Form approved
OMB Number: XXXX-XXXX
Expiration Date: XX/XX/XXXX
TGS Updated Digital Collection + Double Collection Questionnaire
Travel Information
What was your flight number and what country did that flight depart from? You can find these on your boarding pass. Look for a code starting with 2 letters followed by 1-4 numbers.
Airline Code text entry
Flight Number text entry
Flight Country of Origin dropdown
Did you travel on any connecting flights in order to get to the United States? (Single select)
Yes
No
What country did your travel itinerary to the United States originate from? (Optional)
Drop down options for countries excluding ‘United States’
List all countries you were in during the last 10 days. Select as many as you like. (Multiple select)
Drop down options
What state(s) are you traveling to in the United States? Select as many as you like. (Multiple
Select)
Drop down options
Do you live in the United States? (Single select)
Yes
No
How long have you been outside the country on this trip? (Single select)
1-3 days
4-7 days
8-14 days
15-30 days
1-6 months
7-12 months
More than 12 months
What is or was the main reason for your trip? (Single select)
Tourism/vacation
Business/occupational
Visiting friends/relatives
Migration
Student
Other (please specify)
Background Information
Why are you interested in participating today? Select as many as you like. (Multiple select)
I want a free at-home test to take later
It was recommended to me at the airport by testing staff
I want to help the CDC monitor disease entering the United States
I want to support public health work
I thought this was required
Other (Please specify)
What is your age? (Single select)
18-49 years old
50-64 years old
65+
Prefer not to answer
What sex were you assigned at birth, on your original birth certificate? (Single select)
Male
Female
I don’t know
Prefer not to answer
Which of the following would you say is your ethnicity? (Single select)
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Which of the following would you say is your race? Select as many as you like. (Multiple select)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
COVID-19 Information
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
Have you ever tested positive for COVID-19? (Single select)
Yes
No
I don’t know/Prefer not to answer
If yes, what was the approximate date of your most recent positive test? (Single select)
Month, Year
I don’t know/Prefer not to answer
Have you received at least one COVID-19 vaccine? (Single select)
Yes
No
I don’t know/Prefer not to answer
If yes, when did you receive your most recent vaccination? (Single select)
Month, Year
I don’t know/Prefer not to answer
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 D-74, 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 | 2024-08-01 |