Form 0920-1260 Daily Reports of AGE Logs

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 medical practice. Enter "none" if there is no underlying illness.

Vessel Name

Date From

Total No. of Pax.

Total No. of Crew

Voyage Number

Date To

Reportable Total No. of Pax Ill

Reportable Total No. of Crew Ill

Diarrhea Episodes

Vomiting Episodes

Abdominal Cramps

Headache

Myalgia

Last symptom

Specimen Requested

Specimen Received

Antidiarrheal Medication

Reportable

Underlying Illness (Specify)/ Comments

Patient ID

Report to Medical

Age

Sex

Pax or Crew

Cabin No.

Crew Position

Illness Onset

Fever

Date

Time

Last Name

First Name

Date

Time

#

Blood Y/N

#

Y/N

°F

Y/N

Y/N

Y/N

Date

Time

Y/N

Y/N

Y/N

Y/N