Maritime Illness Database and Reporting System (MIDRS)

OMB 0920-1260

The Centers for Disease Control's (CDC) Vessel Sanitation Program (VSP) is requesting a new three-year PRA clearance to transition approval for Maritime Illness Database and Reporting System (MIDRS) and related medical records (AGE Log and 72 hour food/activity history) currently approved under Foreign Quarantine Regulations (OMB Control No. 0920-0134, expiration date 05/31/2019), sponsored by the CDC National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). The MIDRS collection will monitor Acute Gastrointenteritis (AGE) illness on passenger ships (“cruise ships”), conduct sanitation inspections and epidemiologic investigations, and provide public health guidance when outbreaks occur, and formulating public health recommendations to prevent future outbreaks.

The latest form for Maritime Illness Database and Reporting System (MIDRS) expires 2022-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0920-1260 Recordkeeping of Engineering and Sanitation Records Form and Instruction
Form 0920-1260 (Passenger) 72-hour Food/Activity History Template (AGE cases) Form and Instruction
Form 0920-1260 Last Symptom Check and Return to Work Clearance (food and nonfood employees) Form and Instruction
Form 0920-1260 Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew) Form and Instruction
Form 0920-1260 Three-day Pre-embarkation AGE Illness Assessment (all crew members) Form and Instruction
Form 0920-1260 (CREW) 72-hour Food/Activity History Template (AGE cases) Form and Instruction
Form 0920-1260 Recordkeeping of AGE Surveillance Records Form and Instruction
Form 0920-1260 Daily Reports of AGE Logs Form and Instruction
Form 092-1260 Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax) Form and Instruction
Form 0920-1260 AGE Illness Report 4 hours before arrival (phone/email/fax) Form and Instruction
Form 0920-1260 AGE Illness Report 4 hours before arrival (web) Form and Instruction
Form 0920-1260 AGE Illness Report 24 hours before arrival (phone/email/fax) Form and Instruction
Form 0920-1260 AGE Illness Report 24 hours before arrival (web) Form and Instruction
71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases Form and Instruction
71.21 (c) Recordkeeping - medical records (72-hour food/activity history) Form and Instruction
71.21 (c) Recordkeeping – medical records (Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees) Form and Instruction
71.21 (c) Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees Form and Instruction
71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) Form and Instruction
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members Form and Instruction
71.21 (c) Recordkeeping – medical records (Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times) Form and Instruction
71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times Form and Instruction
71.21 (c) Recordkeeping – medical records (AGE Logs) Form and Instruction
71.21 (c) AGE Logs Form and Instruction
71.21(c) Recordkeeping - Gastrointestinal Illnesses Report 24 and 4 hours before arrival Form and Instruction
71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS) Form and Instruction
Att8 IntlConventionofSafetyofLifeatSea.pdf Supplementary Document
Att7 ResearchDeterminationForm 20210916.pdf Supplementary Document
1 - VSP MIDRS Revision List Attachments 20220125.docx Supplementary Document
Att4b.VSP2018OperationsManual.pdf Supplementary Document
Att4a.42CFR71.1bii.pdf Supplementary Document
Att3b. 1987FRN_VSPfromDGMQtoNCEH.pdf Supplementary Document
Att3a.1985FRN_VSPinDGMQ.pdf Supplementary Document
Att2. MIDRS_60D_FRN.pdf Supplementary Document
Att1c. 42CFRPart71 -- Foreign Quarantine.pdf Supplementary Document
Att1b.42USCSection269.pdf Supplementary Document
Att1a. 42USCSection264.pdf Supplementary Document
0 - Privacy Act Checklist MIDRS Rev 20220125.docx Supplementary Document
Att10.PIA.pdf Supplementary Document
Att9.IntlConventionofSafetyofLifeatSea.pdf Supplementary Document
Att6.ResearchDeterminationForm.pdf Supplementary Document
Att4b.VSP2018OperationsManual.pdf Supplementary Document
Att3b. 1987FRN_VSPfromDGMQtoNCEH.pdf Supplementary Document
Att3a.1985FRN_VSPinDGMQ.pdf Supplementary Document
Att2.60dayFRN.pdf Supplementary Document
Att1c. 42CFRPart71.pdf Supplementary Document
Att1b.42USCSection269.pdf Supplementary Document
Att1a. 42USCSection264.pdf Supplementary Document
1 - SSB_MIDRS Revision 20220125.docx Supporting Statement B
1 - SSA_MIDRS Revision 202200404 v2.docx Supporting Statement A
Recordkeeping of Engineering and Sanitation Records Form and Instruction
(Passenger) 72-hour Food/Activity History Template (AGE cases) Form and Instruction
Last Symptom Check and Return to Work Clearance (food and nonfood employees) Form and Instruction
Interviews to Determine AGE Status (initial, 24-hr, 48-hr)(asymptomatic cabin mates and immediate contacts of symptomatic crew) Form and Instruction
Three-day Pre-embarkation AGE Illness Assessment (all crew members) Form and Instruction
(CREW) 72-hour Food/Activity History Template (AGE cases) Form and Instruction
Recordkeeping of AGE Surveillance Records Form and Instruction
Daily Reports of AGE Logs Form and Instruction
Special Reports exceeding 2%-3% AGE Threshold (web/phone/email/fax) Form and Instruction
AGE Illness Report 4 hours before arrival (phone/email/fax) Form and Instruction
AGE Illness Report 4 hours before arrival (web) Form and Instruction
AGE Illness Report 24 hours before arrival (phone/email/fax) Form and Instruction
AGE Illness Report 24 hours before arrival (web) Form and Instruction
71.21 (c) 72-hour food/activity history - AGE Passenger and Crew cases Form and Instruction
71.21 (c) Recordkeeping - medical records (72-hour food/activity history) Form and Instruction
71.21 (c) Recordkeeping – medical records (Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees) Form and Instruction
71.21 (c) Documentation of date/time of last symptom and clearance to return to work for food and nonfood employees Form and Instruction
71.21(c) Recordkeeping - medical records (Documentation of 3-day pre-embarkation AGE illness assessment for all crew members) Form and Instruction
71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members Form and Instruction
71.21 (c) Recordkeeping – medical records (Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times) Form and Instruction
71.21 (c) Interviews with AGE crew case cabin mates and immediate contacts to determine AGE illness status and documentation of interview dates/times Form and Instruction
71.21 (c) Recordkeeping – medical records (AGE Logs) Form and Instruction
71.21 (c) AGE Logs Form and Instruction
71.21(c) Recordkeeping - Gastrointestinal Illnesses Report 24 and 4 hours before arrival Form and Instruction
71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS) Form and Instruction

All Historical Document Collections

202204-0920-002 Approved without change	Revision of a currently approved collection	2022-04-05
201812-0920-009 Approved without change	New collection (Request for a new OMB Control Number)	2019-03-04

OMB Details

71.21(c) Gastrointestinal Illness Report - 24 and 4 hours before arrival (MIDRS)

Federal Enterprise Architecture: Health - Public Health Monitoring

Form NA	Gastrointestinal Illness (GI) Template	NA	Form and instruction
Form NA	MIDRS Template - screenshot	NA	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.