Documentation of 3-day pre-embarkation AGE illness asses

Maritime Illness Database and Reporting System (MIDRS)

Att5e.Documentation of 3-day pre-embarkation AGE illness assessment

71.21 (c) Documentation of 3-day pre-embarkation AGE illness assessment for all crew members

OMB: 0920-1260

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Attachment 5e. Documentation of 3-day pre-embarkation AGE illness assessment

Form approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/20XX

Documentation of 3-day pre-embarkation AGE Illness Assessment for Crew Members

Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




Crew member name:


AGE Illness assessment:


Date completed:




CDC estimates the average public reporting burden for this collection of information as 3 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; ATTN: PRA (0920-XXXX).



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorEtheredge, Alisha (CDC/DDNID/NCEH/OD)
File Modified0000-00-00
File Created2022-04-06

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