Vessel Sanitation Program

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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





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