0920-1318 Air Travel or Death Investigation orTraveler Follow-up F

Form Approved
OMB Control No.0920-1318
Exp 6/30/2022

Air Travel Illness or Death Investigation or Traveler Follow Up Form
U.S. Centers for Disease Control and Prevention

Section 1. Quarantine station notification
QARS Unique ID #:

CDC User ID :

Person notifying CDC:

State:

Phone:

Agency notifying CDC:
Type of notification:

Port of Entry:

□ Illness

□ Death

Email:

Date of initial
Time of initial notification
_____/_____/______
mm dd
yyyy
notification to CDC:
to CDC (24 hrs):
□ Traveler Follow up
When was the Quarantine Station notified?:

_____ : _____
hh : mm

□ Before any travel was initiated
□ During travel
Where was the traveler when the QS was notified?:
□ Prior to boarding conveyance
□ In U.S. jurisdiction / Inbound
□ While traveler was on a conveyance
□ In foreign jurisdiction / Outbound
□ After disembarking conveyance
□ Unknown
□ After travel completed (reached final destination for that leg of trip)
□ Unknown
NOTE: If ill/deceased person also traveled via □ Land and/or □ Maritime conveyances, please fill out the appropriate form and attach
Type of traveler:

□ Passenger

□ Crew

Section 2. Pertinent medical history of ill or deceased person
Relevant history: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:
Traveler has taken:
□ Antibiotic/antiviral/antiparasitic(s) in the past week; list with date(s) started: _________________________________________________
□ Fever-reducing medications (e.g. acetaminophen, ibuprofen) in the past 12 hrs; list with time of last dose: _________________________
□ Other medications (related to current symptoms/illness); list with date(s) started: ______________________________________________

Village/City/State

Province/Country

Relevant Exposures in the Past 3 Weeks:
Arrival
Exposure to ill persons?
Exposure to animals?
Date
□ No
□ No
□Yes, ____________
□Yes, ____________

Other exposures (chemical, drug
ingestion, etc)?
□ No
□Yes, ____________

Relevant Vaccinations
Traveler up to date on relevant vaccinations □ Yes □ No □ Vaccinated with NON-WHO or NON-FDA approved vaccine □ Unknown
Vaccine Type: ________; Dose 1 date: __/__/__ Manufacturer _____ ; Dose 2 Date: __/__/__ Manufacturer _____; Dose 3 date: __/__/__ Manufacturer _____
Information Source: □ Vaccine card □ Medical Record □ Vaccine Digital Passport □ IATA Travel Pass □ State Records □ Traveler Recollection □ Other
Specify:_____

Relevant Testing
Disease tested: _____ Testing Method: _______ Specimen Source: ________ Specimen Collection Date: _______ Date Lab Test Available: _______ Interpretations
of Results.
Comments:

Signs, Symptoms, and Conditions (check all that apply):
□ FEVER (≥100F or ≥38°C) OR
feeling feverish/having chills in past 72 hrs
Onset date: _____/_____/______
Current temperature: ______0 F/C
□ Rash
Onset date: _____/_____/______
Appearance:
□ Maculopapular □ Vesicular/Pustular
□ Purpuric/Petechial □ Scabbed □ Other

□ Difficulty breathing/shortness of breath
Onset date: _____/_____/_______
□ Swollen glands
Onset date: _____/_____/_______
Location: □ Head/neck □ Armpit □ Groin
□ Vomiting
Onset date: _____/_____/_______
Number of times in past 24 hrs? ______

□ Decreased consciousness
Onset date: _____/_____/_______
□ Recent onset of focal weakness
and/or paralysis
Onset date: _____/_____/_______
□ Unusual bleeding
Onset date: _____/_____/_______
□ Obviously unwell

□ Conjunctivitis/eye redness
Onset date: _____/_____/_______
□ Coryza/runny nose
Onset date: _____/_____/_______
□ Persistent cough

□ Diarrhea
Onset date: _____/_____/_______
Number of times in past 24 hrs?: ______
□ Jaundice
Onset date: _____/_____/_______

□ Injury
□ Chronic condition
□ Asymptomatic

□ Headache
Onset date: _____/_____/_______

Onset date: _____/_____/______
□ With blood □ Without blood

□ Other: __________________________

□ Loss of Sense of Taste or Smell
Onset date: _____/_____/_______
□ Sore throat
Onset date: _____/_____/_______

Deceased Persons:

Date of Death:

Time of death (24 hours):

______/______/__________
mm

dd

_____:_____
hh : mm

yyyy

Presumptive Diagnosis or Cause of Death:
Does anyone else on the plane have similar illness?: □ No □ Yes* □ Unknown
*If yes, please fill in a new form for each person in the cluster

Response or Info Only:
□ Requires DGMQ Response & Follow-up (Proceed to next section)
□ Information Report Only / No Follow-up needed (STOP HERE)

Section 3. General information about the ill or deceased person or traveler who may need follow up
Last/paternal name:

First/given name:

Middle name:
Gender:

□ Male
□ Female

Country of birth:

Maternal name (if applicable):
Date of
birth:

_____/_____/______
mm

dd

Passport country/citizenship:

Other names used (e.g., former name, alias):

Age (if date of birth unknown):

□ Days
□ Months

yyyy

□ Weeks
□ Years

Type of ID:

ID document #:

Alien #:

For deceased persons, go to Section 5. Otherwise, continue below.
Home address:
City:

State/province:

Zip/postal code:

If visiting, total duration of
U.S. stay:

□ Days
□ Weeks

Country of residence:

Home phone:

Contact in U.S. - Address/hotel:

□ Months
□ Years

E-mail:

Contact in U.S. - City:

□ Same as home address above
Contact in U.S. - State/territory:

Contact phone in U.S.:

Emergency contact name:

Emergency contact relationship:

□ Cell
# of days reachable at contact phone: _____
Emergency contact phone:

Section 4. Flight information
Type*

Domestic
or Int’l?

Airline

Flight #

Departure Airport
Code

Departure
Date

Arrival Airport
Code

Arrival
Date

Seat #

Flight
Duration

CURRENT FLIGHT:
PREVIOUS AND/OR UPCOMING FLIGHTS:

*C/FB = Commercial, foreign-based carrier

C/US = Commercial, U.S.-based carrier

P = Private

CH = Charter

CG = Cargo

MD = Medevac RP = Repatriation O = Other

Section 5: Public Health Entry Requirements
Entry Requirement:
Did traveler meet the US Global Public Health Entry Requirements: □ Yes □ No □ N/A Please specify:
Comments:

Section 6: Disposition of traveler/ill/deceased person
Ill person was (check all that apply):
□ Released to continue travel
□ Advised to seek medical care
□ EMS responded
□ Recommended to not travel
□ Transported to hospital (□ MOA activated): ______________________
□ Transported to non-hospital location: ____________________________
□ Detained by law enforcement, location: __________________________

Deceased Person:
Body released to medical examiner?: □ Yes □ No
Medical examiner telephone: ___________________
City/State/Country: __________________________

□ Denied entry by law enforcement
□ Information transmitted to state and/or local health departments
□ Other: ____________________________________________________
Public reporting burden of this collection of information is estimated to average 15 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 0920-1318