Vessel Sanitation Program Acute Gastroenteritis Log |
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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. |
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Vessel Name |
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Date From |
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Total No. of Pax. |
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Total No. of Crew |
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Voyage Number |
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Date To |
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Reportable Total No. of Pax Ill |
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Reportable Total No. of Crew Ill |
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Diarrhea Episodes |
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Vomiting Episodes |
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Abdominal Cramps |
Headache |
Myalgia |
Last symptom |
Specimen Requested |
Specimen Received |
Antidiarrheal Medication |
Reportable |
Underlying Illness (Specify)/ Comments |
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Patient ID |
Report to Medical |
Age |
Sex |
Pax or Crew |
Cabin No. |
Crew Position |
Illness Onset |
Fever |
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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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