Form 0920-0134 Air Travel Illness or Death Investigation Form

Form Approved OMB Control No.0920-0134

Exp X/XX/XXXX

Air Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

Section 1. Quarantine station notification

QARS Unique ID #:

CDC User ID :

Port of Entry:

State:

Person notifying CDC:

Phone:

Email:

Agency notifying CDC:

Date of initial notification to CDC:

/ / mm dd yyyy

Time of initial notification to CDC (24 hrs):

: hh : mm

Type of notification: □ Illness □ Death □ Traveler Follow up

When was the Quarantine Station notified?: Before any travel was initiated During travel Prior to boarding conveyance While traveler was on a conveyance After disembarking conveyance After travel completed (reached final destination for that leg of trip) Unknown

Type of traveler: □ Passenger □ Crew

Where was the traveler when the QS was notified?: In U.S. jurisdiction / Inbound In foreign jurisdiction / Outbound Unknown

NOTE: If ill/deceased person also traveled via □ Land and/or □ Maritime conveyances, please fill out the appropriate form and attach

Section 2. Pertinent medical history of ill or deceased person

Relevant history: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:

Traveler has taken: Antibiotic/antiviral/antiparasitic(s) in the past week; list with date(s) started: Fever-reducing medications (e.g. acetaminophen, ibuprofen) in the past 12 hrs; list with time of last dose: Other medications (related to current symptoms/illness); list with date(s) started:

Relevant Exposures in the Past 3 Weeks:

Village/City/State

Province/Country

Arrival Date

Exposure to ill persons?

Exposure to animals?

Other exposures (chemical, drug ingestion, etc)?

No □Yes,

No □Yes,

No □Yes,

Relevant Vaccinations Traveler up to date on relevant vaccinations □ Yes □ No □ Vaccinated with NON-WHO or NON-FDA approved vaccine □ Unknown Vaccine Type: ; Dose 1 date: / / Manufacturer ; Dose 2 Date: / / Manufacturer ; Dose 3 date: / / Manufacturer Information Source: □ Vaccine card □ Medical Record □ Vaccine Digital Passport □ IATA Travel Pass □ State Records □ Traveler Recollection □ Other Specify:

Relevant Testing

Disease tested: Testing Method: Specimen Source: Specimen Collection Date: Date Lab Test Available: Interpretations of Results. Comments:

Signs, Symptoms, and Conditions (check all that apply):

FEVER (≥100F or ≥38°C) OR feeling feverish/having chills in past 72 hrs Onset date: / / Current temperature: 0 F/C Rash Onset date: / /

Difficulty breathing/shortness of breath Onset date: / / Swollen glands Onset date: / / Location: □ Head/neck □ Armpit □ Groin

Decreased consciousness Onset date: / / Recent onset of focal weakness and/or paralysis Onset date: / /

Appearance: Maculopapular □ Vesicular/Pustular Purpuric/Petechial □ Scabbed □ Other Conjunctivitis/eye redness Onset date: / / Coryza/runny nose

Vomiting Onset date: / / Number of times in past 24 hrs? Diarrhea Onset date: / / Number of times in past 24 hrs?:

Unusual bleeding Onset date: / / Obviously unwell Injury

Onset date: / / Persistent cough

Jaundice Onset date: / /

Chronic condition Asymptomatic

Onset date: / / With blood □ Without blood

Headache Onset date: / / Loss of Sense of Taste or Smell Onset date: / /

Other:

Sore throat Onset date: / /

Deceased Persons:

Date of Death:

/ / mm dd yyyy

Time of death (24 hours):

: hh : mm

Presumptive Diagnosis or Cause of Death:

Does anyone else on the plane have similar illness?: □ No □ Yes* □ Unknown *If yes, please fill in a new form for each person in the cluster

Response or Info Only: Requires DGMQ Response & Follow-up (Proceed to next section) Information Report Only / No Follow-up needed (STOP HERE)

Section 3. General information about the ill or deceased person or traveler who may need follow up

Last/paternal name:

First/given name:

Middle name:

Maternal name (if applicable):

Other names used (e.g., former name, alias):

Gender:

Male Female

Date of birth:

/ / mm dd yyyy

Age (if date of birth unknown):

□ Days □ Weeks □ Months □ Years

Country of birth:

Passport country/citizenship:

Type of ID:

ID document #:

Alien #:

For deceased persons, go to Section 5. Otherwise, continue below.

Home address:

City:

State/province:

Zip/postal code:

Country of residence:

Home phone:

If visiting, total duration of U.S. stay:

□ Days □ Months □ Weeks □ Years

Contact in U.S. - Address/hotel: Same as home address above

E-mail:

Contact in U.S. - City:

Contact in U.S. - State/territory:

Contact phone in U.S.:

Cell # of days reachable at contact phone:

Emergency contact name:

Emergency contact relationship:

Emergency contact phone:

Section 4. Flight information

Type*

Domestic or Int’l?

Airline

Flight #

Departure Airport Code

Departure Date

Arrival Airport Code

Arrival Date

Seat #

Flight Duration

CURRENT FLIGHT:

PREVIOUS AND/OR UPCOMING FLIGHTS:

*C/FB = Commercial, foreign-based carrier C/US = Commercial, U.S.-based carrier P = Private CH = Charter CG = Cargo MD = Medevac RP = Repatriation O = Other

Section 5: Public Health Entry Requirements

Entry Requirement: Did traveler meet the US Global Public Health Entry Requirements: □ Yes □ No □ N/A Please specify:

Comments:

Section 6: Disposition of traveler/ill/deceased person

Ill person was (check all that apply):

Deceased Person:

Released to continue travel Advised to seek medical care EMS responded Recommended to not travel Transported to hospital (□ MOA activated): Transported to non-hospital location: Detained by law enforcement, location:

Body released to medical examiner?: □ Yes □ No Medical examiner telephone: City/State/Country:

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data

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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0134