Form NPS Form 10-685 NPS Form 10-685 DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS) CONCESS

NPS Form 10-685 (Rev. 01/2018)
National Park Service

DISEASE REPORTING AND SURVEILLANCE SYSTEM (DRSS)
CONCESSION/PARTNER EMPLOYEE ILLNESS REPORT

OMB Control No. 1024-0286
Expiration Date ##/##/####

PARK NAME
Park Address Line 1
Park Address Line 2
Telephone: (###) ###-#### Fax: [(###) ###-#### - optional]
Email: [Insert Email Address - Optional]
Website: [Insert Website- Optional]
THIS FORM IS ONLY AUTHORIZED FOR USE IN
YELLOWSTONE NATIONAL PARK, GLACIER NATIONAL PARK,
GRAND TETON NATIONAL PARK, GRAND CANYON, AND YOSEMITE NATIONAL PARK

Thank you for agreeing to help the National Park Service (NPS) Office of Public Health
Your input is very important to the NPS Office of Public Health. These questions seek to identify the number of sick
employees and where they work, but we ask that you not provide any personally identifiable information in any of your
submissions (e.g., employee names). The information will be used to help both the [concession company] and the NPS
Office of Public Health, working in collaboration, to detect high-risk disease transmission events, monitor and track their
spread, implement appropriate public health response efforts, and assess the effects of these response efforts in order
to protect people in the National Parks as efficiently and effectively as possible. The questions should take less than 10
minutes to complete. All of your answers are voluntary. If you have any further questions about this survey or its use,
please feel free to reach out to the NPS Office of Public Health at publichealthprogram@nps.gov.

NEW
Contact Information of person completing the form
Name ______________________________________________
Email Address -______________________________________
1. What is your NPS Park Unit?
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Yellowstone National Park
Glacier National Park
Grand Teton National Park
Yellowstone National Park
Grand Canyon National Park

2. What was the date the employee reported the illness?
Click here to enter a date.
3. What was the date of the employee’s symptom onset?
Click here to enter a date.
4. What was the approximate time of the employee’s symptom onset?
□
□

The time was: Click here to enter text.
Time unknown

Page 1 of 4

NPS Form 10-685 (Rev. 01/2018)
National Park Service

OMB Control No. 1024-0286
Expiration Date ##/##/####

5. During the employee’s illness, did they experience any of the following symptoms listed below?
Please mark all that apply.
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Nausea
Vomiting
Abdominal Pain/Cramps
Diarrhea
Bloody Diarrhea
Fever
Shortness of breath
Rash
Pink eye or eye irritation
Unsure
Other: Click here to enter text.

6. Which company/organization does the sick employee work for? (Please select one response.)
□
□
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[Company A]
[Company B]
[Company C]

7. What is the sick employee’s employment location? (Please select one response.)
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[Location A]
[Location B]
[Location C]

8. What is the sick employee’s facility of employment? (Please select one response.)
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[Facility A]
[Facility B]
[Facility C]

9. What type of position does the sick employee have? (Please select one response.)
□
□
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[Position A]
[Position B]
[Position C]
Other (Please specific.) Click here to enter text.

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[Residence A]
[Residence B]
[Residence C]
Other (Please specific.) Click here to enter text.

10. Which residence does the sick employee live in? (Please select one response.)

11. Did this employee visit a health care provider?
□ Yes
□ No
□ Unsure

NPS Form 10-685 (Rev. 01/2018)
National Park Service

OMB Control No. 1024-0286
Expiration Date ##/##/####

12. [NEW] If the healthcare provider diagnosed the employee with a specific illness, what illness was
diagnosed? If no illness was diagnosed, type N/A.

13. As a result of this sickness, has this employee been placed on sick leave?
□ Yes
□ No
□ Unsure
14. If the employee has been placed on sick leave, for how long?
□
□

Click here to enter text.
Not applicable or unsure

15. [NEW] Do you have any other comments? Please be specific and be sure NOT to include any
personally identifying information about employees (e.g., do not include employees' names).

Thank you for completing this survey.
If you have any further questions please feel free to reach out to the NPS Office of Public Health at
publichealthprogram@nps.gov.

NPS Form 10-685 (Rev. 01/2018)
National Park Service

OMB Control No. 1024-0286
Expiration Date ##/##/####

PRIVACY ACT STATEMENT
Authority: The NPS Organic Act of 1916 (Organic Act) (54 U.S.C. §100101 et seq.) and the Public Health Service Act (42
U.S. Code Chapter 6A) gives the NPS broad authority to regulate the use of the park areas under its jurisdiction.
Purpose: The NPS OPH uses the “Disease Reporting and Surveillance System” (DRSS) to enhance surveillance,
estimate the burden of illnesses, and improve knowledge about where these outbreaks were occurring within the park.
DRSS documents concessionaire employees’ illnesses as well as illnesses occurring on tour buses through an on-line,
real-time reporting system that allows concession management, the park, and the OPH to detect an increase in illness
reports that may suggest the beginning of an outbreak.
Disclosure: This collection will collect names and email addresses that will be used to follow up with respondents as
needed. While no particular statements offering assurances of confidentiality are provided to the individual on the
certification form, the NPS manages the forms in accordance with procedures established in the National Park Service
System of Record INTERIOR/NPS-10 - Central Files — (86 FR 50156 September 7, 2021).
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the National Park Service uses this form to collect
information on the symptoms, duration, and location of illness, public health workers are able to work rapidly and
appropriately to address the incidents. Your response is voluntary, but failure to complete this form will result in exclusion
from participation in the YCC Program. According to the Paperwork Reduction Act of 1995, 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. OMB has approved this collection of information and assigned Control No. 1024-0286.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 10 minutes, including time for reviewing
instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the
burden estimate or any other aspect of the form to the Departmental Information Clearance Officer, National Park Service,
12201 Sunrise Valley Drive, (MS -242) Reston, VA 20191, Please do not send your completed form to this address.