Deck 16 forward)
Calypso Bar (Deck 15 midship)
Mermaid's Bar (Deck 15 forward)
Outrigger's Bar (Deck 15 aft)
Wheelhouse Bar/Salty Dog (Deck 7 forward)
Club Fusion (Deck 7 aft)

Page:3

Q15 On 28 October (Port: At sea), please indicate if you ate or drank in any of the Bars and Cafes listed
below. Please indicate "Yes", "No", or "Unsure" for each location.
Yes

No

Unsure

International Cafe (Deck 5 midship)
Vines Bar (Deck 5 midship)
Speakeasy Lounge (Deck 6 midship)
Casino Bar (Deck 6 forward)
Tradewinds Bar (Deck 16 forward)
Crooner's Bar (Deck 7 midship)
Explorer's Bar (Deck 7 midship)
Adagio Bar (Deck 16 forward)
Calypso Bar (Deck 15 midship)
Mermaid's Bar (Deck 15 forward)
Outrigger's Bar (Deck 15 aft)
Wheelhouse Bar/Salty Dog Bar (Deck 7
forward)
Club Fusion (Deck 7 aft)

Part III. Food and Beverage Consumption
Instruction: Please indicate whether you consumed the following food/beverage items on 27 October
(Port: Saguenay ) or 28 October (At sea). The food and beverages are arranged in categories. Please
select "Yes", "No" or "Unsure" for each food/beverage item.
Q16 Beverages
Yes

No

Unsure

Coffee
Tea
Fresh fruit or vegetable drink
Carbonated drinks (soda)
Bottled water
Tap water
Other non-alcohol drinks
Wine
Beer
Mixed drinks containing alcohol
Other drinks containing alcohol
Other beverage, please
specify

Page:4

Q17 Soups and Salads
Yes

No

Unsure

Yes

No

Unsure

Alaskan-style Seafood
Roasted Garlic Cream Soup
French Onion Soup
Creamy Asparagus Soup
Chicken Noodle Soup
Chunky Seafood Soup
Lentil Soup
Coconut Soup
Green Pea Soup
Hot and Sour Soup
Chilled Sweet Corn and Potato Soup
Greek Salad
Ceasar Salad
Black Rice Vegetable Salad
Shrimp Cocktail Salad
Homemade Mix Pate
Red Snapper Escabeche
Cold Smoked Salmon and Crayfish Tails
Garden Salad
Other soups and salads, please specify

Q18 Grains and Pastas
Rigatoni
Tortellini
Ravioli
Fettuccine
Pasta Farfalle Alla Rustica
Fusilli Primavera
Wagonwheel Shrimp Picasa & Capers
Seafood Spanish Paella
Spaghetti
Fried Rice
Saffron Basmati Rice
Rice Pilaf with Green Peas
Steamed Rice
Other soups and salads, please specify

Page:5

Q19 Meat and Poultry
Yes

No

Unsure

Yes

No

Unsure

Chicken (any style)
Cornish hens
Turkey
Hamburger
Ground beef other than hamburger
Beef steak or roast
Pork chops or roast
Veal
Lamb
Deli meats
Ham
Hot dogs
Bacon
Corned beef hash
Breakfast sausage (linked, patty, ground)
Dinner style sausage/bratwurst/Kielbasa
Pepperoni or salami
Prosciutto, capocollo, other Italian style meat
Other processed or cooked meat
Other meats and poultry, please specify

Q20 Fish and Seafood
Calamari
Clams, mussels, scallops
Crab
Escargot
Octopus, squid or eel
Lobster
Seafood salad
Shrimp/prawns
Smoked or dried fish (Salmon)
Gravlax
Tuna (including steak or salad)
Sushi
Other fish and seafood, please specify

Page:6

Q21 Fresh Fruit
Yes

No

Unsure

Apples
Apricots
Blackberries
Blueberries
Raspberries
Strawberries
Other fresh berries
Cantaloupe
Honeydew
Watermelons
Other melons
Bananas
Cherries
Grapefruit
Grapes
Fresh lemon/line (including drink garnishes)
Oranges, nectarines, tangerines
Pears
Peaches
Plums
Kiwi
Mango
Papaya, guava, pomegranate
Other exotic fruit
Coconut
Other fresh fruit, please specify

Page:7

Q22 Fresh Vegetables
Yes

No

Unsure

Asparagus
Bell peppers
Beets, turnips, radishes
Cauliflower
Carrots
Cabbage
Corn
Celery
Cucumber
Broccoli
Eggplant
Green onions/scallions (raw or cooked)
Fresh basil/pesto
Fresh parsley
Fresh cilantro
Leeks
Lettuce
Okra, rhubarb
Onions (raw or cooked)
Fresh Avocado/guacamole
Other fresh hot peppers (Jalapenos)
Other greens (kale, collard, chard)
Mushrooms
Mixed Vegetables
Potatoes (mashed, baked, french fries)
Snow peas (eaten in pod)
Other fresh peas
Tomatoes (whole or sliced)
Sprouts (bean, alfalfa)
Spinach
Zucchini or other "soft" squash
Other "hard" squash (acorn, butternut)
Other fresh vegetables, please specify

Page:8

Q23 Eggs and Dairy Products
Yes

No

Unsure

Poached eggs
Fried eggs
Eggs Benedict
Boiled eggs
Scrambled eggs
Omelet
Yogurt
Milk
Butter/Margarine
Cheese
Sour cream
Whipped cream
Cream cheese
Cottage cheese
Ricotta
Shredded cheese
Cheese cut from solid blocks
Any gourmet or artisanal cheese
Other eggs and dairy, please specify

Page:9

Q24 Miscellaneous Foods
Yes

No

Unsure

Pancakes, waffles
French Toast
Hash Brown Potatoes
Canapes
Cole slaw
Curry
Any cold soups (potato soup)
Any hot soups or broth (vegetable)
Deli-style sandwiches (including vegetarian)
Any stews (beef)
Tofu
Chicken/Duck Pate
Any gravies or sauces
Any salad dressings
Any pizza
Any baked items (breads, crossiants)
Any pastries (cakes, pies, donuts)
Other miscellaneous foods

Thank-you for taking the time to complete this important survey

Page:10