Traveler Health Screening Declaration
Personal Information
Full Name
Passport/ID Number
Nationality
Date of Birth
Flight / Vessel No.
Seat No.
Contact Information During Stay
Address
Phone Number
Health Declaration
In the past 14 days, have you experienced any of the following symptoms?
Fever
Cough
Sore Throat
Difficulty Breathing
Other (specify below)
Have you had close contact with any confirmed infectious disease case in the past 14 days?
Yes
No
List countries/regions visited in last 14 days
Declaration
I hereby declare the above information is true and complete.
Date
Signature