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Run: Cruise Ship Port Health Authority Illness Notification Form

A pre-arrival illness notification form for cruise ships to report passenger and crew illness counts, symptoms, care status, and response actions to port hea...

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Submission Notice

Purpose of submission

I confirm this report contains only minimum-necessary health information for public health notification and may be shared with the relevant port health authority. (required)

Yes No N/A

Submitter name (required)

Submitter role (required)

Submitter email (required)

Voyage and Vessel Details

Vessel name (required)

Voyage number or sailing identifier

Next port of call (required)

Estimated arrival date and time (required)

Arrival time zone (required)

Illness Summary

Date of report (required)

Total passengers onboard (required)

Total crew onboard (required)

Number of ill passengers (required)

Number of ill crew (required)

Primary symptom categories (required)

Symptom description (required)

Describe the main symptoms observed, onset pattern, and whether cases appear linked. Do not include unnecessary personal identifiers.

Medical Care and Isolation

Number of cases currently under medical care (required)

Number of cases currently isolated (required)

Location of medical care

Any cases required hospitalization ashore? (required)

Hospitalization details

Ship Response Actions

Response actions taken (required)

Additional response details

Include timing, scope, and any operational impacts relevant to the public health response.

Current risk assessment (required)

Public Health Follow-up

Preferred contact method (required)

Follow-up contact number

Additional notes

Use this field for any other information relevant to the port health authority review.

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Email (required)

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