0920-1335 Attachment L_Cruise COVID19 Contact Investigation Worksh

[NCEZID] Phased Approach to the Resumption of Cruise Ship Passenger Operations

Attachment L_Cruise COVID19 Contact Investigation Worksheet.xlsx

OMB: 0920-1335

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Ship name:
















*CDC close contact definition






Voyage #:
















¥if end of quarantine test result is positive, this close contact is now a case and must be reported as a case on the EDC form






Current voyage start date (MM/DD/YYYY):























Current voyage end date (MM/DD/YYYY):




























This worksheet is to be used for close contacts* of lab-confirmed COVID-19 cases.
Close Contact Information Vaccine History Immediate Contact Testing Quarantine History & End of Quarantine Testing
Close Contact ID# Close Contact Initials (e.g., Jane Doe = JD) Traveler type (crew or passenger) Date of Birth (MM/DD/YYYY) Country of Residence Embarkation Date (MM/DD/YYYY) Disembarkation Date (MM/DD/YYYY) Case initials (e.g., Jane Doe = JD) close contact was exposed to If known, how was contact exposed (i.e., cabinmate, dining mate, travel companion, shared excursion, etc.)? Does person have risk factors for severe illness? Is person fully vaccinated? Vax Dose #1 Date (MM/DD/YYYY) Vax Dose #1 Manufacturer Vax Dose #2 Date (MM/DD/YYYY) Vax Dose #2 Manufacturer Vax Booster Date (MM/DD/YYYY) Vax Booster Manufacturer Was close contact tested for COVID-19? Type of testing received Date specimen collected (MM/DD/YYYY) Testing result If positive, was this close contact (now a case) reported via EDC? Was close contact quarantined? Quarantine Start Date (MM/DD/YYYY) End of Quarantine Test Date (MM/DD/YYYY) End of Quarantine Test Type End of Quarantine Test Result Quarantine End Date¥ (MM/DD/YYYY) If close contact disembarked while in quarantine, disembarkation test type? Disembarkation Day Test Date (MM/DD/YYYY) Disembarkation Day Test Result If positive, was this close contact (now a case) reported via EDC?
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