Form No number No number International Maritime Illness or Death Investigation Fo

Quarantine Station Illness Response Forms: Airline, Maritime, and Land/Border Crossing

Attachment J - Maritime investigation form FINAL Burden State_2

International Maritime Illness or Death Investigation

OMB: 0920-0821

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I nternational Maritime Conveyance

Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention



If requested by Centers for Disease Control and Prevention (CDC) Quarantine Station, please use this form to submit additional information about the reported onboard illness or death, pursuant to 42 CFR 71.21(a).

  • Complete and fax this form to the CDC Quarantine Station to which the illness or death was reported. Quarantine Station jurisdictions and contact information can be found at www.cdc.gov/ncidod/dq/quarantine_stations.htm

  • Contact the CDC Quarantine Station to confirm receipt of the faxed report or if you have any questions.

  • If you are unable to reach a CDC Quarantine Station, call +1-770-488-7100. Alternate: +1-877-764-5455 (at-sea use).

  • Reminder to cruise ships: do not use this form for gastrointestinal (GI) illnesses, which are reportable to CDC Vessel Sanitation Program (VSP) per established protocol. More information about VSP can be found at: http://www.cdc.gov/nceh/vsp/default.htm or by calling +1-800-323-2132.


Section 1. Contact information of vessel staff completing form


Name: ______________________________________ Title: ___________________________________________________________


Telephone: ___________________________________ E-mail: _________________________________________________________


Section 2. Vessel information


Vessel name: __________________________________ Vessel company: _________________________________________________


Embarkation port:______________________________ Length of voyage:____________________(days)


Next US port: _________________________________ Arrival date/time: ___/____/_____ _________

mm dd yyyy (24 hr) hh:mm


Duration of stay at next US port: ________ hours Number (#) on board: Crew:____________; Passengers:____________


List all port stops before arrival: ___________________________________________________________________________________


List all port stops after departure from next US port: ___________________________________________________________________

Section 3. General information on ill or deceased person


Surname/Last Name: ________________________________________________ Middle name: ______________________________


First/given name: __________________________________________________ Gender: □ Male □ Female □ Crew □ Passenger


Occupation (if crew, list job title & duties):__________________________________________________________________________


Date of birth: ____/_____/________ Birth country: ______________________ Country of residence:__________________________

mm dd yyyy


Passport Country/Number: ________________________ Date boarded vessel: ____/_____/______ Cabin Number: _____________

mm dd yyyy


Home address (street/city): ________________________________________________ State/Province: ________________________


Zip/Postal Code: _______________________ Country: ___________________________Telephone: ____________________________


Duration of US stay: ____________________ Contact in US (hotel/address): _______________________________________________


US City/State: _______________________________________________US Telephone: _____________________________________

Section 4: Information on signs and symptoms of ill or deceased person

Signs/ Symptoms

(check “yes” if present during illness)

No

Yes

If Yes, provide other information below:

Fever or recent history of fever

Onset date: ____/_____/________

mm dd yyyy

Maximum measured temperature: °C/°F

Rash

Onset date: ____/_____/________

mm dd yyyy

Where rash started: □ Head □ Trunk □ Extremities

Distribution of rash: □ Head □ Trunk □ Extremities

Appearance:

Red/Flat □ Red/Raised

Fluid-filled □ Pus-filled

Other

Conjunctivitis (eye redness)


Coryza (runny nose)


Persistent cough

Onset date:____/_____/________

mm dd yyyy

With blood: □ Yes □ No □ Don’t know

Sore throat


Difficulty breathing / Shortness of breath


Swollen glands

Onset date:____/_____/_________

mm dd yyyy

Location: □ Head □ Neck □ Armpit □ Groin

Severe vomiting

Number of times in the last 24 hours: __________

Resulted in dehydration: □ Yes □ No □ Don’t know

Severe diarrhea (loose stools)

Onset date: _____/_____/________

mm dd yyyy

Number of times in the last 24 hours:__________

With blood: □ Yes □ No

Resulted in dehydration: □ Yes □ No □ Don’t know

Jaundice

Onset date: ____/_____/________

mm dd yyyy

Headache


Neck stiffness


Decreased consciousness (e.g. disoriented)


Recent onset of paralysis and / or focal weakness


Unusual bleeding

Site (explain):

Describe illness history (e.g., onset date, progression) :




Pre-existing medical conditions: □ No □ Yes (if yes, describe)




Section 5. Vaccination and disease history of ill or deceased person

(Skip this section if the presumptive diagnosis is not a vaccine preventable disease)


Vaccination history (check box if he/she was vaccinated against the disease in the past and fill in number of doses received):

# of doses # of doses # of doses

Measles _______ □ Pertussis _______ □ Hepatitis A _______ □ Influenza, last received ____/______

Mumps _______ □ Diphtheria _______ □ Hepatitis B _______ mm yyyy

Rubella _______ □ Varicella _______ □ Meningococcal _______ □ Other:________________________


Disease history (check box if he/she had the disease in the past):


Measles □ Mumps □ Rubella □ Varicella □ Pertussis □ Diphtheria □ Hepatitis A □ Hepatitis B

Section 6. Information about deaths (skip to section 7 if not applicable)


Date of death: ____/____/_________ Time of death: _____ : _____

mm dd yyyy (24 hr) hh : mm


Laboratory test results: __________________________________________________________________________________________


Presumptive cause of death: ______________________________________________________________________________________

Disposition of body (check one):


Sent to Medical Examiner (city, country): ________________________________________________________________________


Other: _____________________________________________________________________________________________________


Determined cause of death (by medical examiner or other): _____________________________________________________________________________________________________________


Note: If deceased person did NOT have fever or the suspected cause of death is NOT a communicable disease, STOP and submit form. Otherwise complete rest of the form.

Section 7. Test results of ill or deceased person.

(Skip to section 8 if no tests performed on ship or ashore)

Tests

Date performed

(mm/dd/yyyy)

Results ( if unknown, provide name and number of lab which performed tests)

Chest x-ray (radiograph)





Rapid influenza test





Legionella urine antigen





Other

Test 1: _______________________


Test 2: _______________________


Test 3: _______________________












Section 8. Treatment of ill or deceased person


Seen in ship infirmary: □ No □ Yes

If yes, date of first visit: ____/_____/________

mm dd yyyy


Check treatments/medications prescribed:

Antibiotics/Antimicrobials: list_______________________

Fever-reducing medicines (e.g., aspirin, ibuprofen, acetaminophen) ____________________________________

Other: list __________________________________________________


Presumptive Diagnosis:


__________________________________________________


Comments:________________________________________


__________________________________________________



Seen in health-care facility ashore: □ No □ Yes

If yes, hospitalized □ No □ Yes

If yes, dates: from: ____/_____/_____ to ____/_____/________

mm dd yyyy mm dd yyyy


List name (s) and locating information of facility/health-care provider(s) and date(s) of visit:

_________________________________________________________


_________________________________________________________


Treatment: ________________________________________________


Discharge Diagnosis: _______________________________________


Comments:_______________________________________________


_________________________________________________________

Section 9. Exposure history of ill or deceased person


During the three weeks before illness onset, did he/she have contact with:

Other ill person(s)? □ No □ Yes

If yes, ill persons’ diagnoses or description of illness: __________________________________________________________

Animals/poultry: □ No □ Yes If yes, explain:_________________________________________________________________


Other exposures (e.g., chemical): □ No □ Yes If yes, explain:_____________________________________________________

List places he/she traveled during 3 weeks before illness onset (include ship port stops if disembarked): _____________________________________________________________________________________________________________


Total # of persons (onboard ship or disembarked) with similar signs and symptoms during the past 3 weeks:

(Please verify by a medical log review): Total # Crew:___________ ; Total # Passengers:___________


Section 10. Traveling companions and other contacts of ill or deceased person


Ill or deceased person isolated after illness onset?: □ No □ Yes

If yes:

Date isolated: ____/____/____ Place isolated: □ Cabin □ Infirmary □ Other: _______________________________________

mm dd yyyy


Isolated alone: □ Yes □ No If no, explain: ___________________________________________________________________

Did he/she have contact other people after being placed in isolation?: □ No □ Yes If yes, identify them by titles or

relationships with the ill/deceased person: _____________________________________________________________________



Answer if ill or deceased person is a crew member:

Write number of :

cabin mates:__________________

bathroom mates: ______________

work team mates: _____________

other contacts (e.g., intimate partners): _________


Do any of above persons have similar signs & symptoms?*

No □ Yes If yes, explain:________________________


Does this crew member eat in passenger venues? □ No □ Yes

Does this crew member have contact with passengers?

No □ Yes If yes, describe extent/frequency:


Answer if ill or deceased person is a passenger:


Write number of:

cabin mates: _____________

travel companions: ________

other contacts (e.g., intimate partners): __________



Do any of above persons have similar signs & symptoms?*

No □ Yes If yes, explain:________________________________


If passenger is a child, does he/she attend day care or youth program on ship? □ No □ Yes

If yes, total # of children in day care or 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.

To be completed by quarantine station staff only


Date Quarantine Station notified: ___/___/____ Time of initial notification: ________________

mm/dd/yyyy (24 hr) hh:mm

Final Diagnosis ______________________________________________ QARS Unique ID # ________________

Comments:____________________________________________________________________________________________________

_____________________________________________________________________________________________________________


Public reporting burden of this collection of information is estimated to average 7 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-xxxx.

Version: 11/18/08 OMB Control No 0929-XXXX

Expiration Date: XX/XX/XXXX

File Typeapplication/msword
File TitleInternational Maritime Conveyance
Authorzkq6
Last Modified Bymga1
File Modified2008-11-18
File Created2008-11-17

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