In support of public health authorities, this form intends to gather relevant health information of arriving passengers relating to its status, especially with regard to COVID-19. This form must be filled by an adult representing the traveling group.

Notwithstanding the completion of this form, passengers may further be subjected to additional health screening protocols and procedures by the Public Health Authority.

Rest assured that the collection of personal data is compliant to the stringent requisites of law.

Name

First Name Last Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Date of Birth

Date

Home/Permanent Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Airport of Origin

Airport Destination

Names of Minors Below Legal Age*

Have you had fever in the past 14 days?

Yes No

Have you experienced any shortness of breath in the past 14 days?

Yes No

Did you have a cough in the past 14 days?

Yes No

Have you had a flu in the past 14 days?

Yes No

Have you had diarrhea or experienced nausea or vomiting in the past 14 days?

Yes No

Have you had a sudden loss of taste or smell in the past 14 days?

Yes No

Have you, your family members or persons travelling with you had any contact or have had been close contact with any person having suggestive symptoms of COVID-19?

Yes No

Have you been tested and became positive of COVID-19?

Yes No

I hereby declare, under the penalty of perjury, that the information I have provided above is true and correct, to the best of my knowledge and belief, and without any act of omission.

Signature

Clear

Date Signed

Date

Public Health Travel Declaration Form