| Case ID# |
Case Initials (e.g., Jane Doe = JD) |
Traveler type (crew or passenger) |
Date of Birth (MM/DD/YYYY) |
Country of Residence |
Embarkation Date (MM/DD/YYYY) |
Disembarkation Date (MM/DD/YYYY) |
Is person fully vaccinated? |
Vax Dose #1 Date (MM/DD/YYYY) |
Vax Dose #1 Manufacturer |
Vax Dose #2 Date (MM/DD/YYYY) |
Vax Dose #2 Manufacturer |
Vax Booster Date (MM/DD/YYYY) |
Vax Booster Manufacturer |
Is person symptomatic? |
Date person became symptomatic (MM/DD/YYYY) |
Does person have risk factors for severe illness? |
Sought medical attention (i.e., medical center, in-cabin)? |
If yes, date seen by medical provider (MM/DD/YYYY) |
Identified as a close contact* to a another case? |
If yes (and not fully vaccinated), date began quarantine (MM/DD/YYYY) |
Type of testing received (#1) |
Date specimen collected (#1) (MM/DD/YYYY) |
Testing result (#1) |
Reason for conducting testing (#1) |
Type of testing received (#2) |
Date specimen collected (#2) (MM/DD/YYYY) |
Testing result (#2) |
Reason for conducting testing (#2) |
Type of testing received (#3) |
Date specimen collected (#3) (MM/DD/YYYY) |
Testing result (#3) |
Reason for conducting testing (#3) |
Type of testing received (#4) |
Date specimen collected (#4) (MM/DD/YYYY) |
Testing result (#4) |
Reason for conducting testing (#4) |
Cabin # (at time of diagnosis) |
Any cabin mates (at time of diagnosis)? |
Any shared bathroom (at time of diagnosis)? |
Ship department (i.e., galley/dining room, salon, cook, security, etc.) |
Job location(s) |
Participated in shore leave/trips/excursions w/in past 14 days? |
If yes, which seaport(s)? |
Date(s) of excursions (MM/DD/YYYY) |
Cabin # |
Any cabin mates (at time of diagnosis)? |
Any cabin mates also cases? |
If Yes, initials of cabin mate (e.g., John Doe = JD) |
Initials of travel companion case(s) (e.g., John Doe = JD) |
If Yes, Initials of travel companion case(s) (e.g., John Doe = JD) |
Participated in voyage-related shore trips/excursions w/in past 14 days? |
If yes, which seaport(s)? |
Date(s) of excursions (MM/DD/YYYY) |
# of crew close contacts* identified |
# of passenger close contacts* identified |