Land Travel Illness or Death Investigation Form

Land Travel Illness or Death Investigation Form
U.S. Centers for Disease Control and Prevention

Form Approved
OMB Control No.0920-0134
Exp 03/31/2022

Section 1. Quarantine station notification
QARS Unique ID #:

CDC User ID:

Port of Entry:

Person notifying CDC:

Phone:

Agency notifying CDC:

Date of initial
notification to CDC:

State:
Email:

/
mm

Time of initial notification
to CDC (24 hrs):

/
dd

yyyy

:
hh : mm

□ Illness □ Death

Type of notification:

When was the Quarantine Station notified?:
□ Before any travel was initiated
Type of traveler:
□ Crew □ Passenger □ N/A
□ During travel
□ Prior to boarding conveyance
Where was the traveler when the QS was notified?:
□ While traveler was on a conveyance
□ In U.S. jurisdiction
□ After disembarking conveyance
□ In foreign jurisdiction
□ While at the port as a pedestrian or in vehicle
□ Unknown
□ After travel completed (reached final destination for that leg of trip)
□ 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?
□ No
□Yes,
□ No
□Yes,
□ No
□Yes,
Relevant Vaccinations

Exposure to animals?
□ No
□Yes,
□ No
□Yes,
□ No
□Yes,

Other exposures (chemical, drug
ingestion, etc)?
□ No
□Yes,
□ No
□Yes,
□ No
□Yes,

Traveler up to date on relevant vaccinations □ Yes □ No □ Vaccinated with NON-WHO or NON-FDA approved vaccine □ Unknown
Vaccine Type:
; Dose 1 date: / / Manufacturer
; Dose 2 Date: / / Manufacturer
; Dose 3 date: / / Manufacturer
Information Source: □ Vaccine card □ Medical Record □ Vaccine Digital Passport □ IATA Travel Pass □ State Records □ Traveler Recollection □ Other Specify:

□ FEVER (≥100F or ≥38°C) OR
feeling feverish/having chills in past 72 hrs
Onset date:
/
/
Current
0 F/C
temperature:
□ Rash
Onset date:
/
/
Appearance:
□ Maculopapular □ Vesicular/Pustular
□ Purpuric/Petechial □ Scabbed □ Other

□ Conjunctivitis/eye redness
Onset date:
/
/
□ Coryza/runny nose
Onset date:
/

/

Signs, Symptoms, and Conditions (check all that apply) :
□ Neck stiffness
□ Sore throat
Onset date:
Onset date:
/
/

/

/

□ Difficulty breathing/shortness of breath
Onset date:
/
/

□ Decreased consciousness
Onset date:
/
/

□ Swollen glands
Onset date:
/
/
Location:
□ Head/neck □ Armpit □ Groin

□ Recent onset of focal weakness and/or
Paralysis
Onset date:
/
/

□ Vomiting
Onset date:
/
/
Number of times in past 24 hrs?

□ Unusual bleeding
Onset date:
/

□ Diarrhea
Onset date:
/
/
Number of times in past 24 hrs?:

□ Obviously unwell

□ Jaundice
Onset date:

□ Chronic condition

/

/

□ Injury

/

□ Persistent cough
Onset date:
/
/
□ With blood □ Without blood

□ Headache
Onset date:

□ Asymptomatic
/

/
□ Other:

□ Loss of Sense of Taste or Smell

Deceased Persons:

Date of Death:

/
mm

Onset date:
/
dd

/

/
Time of death (24 hours):

:

yyyy

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):

Gender: □ Male □ Female

Date of birth:

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

/
mm

Age (if date of birth unknown):
□ Days □ Weeks □ Months

/
dd

yyyy

Frequency of
border crossing:

Country of birth:
Passport country/citizenship

Type of ID:

For deceased persons, go to Section 5. Otherwise, continue below.
Home address:
City:
Country of residence:

□ Day

times/

ID document #:

State/province:

□ Years

□ Week □ Month □ year
Visa?:
□ Yes □ No
Zip/postal code:

If visiting, total duration of
U.S. stay:
□ Days □ Weeks □ Months □ Years

Home telephone:

Contact in U.S. - Address/hotel:

E-mail:

Contact in U.S. - City:

Contact in U.S. - State/territory:

□ Same as home address above
Contact phone in U.S.:
□ Cell

Emergency contact name:

Emergency contact relationship:

Number of days reachable at contact phone:

Emergency contact phone:

Section 4. Border Crossing Information
License plate #:

Crossing
Type*

State/province/country issued:

From
(City/Country)

Departure
date

To
(City/Country)

Attempted entry outside an
official POE?:
□ Yes □ No □ Unknown
Arrival
date

Significant
stops

Contact information collected on conveyance
passengers/driver(s)?:
□ Yes □ No □ Unknown
Name of commercial
carrier, if applicable

Bus/Train #

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:

Seat #

□ 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