Form 0920-1260 Att5a2 4 hr AGEIllnssRprt (phone email fax) 20220125

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):