0920-1335 Attachment K_Cruise COVID19 Case Investigation Worksheet

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

Attachment K_Cruise COVID19 Case Investigation Worksheet.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
Current voyage #:





















































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




















































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




















































[Threaded comment] Your version of Excel allows you to read this threaded comment; however, any edits to it will get removed if the file is opened in a newer version of Excel. Learn more: https://go.microsoft.com/fwlink/?linkid=870924 Comment: Simplified to align w/ latest CDC MU webpage guidance This worksheet is to be used only for lab-confirmed COVID-19 cases This worksheet is to be used only for lab-confirmed COVID-19 cases
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 Vax Booster Date (MM/DD/YYYY) Vax Booster Manufacturer Is person symptomatic? Date person became symptomatic (MM/DD/YYYY) 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) Reason for conducting testing (#1) Type of testing received (#2) Date specimen collected (#2) (MM/DD/YYYY) Testing result (#2) Reason for conducting testing (#2) Type of testing received (#3) Date specimen collected (#3) (MM/DD/YYYY) Testing result (#3) Reason for conducting testing (#3) Type of testing received (#4) Date specimen collected (#4) (MM/DD/YYYY) Testing result (#4) Reason for conducting testing (#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
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