Land Travel Form Changes

Land Form Change Justification.docx

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

Land Travel Form Changes

OMB: 0920-0821

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Land Border Form Changes and Justification

Same changes as Air with variation to accommodate Land conveyance differences, detailed below:

Section 4:

  • Removed ‘Make/Model/Year’ to reduce burden.

  • Added ‘Province’ to ‘State/country issued’ to clarify question intent.

  • Moved ‘Attempted entry outside an official POE?:’ and ‘Contact information collected on conveyance passengers/driver(s)?:’ to line above to consolidate space.



Section 4. Border Crossing Information

License plate #:

State/province/country issued:

Attempted entry outside an official POE?:

Yes No □ Unknown

Contact information collected on conveyance passengers/driver(s)?:

Yes No □ Unknown

Crossing Type*



From

(City/Country)

Departure date

To (City/Country)

Arrival date

Significant stops

Name of commercial carrier, if applicable

Bus/Train #

Seat #

Current Segment:
















Past & Upcoming Segments:



























*Crossing Type: V: Personal vehicle TC: Taxi cab M: Motorcycle P: Pedestrian/Bike B: Passenger bus CC: Commercial cargo vehicle A: Ambulance

T: Train O: Other



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBuckley, Kirsten (CDC/OID/NCEZID)
File Modified0000-00-00
File Created2021-01-30

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