Gastrointestinal illness report form

Step 1 of 2 - Enter information

International Maritime Organization (IMO) number (between 7 to 8 digits)

Cruise line name

Vessel name

Captain's name

Captain's email address (user@domain.com)

Ship phone number (between 10 and 15 digits)

Ship fax number (between 10 and 15 digits)

Voyage number

Report type

Previous port

Next Canadian port

(Other) Next Canadian port

Next Canadian port arrival date (in Coordinated Universal Time (UTC)) (YYYY-MM-DD)

Next Canadian port arrival time (in Coordinated Universal Time (UTC)) (hh:mm AM/PM)

Embarkation date (YYYY-MM-DD)

Disembarkation date (YYYY-MM-DD)

Total number of passengers on board

Number of passenger gastrointestinal cases

Total number of crew on board

Number of crew gastrointestinal cases

Medical contact name

Medical contact title

Medical contact email address (user@domain.com)

Medical contact phone number (between 10 and 15 digits)

Submitter is medical contact?

NoYes

Your name

Your title

Your email address (user@domain.com)

Your phone number (between 10 and 15 digits)

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