Air Travel Illness or Death Reporting

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

Attachment H - Airline Illness Screening form FINAL3

Air Travel Illness or Death Investigation

OMB: 0920-0821

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I nternational Air Travel Illness or Death Investigation Form

U.S. Centers for Disease Control and Prevention

Section 1. Quarantine station notification

Port of Entry:




Notified by: (name of person)

Phone:

Email:

Notified by: (name of agency)




Type of notification:

Traveler illness

Traveler death

Date of initial notification:


_____/_____/_______

(mm / dd / yyyy)

Time of initial notification:

(24 hours)

:

(hh : mm)

For Illness Report, go to Section 2. For Death Report, go to Section 8.

Section 2. Information on signs and symptoms of ill or deceased person (passenger or crew)

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

FEVER (or recent history of)

Temp: ______________0 F/C

rash

conjunctivitis/eye redness

persistent cough

sore throat

difficulty breathing / shortness of breath

severe vomiting

severe diarrhea

headache

neck stiffness

decreased consciousness

recent onset of focal weakness and / or paralysis

unusual bleeding

obviously unwell

asymptomatic

other (describe:____________________________

Brief history of present illness:


Are there other people on the plane with similar illness? Yes No

Does traveler have FEVER (or recent fever history) AND at least one other sign/symptom/condition listed above?

NO (STOP HERE)

NO (but you are concerned illness may be of public health significance (Proceed to next sections)

YES (Proceed to next sections)

Section 3. Pertinent medical history

Do you have underlying medical conditions that could explain your current symptoms?  No  Yes______________

Are you currently taking: (describe)

a. Medications that could reduce a fever (e.g., aspirin, ibuprofen, Motrin, Aleve, acetaminophen, Tylenol)?

No Yes Which one? __________________________________________________

b. Antibiotics/Antimicrobials? No Yes What?_____________________________

c. Medication that could be related to your current symptoms? ? No Yes..What?_____________________

During or prior to the flight did you take:

a. Fever-reducing medications No Yes

b. What did you take? _____________________ How long ago was your last dose? _______hrs

Disease/Vaccination History (if applicable) Prior Disease? Prior Vaccination?

Chickenpox No Yes No Yes

Rubella (German Measles) No Yes No Yes

Measles No Yes No Yes

Section 4. History of current illness

I. Fever History:

Date of fever onset ___/___/___

If you measured your temperature during this illness, what was your maximum temperature? _______________ 0 F/C

II. Rash History:

Date of rash onset ___/___/___

Where did the rash start? Head Trunk Extremities Other _______________________

Current distribution of rash: Head Trunk Extremities Other _______________________

Appearance of rash: Red-raised Red-flat Fluid- or pus-filled Other________________________

Passenger had contact with someone with a rash/known chickenpox/measles/rubella in the last 3 weeks? No Yes

III. Respiratory Illness History:

Cough No Yes onset _____/_____/_____

with blood? No Yes (mm / dd / yyyy)

Coryza*? No Yes

(*runny nose)

IV. Gastrointestinal Illness History:

Diarrhea: Date onset _____/_____/_______ With blood? No Yes

Number of times in past 24 hrs? ____

Vomiting: Date onset _____/_____/_______ With blood? No Yes

Number of times in past 24 hrs? ____




Section 5. Exposure history of ill or deceased person

* e.g., visits to zoo, animal market, poultry farms, family/friends with back yard poultry or pigs


Countries visited in the last 3 WEEKS

Visited Urban Areas?

Visited Rural Areas?

How long ago?

Activities (e.g. student, missionary, personal or business travel, etc. )

Exposure to animals?*

Exposure to ill persons?


Yes No

Yes No



Yes No

Yes No


Yes No

Yes No



Yes No

Yes No


Yes No

Yes No



Yes No

Yes No


Yes No

Yes No



Yes No

Yes No


If exposed to ill animals or birds, describe nature of contact:



If exposed to ill person, ill persons’ diagnoses or description of illness:



Other exposures (chemical, powder, radiation, etc)? No Yes

If yes, where?

If yes, when?

Occupation:


Section 6. Traveling companions & other contacts of ill or deceased person

Number of traveling companions:


Are any traveling companions ill? No Yes N/A (no companions)

If yes, use another illness screening and response worksheet for each.

Section 7. Flight information

Airline &

Flight #

Departure Airport

Departure Date &

Time

Arrival Airport

Arrival Date &

Time

Seat #

Flight Duration

CURRENT FLIGHT:








PREVIOUS AND UPCOMING CONNECTING FLIGHTS:























Section 8. General information about the ill or deceased person

Paternal/Last name:

First name:

Type of traveler: Crew Passenger

Aliases:


Country of birth:

Gender:

Male

Female

Date of birth:

_____/_____/__________

(mm / dd / yyyy)

Age (if Date of Birth Unknown):



Days Weeks

Months Years

For deceased persons, go to Section 9. Otherwise, continue below:

Contact in US - Address/hotel:



Home address?

Contact in US - City:

Contact in US -State/Province:

Contact phone in US:


Cell?

Number of days reachable at contact phone: ______ days

Permanent number? Yes No

If not permanent, home phone #:

Home address


Home City:

Home State/Province:


Home Zip/Postal Code



Home Country (Country of Residence):


If visiting, total

duration of US stay:

days months weeks years

Passport country:

Passport #:

Alien #:

Emergency contact name:


Emergency contact relationship:

Emergency contact phone:

Section 9. General information about the deceased person onboard the flight

Date of death:

_____/_____/__________

(mm / dd / yyyy)

Time of death

(24 hours)

: (hh : mm)

Suspected cause of death:

If infectious disease is suspected as a contributing cause of death, then complete ALL sections of this form.

Medical examiner notified?

Yes No

Medical examiner name:


Medical examiner telephone:


Name of person body released to:

Title of person body released to:

Agency:

Office telephone:

Cell:

Email:

Public reporting burden of this collection of information is estimated to average 6 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.


File Typeapplication/msword
File TitleYou are called by an airline or CBP about an “ill” passenger
AuthorCDC
Last Modified Bymga1
File Modified2008-11-18
File Created2008-11-17

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