Explanation of Key Fields in Maritime Conveyance Illness or Death Investigation Form
This document provides many explanations for fields on the form but does not cover all fields. For further questions about anything related to the form or maritime reporting, please e-mail MaritimeAdmin@cdc.gov. Note: red text and an asterisk symbol (*) denotes required fields on the form.
Please do not submit any forms through e-mail that include personally identifiable information (PII). PII is any information that can be used alone or in combination to identify an individual. This includes names, addresses, phone numbers, dates (birth, hospital admission, travel), identifying numbers (passport, social security, driver’s license, alien), medical records, photographs, and for rare diseases, geographic locations.
Section 1: Port Health Station Notification
- E-mail: (*) Insert your e-mail or the e-mail of the person who is responsible for follow-up.
- Type of notification: (*) Illness/ Death
Check the appropriate type of notification.
- Type of traveler: (*) Crew/Passenger
Check crew or passenger for this specific conveyance. One form is filled out for each person who is ill or deceased.
- Conveyance type: (*) Cruise Ship/Cargo/Other
If Other is checked, enter the type of vessel in the text box.
Section 2: Vessel Information
- Vessel company/Name: (*) Select company/vessel name from the dropdown list.
If name is not in the dropdown, select Other. Enter name in the text box provided.
- Voyage Number: Enter the voyage number. This is the vessel’s numeric identification assigned per trip.
- Number on board:
- Crew: Enter the total number of crew members on the vessel.
- Passengers: Enter the total number of passengers on the vessel.
- Country of departure: (*) Select the country where the vessel last departed before the illness or death occurred.
- Departure date (*) & time (24 hr): Enter the date in this format (mm/dd/yyyy) (*) and the time (hh:mm, in 24-hour format). Use the date and time for the Country of departure.
- Arrival date & time (24 hr) at final port: Enter the date in this format (mm/dd/yyyy) and the time (hh:mm, in 24-hour format) the vessel arrived or is expected to arrive at the final destination of the voyage.
- Next U.S. Port: (*) Enter in the text box the next U.S. port where the vessel will be stopping.
Then select the state where the port is located from the dropdown menu to the right.
- Arrival date (*) & time (24 hr) at next U.S. port: Enter the expected date in this format (mm/dd/yyyy) (*) and time (hh:mm, in 24-hour format).
- Person information while onboard vessel:
- If crew member has contact with passengers, describe extent/frequency: Indicate the amount of time per day that the ill or deceased crew member has/had contact with any passengers. For example, 3 hours per day, 4 days per week.
- Embarkation port: (*) Enter the port where the traveler boarded the vessel.
- Embarkation date: (*) Enter the date in this format (mm/dd/yyyy) when the traveler boarded the vessel.
- Disembarkation port: Enter the port where the traveler permanently left the vessel. If the traveler has not permanently left the vessel, leave blank.
- Disembarkation date: Enter the date in this format (mm/dd/yyyy) when the traveler permanently left the vessel. If the traveler has not permanently left the vessel, leave blank.
Section 3: Medical History
Include relevant medical history of ill or deceased person: present illness, other medical problems, vaccinations, overseas physician diagnosis, etc.:
Use the following elements to characterize the specific complaint or concern: Date or time of onset; modifying factors (things that make symptoms better or worse); quality, severity, location, and timing of symptoms;
- Example: “Headache started this morning; moving his neck makes it worse; throbbing, constant pain over his entire head; has a history of migraine headaches, but this feels different and is the worst he has ever had.”
- Signs, symptoms, and conditions: (*) Select all that are appropriate, but at least one. Please see the Definitions of Signs, Symptoms, and Conditions of Ill Travelers for more details.
- Deceased Persons:
- Date of death: Enter the date of death in this format (mm/dd/yyyy); if exact date is unknown, enter best estimate.
- Time of death (24 hr): Enter the time of death in this format (hh:mm, 24-hour format).
- Presumptive diagnosis/cause of death: (*) Select the presumptive diagnosis from the dropdown menu. (If not in the dropdown menu, select Other and enter presumptive diagnosis in the text box provided.) Choose the suspected illness or the illness you ruled out when the traveler first became ill or died.
- Example: The traveler has a fever and muscle aches, and you want to rule out dengue fever. Select Dengue Fever and not Fever from the dropdown options.
The National Notifiable Diseases Surveillance System website provides more information on the clinical descriptions, laboratory diagnostic criteria, and case classifications for infectious diseases nationally reportable in the United States.
Section 4: Evaluation of ill or deceased person
- Traveler has taken (include those given on board): List only medications pertinent to the traveler’s current symptoms or illness. Enter date in this format: mm/dd/yyyy.
- Example: Traveler with rash began taking amoxicillin on 03/22/2013.
- Arrival Date: Be sure to enter any dates in this format: mm/dd/yyyy.
- Exposure to ill person, animals, or other: For each column, check yes for any known exposures. Enter details in the text box to the right.
- Number of potentially exposed contacts (e.g., cabin, work, bathroom mates): Contacts are the people who spent a lot of time with the ill or deceased person. These are likely to be the people who shared a cabin, worked closely together, or routinely shared a bathroom.
- Are any traveling companions ill? If yes, fill out this form for each ill traveling companion.
- Seen in ship infirmary?
- Yes, date of first visit: Enter the date using this format (mm/dd/yyyy).
- Ill/deceased person isolated after illness onset?
- Yes, date isolated: Enter the date using this format (mm/dd/yyyy).
- Seen in health-care facility ashore?
- Select Yes if traveler was admitted to an inpatient ward at the hospital, and enter name of hospital.
- Select No if traveler was seen only in an emergency department or outpatient clinic and was discharged.
- Discharge/final diagnosis/cause of death (determined by medical examiner or other):
- If Other is selected, enter the diagnosis in the text box to the right.
Section 5: General information about ill or deceased person
- Date of Birth: Enter date of birth in this format (mm/dd/yyyy).
- If visiting, total duration of U.S. stay: If the traveler is not a U.S. resident, enter the length of time the traveler plans to be in the United States.
- Contact in U.S. – Address / hotel: If the traveler is not a U.S. resident, enter a temporary address (e.g., hotel, friend or relative’s home) and phone number where the traveler can be reached in the United States.
- Comments: Use this space to provide additional information or expand on areas in the form where there was not enough room.