Attachment 5a2. 24/4-hr AGE Illness Report (phone/email/fax)
Form Approved
OMB No. 0920-1260
Exp. Date 04/30/2022
CDC estimates the average reporting burden for this collection of information as three 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 (0920-1260).
Gastrointestinal Illness(GI) Template
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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):
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | NCEH/ATSDR Office of Science |
File Modified | 0000-00-00 |
File Created | 2022-04-06 |