Form 0920-1335 COVID-19 Case Investigation worksheet

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

Case Investigation Worksheet_08062021.xlsx

Cruise Ship Physician - COVID-19 Case Investigation Worksheet (if necessary)

OMB: 0920-1335

Document [xlsx]
Download: xlsx | pdf
Ship name:
















*CDC close contact definition
























*CDC close contact definition
Voyage #:















































Voyage start date (MM/DD/YYYY):














































Voyage end date (MM/DD/YYYY):














































This worksheet is to be used for 1) lab-confirmed COVID-19 cases, and 2) CLI cases with negative COVID-19 test results without a positive test result for another respiratory pathogen (i.e., influenza A or B, RSV, Streptococcal pharyngitis, Legionella, etc.). This worksheet is to be used for 1) lab-confirmed COVID-19 cases, and 2) CLI cases with negative COVID-19 test results without a positive test result for another respiratory pathogen (i.e., influenza A or B, RSV, Streptococcal pharyngitis, Legionella, etc.).
Demographic and Medical Information Exposure Information
Demographic Vaccine History Medical Test results (four most recent tests, including positive and negative results) Crew Passenger Close contacts
Case ID# Case 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) 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 Is this a vaccine breakthrough case? Is person symptomatic? Does person have risk factors for severe illness? Sought medical attention (i.e., medical center, in-cabin)? If yes, date seen by medical provider (MM/DD/YYYY) Identified as a close contact* to a another case? If yes (and not fully vaccinated), date began quarantine (MM/DD/YYYY) Type of testing received (#1) Date specimen collected (#1) (MM/DD/YYYY) Testing result (#1) Type of testing received (#2) Date specimen collected (#2) (MM/DD/YYYY) Testing result (#2) Type of testing received (#3) Date specimen collected (#3) (MM/DD/YYYY) Testing result (#3) Type of testing received (#4) Date specimen collected (#4) (MM/DD/YYYY) Testing result (#4) Cabin # (at time of diagnosis) Any cabin mates (at time of diagnosis)? Any shared bathroom (at time of diagnosis)? Ship department (i.e., galley/dining room, salon, cook, security, etc.) Job location(s) Participated in shore leave/trips/excursions w/in past 14 days? If yes, which seaport(s)? Date(s) of excursions (MM/DD/YYYY) Cabin # Any cabin mates (at time of diagnosis)? Any cabin mates also cases? If Yes, initials of cabin mate (e.g., John Doe = JD) Initials of travel companion case(s) (e.g., John Doe = JD) If Yes, Initials of travel companion case(s) (e.g., John Doe = JD) Participated in voyage-related shore trips/excursions w/in past 14 days? If yes, which seaport(s)? Date(s) of excursions (MM/DD/YYYY) # of crew close contacts* identified # of passenger close contacts* identified
1
















































2
















































3
















































4
















































5
















































6
















































7
















































8
















































9
















































10
















































11
















































12
















































13
















































14
















































15
















































16
















































17
















































18
















































19
















































20
















































File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy