VSP AGE Log

Form approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/20XX

Vessel Sanitation Program Acute Gastroenteritis Log
Note: The Header/Banner section of the AGE Surveillance Log must be completed for EVERY voyage, even if the case counts are zero for both passenger and crew.
Even if there is an underlying illness, there may be justification in reporting the patient as reportable. This should be based on sound clinical judgment and based on
Date From
Vessel
Name
Total No. of Crew
medical
practice.
Enter "none" if there is no underlying
illness. Total No. of Pax.

Y/N

Y/N

Date

Time

Reportable

Y/N

Antidiarrheal
Medication

°F

Specimen
Received

Y/N

Last symptom

Specimen
Requested

Vomiting
Episodes
#

Fever

Myalgia

#

Blood
Y/N

Headache

Date Time

Diarrhea
Episodes

Illness Onset

Reportable Total No. of Crew Ill

Abdominal
Cramps

First Name

Crew Position

Last Name

Cabin No.

Time

Sex

Date

Age

Report to Medical
Patient
ID

Reportable Total No. of
Pax Ill

Date To

Pax or Crew

Voyage Number

Y/N

Y/N

Y/N

Y/N

Underlying Illness (Specify)/
Comments

CDC estimates the average public reporting burden for this collection of information as 10 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)
AGE Log Example

Confidential

2018 version