Form Approved
OMB Number: 0920-1406
Expiration Date: 06/30/2026
Mass Gathering
Have you attended any events in Australia/New Zealand associated with the 2023 FIFA Women’s World Cup?
Yes
No
Prefer not to answer
Have you attended any events in France associated with the 2024 Olympic Games?
Yes
No
Prefer not to answer
Did you perform Hajj in Saudi Arabia?
Yes
No
Prefer not to answer
Did you perform Umrah in Saudi Arabia?
Yes
No
Prefer not to answer
Did you attend any other large events (>10,000 people) during your travel?
Yes
No
Prefer not to answer
If YES, what was the event and the country?
Other
Did you take a COVID-19 test in the 2 days before your flight? (Single select)
Yes, antigen test
Yes, PCR or other molecular test
Yes, not sure what type
No
Prefer not to answer
Are you currently experiencing, or have you experienced ____ symptom in the last 10 days?
Yes
No
Prefer not to answer
Have you received a flu vaccine in the last 12 months?
Yes
No
Don’t Know
If yes, what was the date of your last flu vaccine?
Month, Year
Don’t remember
Have you ever received an RSV vaccine?
Yes
No
Don’t Know
If yes, what was the date of your last RSV vaccine?
Month, Year
Don’t remember
Public reporting burden of this collection of information is estimated to average 5 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 H 21-8, Atlanta, Georgia 30333; ATTN: PRA XXXX-XXXX
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Smith, Teresa (CDC/DDID/NCEZID/DGMQ) |
File Modified | 0000-00-00 |
File Created | 2023-08-18 |