Medical Declaration Form

Medical Declaration Form
Each traveler coming from a country for which the United States has applied entry restrictions due to COVID-19 needs to fill out this form.
The collection of this information is being collected as part of the public health response to the coronavirus disease 2019 (COVID-19) pandemic. The information collected will be used by U.S. public health authorities and other international, federal, state, or local agencies for public health purposes.
Name
First NameLast Name
Email
example@example.com
Birthdate
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Airport / Terminal of Origin
Date of Arrival
MonthDayYear
Date
Airline
Flight Number
Seat Number
Destination Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

In the past 24 hours, have you had any of the following:

Rows	Yes	No
Fever (100.4° F / 38° C or higher), felt feverish, or had chills
New or worsening persistent (frequent or continuing) cough
New or worsening difficulty breathing
Loss of Taste
Loss of Smell
Diarrhea

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