Traveler Contact Information Form

Form Approved

OMB Control No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Traveler Contact Information

The required contact data under this information collection request are the same and are as follows:

• Full name (last, first, and, if available, middle or others);

• Address while in the United States (number and street, city, state, and zip code), except that U.S. citizens and lawful permanent residents will provide address of permanent residence in the U.S. (number and street, city, state, and zip code; as applicable);

• Primary contact phone number to include country code;

• Secondary contact phone number to include country code, which may be an emergency, work, or home number;

• Email address:

• Date of birth*;

• Sex*;

• Country of residence*;

• If a passport is required: Passport number, passport country of issuance, and passport expiration date*;

• If a travel document other than a passport is required: Travel document type, travel document number, travel document country of issuance and travel document expiration date*;

• Airline name*;

• Flight number*;

• City of departure*;

• Departure date and time*;

• City of arrival*;

• Arrival date and time*; and

• Seat number*.

All fields are required to the extent that such information exists for the passenger

CDC and CBP will maintain the designated information within their respective systems in accordance with Federal law, including the Privacy Act of 1974 (5 U.S.C. 552a). Identifiable information may be used and shared only for lawful purposes, including with authorized personnel of the United States Department of Health and Human Services; the United States Department of Homeland Security; state, local, tribal, and territorial public health departments; and other cooperating authorities, as authorized by law. CDC and CBP will retain, use, delete, or otherwise destroy the designated information in accordance with the Federal Records Act, applicable Privacy Act System of Records Notices, and other applicable law.