Passenger “Acknowledgement” and collection of informatio

Form
OMB Control No.: 0920-XXXX
Expiration date: XX/XX/XXXX

Requirement for Airlines and Operators to Collect and Transmit Designated Information for Passengers and Crew arriving into the United States; Requirement for Passengers to Provide Designated Information

Instructions for Airlines and Operators: Below is information that airlines and operators may use for the collection of passenger information for this Order. The Form, OMB Control No., and Expiration date, the burden statement, and the Privacy Act Statement must be used when collecting passenger information. If applicable to the format used for the collection of information, place Form, OMB Control No., and Expiration date in the top right-hand corner of the collection form (as shown above). If using a format in which that is not applicable, place the information before the collection of information. The burden statement and Privacy Act Statement should be listed at the end of the information collection.

Passenger Notification and Acknowledgement for CDC Order:

The U.S. Centers for Disease Control and Prevention (CDC) requires all passengers boarding an international flight to the United States to provide their full name, address in the US, primary phone number, secondary phone number, and email address within 72 hours before their flight departs. The information may be used by U.S. public health officials to follow up with passengers who may have been exposed to a contagious disease before or during travel. As a U.S. Government requirement, passengers must provide complete and accurate contact information. Failure to do so may subject the passenger or their authorized representative to criminal penalties under, inter alia, 42 U.S.C. 271 and 42 CFR 71.2, in conjunction with 18 U.S.C. 3559 and 3571. Willfully giving false or misleading information to the government may result in criminal penalties under, inter alia, 18 U.S.C. 1001.

Each passenger is required to complete the following statement:

[ ] I understand that the U.S. Government requires me to provide my contact information and that

failure to provide complete and accurate information may result in criminal penalties.

[ ] I confirm the information I have provided is complete and accurate.

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

Privacy Act Statement

The United States Centers for Disease Control and Prevention (CDC) requires airlines and other aircraft operators to collect this information pursuant to 42 C.F.R. §§ 71.4, 71.20, 71.31 and 71.32, as authorized by 42 U.S.C. §§ 264 and 268. Providing this information is mandatory for all passengers arriving by aircraft into the United States. Passengers are required to provide complete and accurate information, and failure to do so may lead to other consequences, including criminal penalties. CDC will use this information to help prevent the introduction, transmission, and spread of communicable diseases by performing contact tracing investigations and notifying exposed individuals and public health authorities; and for health education, treatment, prophylaxis, or other appropriate public health interventions, including the implementation of travel restrictions.

The Privacy Act of 1974, 5 U.S.C. § 552a, and the associated CDC System of Records No. 09-20-0171, Quarantine- and Traveler Related Activities, Including Records for Contact Tracing Investigation and Notification under 42 C.F.R. Parts 70 and 71. See 72 Fed. Reg. 70867 (Dec. 13, 2007), as amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018) [hyperlink] govern the collection and use of this information. CDC will only disclose information from the system outside the CDC and the U.S. Department of Health and Human Services as the Privacy Act permits, including in accordance with the routine uses published for this system in the Federal Register, and as authorized by law. You may contact the system manager at dgmqpolicyoffice@cdc.gov or by mailing Policy Office, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H16-4, Atlanta, GA 30329, if you have questions about CDC’s use of your data.