Recordkeeping - MIDRS Template

Attachment 5a. MIDRS Template

Gastrointestinal Illness(GI) Template Form approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/20XX

CDC estimates the average public reporting burden for this collection of
information as 3 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; ATN: PRA (0920-XXXX)

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Complete the entire template. DO NOT CHANGE THE TAGS IN THIS TEMPLATE.
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RequestType:
(Help,ContactInfo,PortCodes,TemplateGI,ReportGI,ReportSummaryGI,RecallReportGI
)

UserID:

SenderEmailAddress:

EmergencyContactName:
(Acceptable Characters: a-z,A-Z,0-9, space, ! ` , . : ? )

EmergencyContactNumber:
(country code area code phone number)
(Acceptable Characters: a-z,A-Z,0-9, space, ! ` , . : ? )

ShipName:

VoyageNumber:
(Acceptable Characters: a-z,A-Z,0-9, space, ! ` , . : ? )

ReportType(24hr,4hr,Special):

CruiseLength(Days):

EmbarkationPortCode(e.g.,VDZ,STT,MIA): XXX

EmbarkationDate(e.g.,10/23/2000): MM/DD/YYYY

NextUSPortArrivalCode(e.g.,VDZ,STT,MIA): XXX

NextUSPortArrivalDateTime(e.g.,10/23/2000 15:35): MM/DD/YYYY HH:MM

DisembarkationPortCode(e.g.,VDZ,STT,MIA): XXX

DisembarkationDate(e.g.,10/23/2000): MM/DD/YYYY

TotalPassengers:

TotalCrew:
(Must have at least one crew member)

PassengerGastroenteritisCase(s):

CrewGastroenteritisCase(s):

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Public reporting burden of this collection of information is estimated to
average 3 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. Send comments
regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: PHS Reports
Clearance Officer: ATTN:PRA;

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Controlled Unclassified Information (CUI)
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