0920-1181 Domestic Manifest Template

OMB Control No.: 0920-1181

Expiration date: XX/XX/XXXX

Department of Health and Human Services

Centers for Disease Control and Prevention

ORDER OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION,

DEPARTMENT OF HEALTH AND HUMAN SERVICES

[INSERT Airline Name]

Attn: [INSERT Name and Title of Airline Representative/POC]

[INSERT Airline Address]

[INSERT Airline POC Telephone Number]

[INSERT Airline POC Fax Number]

On [INSERT Departure Date], a passenger with [INSERT disease] departed [INSERT Departure Airport Code, City, State, Country] on [INSERT Airline and Flight Number] arriving into [INSERT Arrival Airport Code, City, State, Country] on [INSERT Arrival Date if different from departure date].

The passenger is believed to have been infectious and in contact with other passengers and crew during the flight(s). The Centers for Disease Control and Prevention (CDC) considers passengers seated in close proximity to an individual with [INSERT disease] [INSERT on flights that exceed X hours (when length of flight is to be specified)] to be at risk for exposure and infection.

In accordance with 42 CFR § 70.10 as authorized by 42 U.S.C. § 264, [INSERT Airline Name] is hereby ordered to produce to the CDC’s Director of the Division of Global Migration Health, or his representative, on [HQ INSERT Date and time of deadline – typically 24 hours Eastern Time] a record, electronic (preferred) or written (Mailing address will be provided upon request), for the following passengers and crew:

• The ill passenger, [INSERT index case name], seated in [INSERT seat# DELETE if no seat number could be obtained] and the passengers in [INSERT SEAT# AND ROWS –use QS OPS Manual] aboard [INSERT Airline and Flight Number]

• All babes in arms seated anywhere on the plane (delete if disease is NOT measles or rubella)

• [INSERT- AIRLINE NAME has agreed to notify the crew serving these passengers on this flight] (you must ask the airline about this)-delete if not applicable.

• All flight attendants on board. Include pilots on planes with <50 passengers. [DELETE if disease is not measles]

• Please identify crew members on the manifest [DELETE if disease or information does not identify crew members as potential contacts]

• Zones assigned to flight attendants [DELETE if disease or information does not identify crew members as potential contacts]

• Total numbers of persons on board [DELETE if disease is not measles]

• [REPEAT FOR EACH ADDITIONAL DOMESTIC FLIGHT WITH SAME AIRLINE OR DELETE THIS BULLET if only one flight involved]

This record should contain the information listed below, as available:

• Full name (first, middle initial, last)

• Seat number

• Date of birth

• Sex

• Primary phone number (include country code)

• Secondary phone number (include country code)

• Address while in the US (number, street, city, state and Zip) or permanent residence (number and street, state, and zip code) in the US for US citizens and lawful permanent residents

• Email address

• Passport number and issuing country and expiration date (If passport is required)

• Country of residence

CDC also requests seat configuration for the requested contact area (example: AB/aisle/CDE/aisle/FG, bulkhead in front of row 9).

If this information is not available, it should be noted as part of the response to CDC. Information provided to CDC will be used for a public health investigation to notify potentially exposed passengers and crew so that they may receive timely medical intervention.

CDC is issuing this order to prevent the importation and spread of a communicable disease of public health importance. Failure to comply with this order may result in the imposition of fines or other penalties as provided in 42 USC § 271, or as otherwise provided by law. CDC maintains information retrieved by personal identifier in accordance with federal law, including the Privacy Act of 1974 (5 USC 552a). Identifiable information may be shared with authorized personnel of the U.S. Department of Health and Human Services, state and/or local public health departments, and other cooperating authorities.

In testimony whereof, the Chief, Port Health Protection Branch and Travel Risk Assessment and Mitigation Branch, Division of Global Migration Health, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, has hereunto set his hand at Atlanta, Georgia, this [HQ INSERT Today’s Date (e.g., 1^st day of January 2020)].

____________________________________________________

Clive M. Brown, MBBS, MPH, MSc, DTM&H (London)

Chief, Port Health Protection Branch &

Chief, Travel Risk Assessment and Mitigation Branch

Public reporting burden of this collection of information is estimated to average 6 hours 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1181