Instructions: Please complete the following questions to reflect your experience as accurately as possible and to answer factual questions to the best of your knowledge.

Some fields are optional (required fields to submit a report are questions 1, 2, 10). All information submitted will be kept strictly confidential.
1. Are you a guest?
2. In which country is the facility that you were staying when you began to feel unwell in?
3. Which type of facility is this?
Facility Name
Please select the facility name from the list above (if 'Other', please specify in the Additional Notes field at the end of the page)
4. What is your age?
Age Group
5. What is your gender?
6. What is your home country?
7. To which countries have you traveled to recently? (within the past 4 weeks)
8. On what date are you making this report?
9. On what date did your symptoms first begin?
(if unsure please estimate)
10. What symptoms did you experience?
Diarrhea?
Vomiting and/or Nausea?
Fever?
Cough/Sore Throat/Difficulty Breathing?
Bleeding (Gums, Stool)?
Headache?
Joint or Muscle Pains?
Eye Pain/Headache/Facial Pain?
Generalized Rash?
Blurred Vision/Convulsions?
11. Are there any additional notes about your symptoms, where you sought care, potential places/sources of exposure, or any other details about your illness that you would like to share?
For further information regarding this form or the information collected, please contact:
Dr. Lisa Indar/ Mr. Jonathan Edwin
indarlis@carpha.org
+1-868-622-4261