Maritime Form Changes

Maritime Form Changes and Justification

Directions:

• Updated link in first bullet to correct website

Section 1:

• Removed ‘Date Form Completed’ and ‘Time Form Completed’ to reduce burden

Section 2:

• Changed section header to Vessel Information to clarify intent

• For section clarity and consistency, moved the following fields up from section 5

• Vessel company

• Vessel name

• Voyage Number

• Number on Board (Crew and Passengers)

• Itinerary

• Next U.S. port

• Arrival Date & Time at Next U.S. Port

• For program purposes, added:

• Country of Departure

• Departure Date & Time

• Added Arrival Date & Time at Final Port

• Added sub-section called ‘Person info while onboard vessel’ to clarify content intent

• Moved ‘Cabin Number’ and ‘If crew, list job title & duties’ up from section 4 to keep relevant information together.

• Reworded & moved ‘If crew member had contact with passengers, describe extent/frequency’ up from original section 7 to keep relevant information together.

• For section clarity and consistency, moved the following fields up from section 5

• Embarkation port

• Embarkation date

• Disembarkation port

• Disembarkation date

Person info while onboard vessel:
Cabin number:	If crew, list job title & duties:			If crew member have contact with passengers, describe extent/frequency:
Embarkation port:		Embarkation date: ______/______/_______ mm dd yyyy	Disembarkation port:		Disembarkation date: ______/______/_______ mm dd yyyy

Section 3:

• Changed section header to Pertinent medical history of ill or deceased person to clarify intent of section.

• Renamed ‘Relevant history: present illness, other medical problems, vaccinations, etc.’ to ‘Relevant history: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:’ to keep relevant information together and clarify question intent.

• To maintain data consistency and clarify intent, moved the Signs, Symptoms, and Conditions down from section 2 and made the following changes:

• Fever:

• Changed ‘…OR history of fever…’ to ‘…OR history of feeling feverish/having chills…’ to streamline question.

• Changed ‘Temperature’ to ‘Current temperature’ to clarify question intent.

• Removed ‘Maximum measured temperature’ to reduce burden.

• Removed ‘History of fever (not measured) to reduce burden.

• Removed ‘Feel warm to the touch’ to reduce to reduce burden.

• Rash:

• Removed ‘Where rash started’ and options to reduce burden.

• Removed ‘Current distribution’ and options to reduce burden.

• Changed options for ‘Appearance’ from ‘Red-flat, Red-raised, Fluid/pus-filled’ to ‘Maculopapular, Vesicular/Pustular, Purpuric/Petechial, Scabbed’ to clarify question intent.

• Removed ‘Severe’ from Vomiting and Diarrhea to clarify question intent.

• Added ‘Onset Date’ to Conjunctivitis/eye redness, Coryza/runny nose, Sore throat, Difficulty breathing/shortness of breath, Swollen glands, Headache, Neck stiffness, Decreased consciousness, Recent onset of focal weakness and/or paralysis, and Unusual bleeding for program purposes.

• Changed ‘Other:’ to ‘Other Signs, Symptoms, Conditions’ to be consistent with MIDRS.

• Moved ‘Date of death’ and ‘Time of death’ for deceased persons up from Section 6 to keep relevant information together.

• Combined ‘Suspect Diagnosis’ from Section 3 and ‘Suspected cause of death before referral to a medical examiner, if body released’ from Section 6, renamed to ‘Presumptive diagnosis/cause of death’, and relocated the new field to Section 3 to keep relevant information together and reduce burden.

• Moved ‘During the past 3 weeks, has anyone (onboard ship or disembarked) has similar signs and symptoms?’ from section 2 down to section 3 to maintain data consistency within the section.

Section 4:

• Renamed section 4 to Evaluation of ill or deceased person to clarify section intent

• Moved ‘Traveler has taken (include those given on board):’ down from Section 3, changed format, added ‘antiparasitic(s)’ (option 1) and ‘related to current symptoms/illness’ (option 3) and removed ‘aspirin’ (option 2) to keep relevant information together and clarify question intent.

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: ______________________________________

• Moved Exposure History questions up from Section 7, reformatted, added ‘Arrival date’ and removed ‘Visited rural areas?’ to keep relevant information together, clarify question intent, and reduce burden.

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, ____________

• Moved the following fields up from section 7:

• Consolidated the ‘Number of: Cabin mates / Bathroom mates / Work Team mates / Other contacts (intimate partners)' question for crew members and ‘Number of: Cabin mates / Other contacts (intimate partners)' for passengers into one question, ‘Number of potentially exposed contacts (e.g. cabin, work, bathroom mates)’ to reduce burden.

• ‘Are any traveling companions ill / If yes, how many’ to keep relevant information together

• If passenger is a child, does s/he attend day care/youth program on ship? / If Yes, total # of children / # with similar signs & symptoms to keep relevant information together.

• Reformatted ‘Seen in ship infirmary’ and date fields to streamline question.

• Added ‘No infirmary’ to ‘Seen in ship infirmary’ to reduce burden.

• To streamline the questions, moved the following fields down from section 3 and reformatted:

• ‘Ill or deceased person isolated after illness onset’ and date fields

• ‘Seen in health-care facility ashore’ and description field

• ‘Hospitalized?’ and date fields

• Added sub-section header of ‘Lab/Imaging Results’ to clarify intent of sub-section.

• Added ‘facility’ and ‘imaging’ to the test results column to clarify question intent:

Results (if unknown, provide name and phone number of lab/facility which performed tests/imaging):

• Changed ‘Cavitation’ and ‘No Cavitation’ to ‘Cavity’ and ‘No cavity’ respectively to utilize correct terminology.

• Moved ‘Body released to medical examiner?’, ‘Medical examiner telephone’ and ‘City/Country’ up from Section 6 and reformatted to keep relevant information together and clear:

Deceased Persons:

Body released to medical examiner?: □ No □ Yes, telephone: ____________________ City/Country:___________________

• Combined ‘Discharge Diagnosis’ and ‘Determined cause of death (by medical examiner or other)’ from Section 6 into new field ‘Discharge/final diagnosis/cause of death’ to reduce burden.

Section 5:

• Renamed section header to General information about ill or deceased person to clarify section intent.

• Reworded ‘Passport country/issuing state’ to ‘Passport country/citizenship’ to clarify question intent.

• Reworded ‘Passport/domestic ID document #’ to ‘ID document #’ to clarify question intent.

• Added ‘Type of ID document’ for program purposes:

Passport country/citizenship:

Type of ID document:

ID document #:

Alien #:

• Removed ‘Date boarded vessel’ to reduce burden.

• Removed sub-section header ‘For deceased person, go to section 5. Otherwise, continue below:’

TO BE COMPLETED BY QUARANTINE STAFF ONLY section:

• Moved ‘If ill/deceased person also traveled via □ Land and/or □ Air conveyances, please fill out the appropriate form’ to bottom of section to prioritize the fields.

• For program purposes, changed the order and made the following changes to the ‘Ill person’ options:

• ‘Seen by EMS’ changed to ‘EMS responded’ to utilize proper terminology

• ‘Detained by ICE/CBP, location’ changed to ‘Detained by law enforcement, location:’ to utilize proper terminology.

• ‘Denied boarding’ changed to ‘Denied boarding by law enforcement’ to utilize proper terminology.

• Removed ‘Quarantine Order issued’ to reduce burden.

• Removed ‘Isolation order issued’ to reduce burden.

• ‘Presumptive Diagnosis’ field, for program purposes,:

• Reworded to ‘Response or Report’

• Changed ‘Condition not requiring public health follow-up‘ to ‘Information Report Only / No Follow-up needed’

• Changed ‘Condition of public health interest/unknown or cluster, needs follow-up’ to ‘Requires DGMQ Response & Follow-up’

• Removed ‘Disease of public health interest’

• Split the variable ‘When was the Quarantine Station notified?’ into two questions and added an ‘Unknown’ option for program purposes:

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

Where was the traveler when the QS was notified?:

□ In U.S. jurisdiction (within 3 nautical miles of U.S. coast or traveling between U.S. ports)

□ Outside U.S. jurisdiction

□ Unknown