Annex : Influenza-like illness log (recommended log) This log is designed for possible use by passenger shipping companies and ships with no designated recording and reporting systems for ILI. Ship name: Voyage Dates From: __/__/__ To: __/__/__ Page: of number: Total number of Total number of ill passengers on passengers: Total number of crew on board: Total number of ill crew: board: Year Reportable Past case Specify Date breath Test (Y/N) (Case Under of hired Pos. throat (Y/N) Flu Investigation CXR During Onset Fever Cough Malaise Coryza Myalgia Illness illness / Vaccine Headache Name Date on Date off Underlying where case Identifier** Shore No. Visit date /Crew /Confirmed) Rapid Complications (Last, ship ship Flu Medications (mm/dd/yy) M/F Shortness Age Vaccine First) (mm/dd/yy) (mm/dd/yy) Seat Pax/Crew Cabin Number Flu country Meal Pax Unique CREW: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Date Time °C/F Y/N/U ND/P/N* ND/P/N* (mm/dd/yy) *ND = test Not Done, PPositive test result or +CXR infiltrates, NNegative test result or +CXR infiltrates, UUnknown **This number rather than the name may be reported to competent authority to protect patient confidentiality
Annex : Influenza-like illness log (recommended log) This log is designed for possible use by passenger shipping companies and ships with no designated recording and reporting systems for ILI. Ship name: Voyage number: Dates From: __/__/__ To: __/__/__ Page: of Total number of passengers on board: Total number of ill passengers: Total number of crew on board: Total number of ill crew: Visit date (mm/dd/yy) Name (Last, First) Unique Number Identifier** Date on ship (mm/dd/yy) Date off ship (mm/dd/yy) Age M/F Pax/Crew Cabin No. CREW: country where hired Pax Meal Seat /Crew Pos. Illness Onset Cough Malaise Fever Shore throat Shortness of breath Headache Coryza Myalgia Rapid Flu Test CXR Flu Vaccine During Past Year Flu Vaccine Date Medications (Y/N) case (Y/N) Reportable case Specify (Case Under Investigation / /Confirmed) Underlying illness Complications Date Time Y/N Y/N Y/N °C/F Y/N Y/N Y/N Y/N Y/N ND/P/N* ND/P/N* Y/N/U (mm/dd/yy) *ND = test Not Done, PPositive test result or +CXR infiltrates, NNegative test result or +CXR infiltrates, UUnknown **This number rather than the name may be reported to competent authority to protect patient confidentiality