Information Collection Instrument

Form approved

OMB Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

TGS Updated Digital Collection + Double Collection Questionnaire

Travel Information

1. What was your flight number and what country did that flight depart from? You can find these on your boarding pass. Look for a code starting with 2 letters followed by 1-4 numbers.

1. Airline Code text entry

2. Flight Number text entry

3. Flight Country of Origin dropdown

2. Did you travel on any connecting flights in order to get to the United States? (Single select)

   1. Yes

   2. No

3. What country did your travel itinerary to the United States originate from? (Optional)

   1. Drop down options for countries excluding ‘United States’

4. List all countries you were in during the last 10 days. Select as many as you like. (Multiple select)

   1. Drop down options

5. What state(s) are you traveling to in the United States? Select as many as you like. (Multiple

Select)

1. Drop down options

1. Do you live in the United States? (Single select)

   1. Yes

   2. No

2. How long have you been outside the country on this trip? (Single select)

   1. 1-3 days

   2. 4-7 days

   3. 8-14 days

   4. 15-30 days

   5. 1-6 months

   6. 7-12 months

   7. More than 12 months

3. What is or was the main reason for your trip? (Single select)

   1. Tourism/vacation

   2. Business/occupational

   3. Visiting friends/relatives

   4. Migration

   5. Student

   6. Other (please specify)

Background Information

1. Why are you interested in participating today? Select as many as you like. (Multiple select)

   1. I want a free at-home test to take later

   2. It was recommended to me at the airport by testing staff

   3. I want to help the CDC monitor disease entering the United States

   4. I want to support public health work

   5. I thought this was required

   6. Other (Please specify)

2. What is your age? (Single select)

   1. 18-49 years old

   2. 50-64 years old

   3. 65+

   4. Prefer not to answer

3. What sex were you assigned at birth, on your original birth certificate? (Single select)

   1. Male

   2. Female

   3. I don’t know

   4. Prefer not to answer

4. Which of the following would you say is your ethnicity? (Single select)

   1. Hispanic or Latino

   2. Not Hispanic or Latino

   3. Prefer not to answer

5. Which of the following would you say is your race? Select as many as you like. (Multiple select)

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

   6. Prefer not to answer

COVID-19 Information

1. Did you take a COVID-19 test in the 2 days before your flight? (Single select)

   1. Yes, antigen test

   2. Yes, PCR or other molecular test

   3. Yes, not sure what type

   4. No

2. Have you ever tested positive for COVID-19? (Single select)

   1. Yes

   2. No

   3. I don’t know/Prefer not to answer

3. If yes, what was the approximate date of your most recent positive test? (Single select)

   1. Month, Year

   2. I don’t know/Prefer not to answer

4. Have you received at least one COVID-19 vaccine? (Single select)

   1. Yes

   2. No

   3. I don’t know/Prefer not to answer

5. If yes, when did you receive your most recent vaccination? (Single select)

   1. Month, Year

   2. I don’t know/Prefer not to answer

Public reporting burden of this collection of information is estimated to average 5 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 XXXX-XXXX