Form NPS Form 10-686 NPS Form 10-686 DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS) TOUR VE

NPS Form 10-686 (Rev. 06/2018)
National Park Service

DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS)
TOUR VEHICLE PASSENGER ILLNESS REPORT

OMB Control No. 1024-0286
Expiration Date ##/##/####

PARK NAME
Park Address Line 1
Park Address Line 2
Telephone: (###) ###-#### Fax: [(###) ###-#### - optional]
Email: [Insert Email Address - Optional]
Website: [Insert Website- Optional]
THIS FORM IS ONLY AUTHORIZED FOR USE IN
YELLOWSTONE NATIONAL PARK, GLACIER NATIONAL PARK,
GRAND TETON NATIONAL PARK, GRAND CANYON, AND YOSEMITE NATIONAL PARK
Thank you for agreeing to help the National Park Service (NPS) Office of Public Health
Your input is very important to the NPS Office of Public Health. These questions seek to identify the number of sick tour vehicle
passengers and where they might have traveled, but we ask that you not provide any personally identifiable information in any of
your submissions (e.g., visitor names).. The information will be used to help both the [concession company] and the NPS Office of
Public Health, working in collaboration, to detect high-risk disease transmission events, monitor and track their spread, implement
appropriate public health response efforts, and assess the effects of these response efforts in order to protect people in the National
Parks as efficiently and effectively as possible. The questions should take less than 10 minutes to complete. All of your answers are
voluntary. If you have any further questions about this survey or its use, please feel free to reach out to the NPS Office of Public
Health at [email protected].

NEW
Contact Information of person completing the form
Name ______________________________________________
Email Address -______________________________________

1. What concession company is filling out this report?
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[Concession Company A]
[Concession Company B]
[Concession Company C]

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Yellowstone National Park
Glacier National Park
Grand Teton National Park
Yosemite National Park
Grand Canyon National Park

2. What is the NPS Park Unit?

3. What is the date of tour group check in?
Click here to enter a date.
4. What lodging facility is the tour group checking in at?
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[Facility A]
[Facility B]
[Facility C]

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[Tour operator A]
[Tour operator B]
[Tour operator C]

5. What is the name of the tour operator or company providing the report?

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NPS Form 10-686 (Rev. 01/2018)
National Park Service

OMB Control No. 1024-####
Expiration Date ##/##/####

6. What is the tour bus or vehicle company?
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[Vehicle operator A]
[Vehicle operator B]
[Vehicle operator C]

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Bus
Ship
Train
Other: Click here to enter text.

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Click here to enter text.
Not applicable

7. What is the type of tour vehicle?

8. What is the [concessioner] tour group ID number?

9. Which city and state did the tour or trip originate from?
Click here to enter text.
10. From which city did the tour group enter the National Park?
Click here to enter text.
11. What is the tour or trip type?
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Overnight
Day tour
Unsure

12. What are the total # passengers on tour vehicle?
Click here to enter text.
13. What are the number of passengers with GI symptoms in the past 72 hours?
GI symptoms include, but are not limited to, nausea, vomiting, abdominal pain/cramps, diarrhea, and
bloody stool.
Click here to enter text.
14. What symptoms did tour vehicle passengers experience? Please mark all that apply.
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Nausea
Vomiting
Abdominal Pain/Cramps
Diarrhea
Bloody Diarrhea
Fever
Shortness of breath
Rash
Pink eye or eye irritation
Unsure
Other: Click here to enter text.

NPS Form 10-686 (Rev. 01/2018)
National Park Service

OMB Control No. 1024-####
Expiration Date ##/##/####

15. Do you have any other comments? Please be specific and be sure NOT to include any personally
identifying information about visitors (e.g., do not include visitors' names).

Thank you for completing this survey.
If you have any further questions about this survey or its use, please feel free to reach out to the NPS Office of
Public Health at [email protected].

NOTICES
PRIVACY ACT STATEMENT
Authority: The NPS Organic Act of 1916 (Organic Act) (54 U.S.C. §100101 et seq.) and the Public Health Service Act (42 U.S. Code
Chapter 6A) gives the NPS broad authority to regulate the use of the park areas under its jurisdiction.
Purpose: The NPS OPH uses the “Disease Reporting and Surveillance System” (DRSS) to enhance surveillance, estimate the burden
of illnesses, and improve knowledge about where these outbreaks were occurring within the park. DRSS documents concessionaire
employees’ illnesses as well as illnesses occurring on tour buses through an on-line, real-time reporting system that allows concession
management, the park, and the OPH to detect an increase in illness reports that may suggest the beginning of an outbreak.
Disclosure: This collection will collect names and email addresses that will be used to follow up with respondents as needed. While no
particular statements offering assurances of confidentiality are provided to the individual on the certification form, the NPS manages the
forms in accordance with procedures established in the National Park Service System of Record INTERIOR/NPS-10 - Central
Files — (86 FR 50156 September 7, 2021).
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the National Park Service uses this form to collect information on
the symptoms, duration, and location of illness, public health workers are able to work rapidly and appropriately to address the
incidents. Your response is voluntary, but failure to complete this form will result in exclusion from participation in the YCC Program.
According to the Paperwork Reduction Act of 1995, 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. OMB has approved this collection of information and
assigned Control No. 1024-0286.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 10 minutes, including time for reviewing instructions, gathering
and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of
the form to the Departmental Information Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, (MS -242) Reston, VA
20191, Please do not send your completed form to this address.