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OMB No: 0920-XXXX
Expiration Date: XX/XX/20XX
Vessel Sanitation Program Acute Gastroenteritis Log
Note: The Header/Banner section of the AGE Surveillance Log must be completed for EVERY voyage, even if the case counts are zero for both passenger and crew.
Even if there is an underlying illness, there may be justification in reporting the patient as reportable. This should be based on sound clinical judgment and based on
Date From
Vessel
Name
Total No. of Crew
medical
practice.
Enter "none" if there is no underlying
illness. Total No. of Pax.
Y/N
Y/N
Date
Time
Reportable
Y/N
Antidiarrheal
Medication
°F
Specimen
Received
Y/N
Last symptom
Specimen
Requested
Vomiting
Episodes
#
Fever
Myalgia
#
Blood
Y/N
Headache
Date Time
Diarrhea
Episodes
Illness Onset
Reportable Total No. of Crew Ill
Abdominal
Cramps
First Name
Crew Position
Last Name
Cabin No.
Time
Sex
Date
Age
Report to Medical
Patient
ID
Reportable Total No. of
Pax Ill
Date To
Pax or Crew
Voyage Number
Y/N
Y/N
Y/N
Y/N
Underlying Illness (Specify)/
Comments
CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions,
searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATN: PRA (0920-XXXX)
AGE Log Example
Confidential
2018 version
File Type | application/pdf |
File Title | AGELogTemplate 2018 v2.xlsx |
Author | igc3 |
File Modified | 2019-02-19 |
File Created | 2018-05-11 |