Form 0920-25CC Maritime Conveyance Illness or Death Investigation Form

Instructions for the Maritime Conveyance Illness or Death Investigation Form

Please download this form, type the vessel name at the top of the form, and save it for future use.

Completing and submitting

• Complete this form as specified by www.cdc.gov/quarantine/cruise-reporting-guidance.html or www.cdc.gov/quarantine/cargo- reporting-guidance.html.

• Remember to use a separate form for each ill or deceased person.

• Note that all fields with red text and an asterisk symbol (*) are required. These fields include: Person filling out form, E-mail, Type of notification, Type of traveler, Conveyance type, Vessel company/name, Country of departure, Departure date, Next U.S. port and state, Arrival date at next U.S. port, Embarkation port, Embarkation date, at least one Sign, Symptom, or Condition, and Presumptive diagnosis/cause of death.

• 
  
  Please note that for some questions (temperature unit, rash type, cough type, chest x-ray result, and presence of cavity) you won’t be able to clear your selection by unclicking the box. To clear your selection you should click on the green default circle located to the right of the main selections. For example, if ‘cavity’ is checked in error, you may clear the selection by clicking the green default circle to the right of ‘no cavity.’ See images below.

• For more information about the fields on this form, visit: www.cdc.gov/quarantine/key-fields.html.

• Submit to the CDC Quarantine Station with jurisdiction over the next U.S. seaport of arrival by one of the methodsdescribed below.

Instructions by section

Sections 1–4 (Quarantine Station Notification, Vessel Information, Medical History, and Evaluation of Ill or Deceased Person)

• To complete Sections 1–4, you may type directly into the form, or print and fill out byhand.

• To submit the form, choose from the following options:

  1. Click on the gray “Send Via E-mail” button in the upper left-hand corner of the form (Note: In order to use this option, your e-mail account must be set up to automatically generate an e-mail message from a PDF), or save the form, then attach to your e-mail and send it to [email protected], or

  2. Look up the contact information for the CDC Quarantine Station with jurisdiction over the next U.S. seaport of arrival at www.cdc.gov/quarantine/QuarantineStationContactListFull.html and send by fax, or

  3. By telephone.

• A confirmation e-mail will be sent to the e-mail address that was entered on the form within 1-2 business days. The quarantine station will contact you if follow-up information is needed.

• If you don’t receive confirmation of your report, or if you have any questions, please contact the CDC Quarantine Station with jurisdiction over the next U.S. port of arrival, the CDC Emergency Operations Center at 770-488-7100, or the Maritime Activity Administrator ([email protected]).

Section 5 (General Information About Ill or Deceased Person)

• Please DON’T submit Section 5 unless the quarantine station asks you to do so.

• To complete Section 5, print out the form and fill in by hand. This section contains personally identifiable information (PII), so you won’t be able to type into the fillable PDF form.

• Submit by fax or telephone.

• Do not submit any forms with PII to CDC through e-mail.

PII is any information that can be used alone or in combination to identify an individual. This includes names, addresses, phone numbers, dates (birth, hospital admission, travel), identifying numbers (passport, social security, driver’s license, alien), medical records, photographs, and for rare diseases, geographic locations.

Reminder to cruise ships

1. CDC requests that cruise ships submit a cumulative ARI report (even if no ARI cases have occurred) preferably within 24 hours before arrival in the U.S., and sooner if a voyage's crew or passenger ARI attack rate reaches 3%. These reports are requested by completing the Cruise Ship Cumulative Acute Respiratory Illness (ARI) Reporting Form. Access to the online reporting form has been provided to cruise lines by CDC. Cruise lines that do not have access may contact CDC (email [email protected]).

2. Send gastrointestinal (GI) illness reports to CDC’s Vessel Sanitation Program (VSP). For more information call 800-323-2132 or visit http://www.cdc.gov/nceh/vsp/.

3. Report a case of Legionnaires’ disease by sending an e-mail to [email protected].

Reset Form

Send Via Email

Maritime Conveyance Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

OMB Approved Control No. 0920-0134 Exp. 03/31/2026

Section 1. Quarantine Station Notification

Person filling out form (*):

Phone:

E-mail (*):

Type of notification (*): Illness Death

Type of traveler (*): Crew Passenger

Conveyance type (*): Cruise ship Cargo Other

Section 2: Vessel Information

Vessel company/name (*):

Voyage number:

Number on board:

Crew:

Passengers:

Country of departure (*):

Departure date (*) & time (24 hr): mm / dd / yyyy hh : mm

Arrival date & time (24 hr) at final port: mm / dd / yyyy hh : mm

Itinerary:

Next U.S. port (*):

Arrival date (*) & time (24 hr) at next U.S. port : mm / dd / yyyy hh : mm

Person information while onboard vessel:

Cabin number:

If crew, list job title & duties:

If crew member has contact with passengers, describe extent/frequency:

Embarkation port (*):

Embarkation date (*): mm / dd / yyyy

Disembarkation port:

Disembarkation date: mm / dd / yyyy

Section 3: Medical History

Age ( years vs. months):

Include relevant medical history of ill or deceased person (present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.):

Signs, Symptoms, and Conditions (*) [Check all that apply] :

FEVER (≥100F or ≥38°C) OR history of feeling feverish/ having chills in past 72 hrs Onset date: Current temperature: 0 F/C Rash Onset date: Appearance: Maculopapular Vesicular Pustular Purpuric/Petechial Scabbed Other Conjunctivitis/eye redness Onset date: Coryza/runny nose Onset date: Persistent cough Onset date: With blood Without blood Sore throat Onset date:

Difficulty breathing/shortness of breath Onset date: Swollen glands Onset date: Location: Head/neck Armpit Groin Vomiting Onset date: # of times in past 24 hrs: Diarrhea Onset date: # of times in past 24 hrs: Jaundice Onset date: Headache Onset date: Neck stiffness Onset date:

Decreased consciousness Onset date: Recent onset of focal weakness and/or paralysis Onset date: Unusual bleeding Onset date: Obviously unwell Chronic condition Asymptomatic Injury Other signs, symptoms, conditions:

Deceased persons: Date of death: Time of death (24 hours): mm / dd / yyyy hh : mm

Presumptive diagnosis/cause of death (*): COVID-19

During the past 3 weeks, has anyone (onboard ship or disembarked) had similar No signs and symptoms? (Please verify by a medical log review): Yes*, total # ill of crew: total # ill of passengers: *If yes, please fill in a new form for each personin the cluster Unknown

Control No. 0920-0134

OMB Approved Exp. 03/31/2026

Section 4. Evaluation of Ill or Deceased Person
Traveler has taken (include those given on board): Antibiotic/antiviral/antiparasitic(s) in the past week; list with dates started: Fever-reducing medications (e.g., acetaminophen, ibuprofen) in the past 12 hours; list with dates started: Other (related to current symptoms/illness); list with date(s) started:
	Countries visited in the past 3 weeks	State/city/village	Arrival date		Exposure to ill persons	Exposure to animals			Other exposures (chemical, drug ingestion, etc.)
					No Yes	No Yes			No Yes
					No Yes	No Yes			No Yes
					No Yes	No Yes			No Yes
Number of potentially exposed contacts (e.g., cabin, work, bathroom mates): Are any traveling companions ill? No Yes*, how many are ill: N/A (no companions) If passenger is a child, does s/he attend day care/youth program on ship? No Yes, total # of children in day care/program: # of children with similar signs & symptoms*: *Note: Submit a separate form for each ill or deceased person not previously reported to a CDC Quarantine Station.
Seen in ship infirmary? No Yes, date of first visit: mm / dd / yyyy No infirmary							Ill/deceased person isolated after illness onset? No Yes, date isolated: mm / dd / yyyy
Seen in health-care facility ashore? No Yes; facility/health care provider(s) information (name, location, dates, telephone number, e-mail):							Hospitalized? No Yes, dates hospitalized: from to mm / dd / yyyy
Lab/Imaging Results
Tests				Date performed (mm/dd/yyyy)				Results (if unknown, provide name and phone number of lab/facility which performed tests/imaging)
Chest x-ray:								Normal Abnormal ( Cavity No cavity)
Legionella urine antigen:								Positive Negative
Test 1: Test 2: Test 3:				1. 2. 3.				1. 2. 3.
Deceased persons: Body released to medical examiner?: No Yes Telephone: City/Country:
Discharge/final diagnosis/cause of death (determined by medical examiner or other):

OMB Approved Control No. 0920-0134 Exp. 03/31/2026

Section 5. General information about ill or deceased person
Last/paternal name:						First/given name
Middle name:		Maternal name (if applicable):					Other names used (e.g., former name, alias):
Gender: □ Male □ Female		Date of birth:	mm/dd/yyyy
Country of birth:	Passport country/citizenship:			Type of ID document:			ID document #:		Alien #:
Home address:		City:					State/province:		Zip/postal code:
Country of residence:		Home phone:					If visiting, total duration of U.S. stay:		Days Weeks	Months Years
Contact in U.S. – Address/hotel:			Same as home address above				E-mail:
Contact in U.S. - City:		Contact in U.S.-State/territory:					Contact phone in U.S.: Cell # of days reachable at contact phone:
Emergency contact name:		Emergency contact relationship:					Emergency contact phone:
Comments:
TO BE COMPLETED BY QUARANTINE STAFF ONLY
QARS Unique ID #:	CDC User ID:				Date Quarantine Station notified:			Time Quarantine Station notified (24 hrs):
When was the Quarantine Station notified? Before any travel was initiated During travel Prior to boarding conveyance While traveler was on a conveyance After disembarking conveyance After travel completed (reached final destination for that leg of trip) Unknown					Ill person was (check all that apply): Released to continue travel Advised to seek medical care EMS responded Recommended to not continue travel Transported to hospital (□ MOA activated): Transported to non-hospital location: Detained by law enforcement, location: Denied boarding by law enforcement Other:
Where was the traveler when the QS was notified?: In U.S. jurisdiction (within 3 nautical miles of U.S. coast or traveling Outside U.S. jurisdiction Unknown					Response or Info Only: Requires DGMQ Response & Follow-Up Information Report Only / No Follow-Up Needed
NOTE: If ill/deceased person also traveled via Land and/or Air conveyances, please fill out the appropriate form

between U.S. ports)

Sections 1-3: Public reporting burden of this collection of information is estimated to average 2 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 0920-0134.

Sections 4-5: 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 0920-0821.

Vessel Company/Name:	Country of departure:	Departure date:
Presumptive Diagnosis: