0920-1181 Informal Manifest Request

Form Approved

OMB Control No. 0920-1181

Expiration date: XX/XX/XXXX

Date

POC

Airline

Address

Fax number

Tel Number

Dear [INSERT Name of POC]:

The Centers for Disease Control and Prevention (CDC) have been notified by the state public health authority of [INSERT state] that a passenger was diagnosed with infectious [INSERT name of disease], and is believed to have been infectious during travel. On [INSERT Departure Date], the passenger 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 CDC considers passengers seated in close proximity to this passenger to be at a significant risk for infection and is conducting a public health investigation. To expedite our ability to identify, inform, and begin interventions on exposed individuals, we are asking that you provide us with the name, seat number, and locator information for the following passengers on the flight indicated below as soon as possible:

[INSERT THE SEATS/ROWS NEEDED ACCORDING TO THE DISEASE-SPECIFIC SOP IN CDC QS OPS MANUAL]

• The ill passenger seated in [INSERT seat#] and the passengers in [INSERT SEAT# AND ROWS].

• [REPEAT FOR EACH ADDITIONAL FLIGHT WITH SAME AIRLINE OR DELETE THIS BULLET]

This information may be provided to the XX Port Health Station staff in person hard copy, by email at xxxxxxxxx@cdc.gov, fax at xxx-xxx-xxxx, or by telephone at xxx-xxx-xxxx.

If you have any questions concerning how the requested information will be used by CDC, please do not hesitate to contact me. I can be reached by phone at xxx-xxx-xxxx or by e-mail at the xxxxxxxxx@cdc.gov.

Thank you very much for your assistance in this investigation.

Sincerely,

INSERT NAME

Officer-in-Charge or Port Health Medical Officer

CDC [INSERT Name] Port Health Station

Telephone: [INSERT]

FAX: [INSERT]

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.