0920-1260 72-hour Food/Activity History Template (AGE cases)

Maritime Illness Database and Reporting System (MIDRS)

Att5c 72-hrFoodActivityHistoryForm 20220125

OMB: 0920-1260

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Gastrointestinal Illness Surveillance System Questionnaire

Form Approved, OMB No. 0920-1260, Exp. Date 04/30/2022


(To be completed if you experienced gastrointestinal illness)


Vessel Name:

Voyage No. :

Date:

Last Name:

First Name:

Date of Birth:

(mm/dd/yyyy)

Age:

(in years)

Sex M / F

Cabin Number:

Total Number of People in Cabin:

Dining Seating:

Dining Table Number:

Symptoms Started Date:

(mm/dd/yyyy)

Time:

(hh:mm)

AM / PM

Do you know other people ill with the same symptoms?

Yes / No

If yes, please list their names:



Did you stay overnight or longer in a boarding city before you joined the vessel?

Yes / No

If yes, where?

City:

State:

Country:

Was the overnight stay in a hotel/motel/commercial residence?

Yes / No

If yes, what was the name and address of the hotel, motel/commercial residence

Name:

Address:

City:

State:

Country:

How did you travel to the city where you boarded the ship for this cruise? Select all that apply.


[ ]

Airplane

Airlines:

Flight No.:


[ ]

Automobile



[ ]

Bus/Motorcoach



[ ]

Train



[ ]

Other

Please specify:

Are you a member of a tour group?

Yes / No

Prior to boarding the ship, did you participate in a pre-embarkation tour/package?

Yes / No

If yes, which tour(s)/package(s) did you participate in? (list all)



Prior you your illness, did you go ashore at any of the ports of call?

Yes / No

If yes, please list the ports of call where you went ashore



Did participate in any shore excursions at any port of call?

Yes / No

If yes, which shore excursions did you participate in? (list all)




Did you eat anything while you were ashore at any port of call?

Yes / No

Did you drink anything (including drinks with ice) while ashore at any port of call?

Yes / No

What did you think is the cause of your illness?:


PLEASE TURN THIS FORM OVER TO PROVIDE FOOD AND SHIPBOARD ACTIVITIES HISTORY

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Last Name ______________________________________

First Name ______________________


Meals and Activities Aboard Vessel Prior to Illness


Please list the specific vessel locations of the meals you consumed and the vessel activities you participated in before you became ill


Day of illness onset
Give Date:__________

Day before illness onset

Two days before illness onset

Three days before illness onset

Breakfast

Place: _______________
Time: _________

Items eaten/drank

Breakfast

Place: _______________
Time: _________

Items eaten/drank

Breakfast

Place: _______________
Time: _________

Items eaten/drank

Breakfast

Place: _______________
Time: _________

Items eaten/drank









































Lunch

Place: _______________
Time: _________

Items eaten/drank

Lunch

Place: _______________
Time: _________

Items eaten/drank

Lunch

Place: _______________
Time: _________

Items eaten/drank

Lunch

Place: _______________
Time: _________

Items eaten/drank









































Dinner

Place: _______________
Time: _________

Items eaten/drank

Dinner

Place: _______________
Time: _________

Items eaten/drank

Dinner

Place: _______________
Time: _________

Items eaten/drank

Dinner

Place: _______________
Time: _________

Items eaten/drank









































Snack

Place: _______________
Time: _________

Items eaten/drank

Snack

Place: _______________
Time: _________

Items eaten/drank

Snack

Place: _______________
Time: _________

Items eaten/drank

Snack

Place: _______________
Time: _________

Items eaten/drank









































Activities

Activities

Activities

Activities

AM






PM






AM






PM






AM






PM






AM






PM







CDC estimates the average 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; ATTN: PRA (0920-1260).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleVessel Sanitation Program
Authoraoy5
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File Created2023-08-25

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