Form 0920-1260 Daily Reports of AGE Logs

Maritime Illness Database and Reporting System (MIDRS)

Att5b DailyReprtsAGELogTemplate 2018 20220125.xlsx

Daily Reports of AGE Logs

OMB: 0920-1260

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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 medical practice. Enter "none" if there is no underlying illness.
Vessel Name
Date From
Total No. of Pax.
Total No. of Crew


Voyage Number
Date To
Reportable Total No. of Pax Ill
Reportable Total No. of Crew Ill


Diarrhea Episodes
Vomiting Episodes
Abdominal Cramps Headache Myalgia Last symptom Specimen Requested Specimen Received Antidiarrheal Medication Reportable Underlying Illness (Specify)/ Comments
Patient ID Report to Medical Age Sex Pax or Crew Cabin No. Crew Position Illness Onset Fever
Date Time Last Name First Name Date Time # Blood Y/N # Y/N °F Y/N Y/N Y/N Date Time Y/N Y/N Y/N Y/N

































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































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