Office of the Chief Health Medical Officer, Jaipur –II

Mini Swasthya Bhawan, Sethi Colony, Jaipur

Phone No: - 0141- 2605858, E Mail- idspjp2@gmail.com

Declaration by tourists / persons who has visited abroad

I ................................................................. /................................... (Name & Faher’s Name),

Age......... Sex............. resident of ...........................................................................................
................................................................................... (Complete Address, with PIN / Postal Code),
hereby declare that –
1. I am travelling form .................................... (country name) on ...................... (Date)
2. I have arrived India on ........................................................................................(Airport
name and city) on .................... (date) .
3. I have / haven’t been screened at airport for Corona/ILI
4. I have/ haven’t submitted self declaration form at airport at time of arrival.
5. My itenarary for travel in India in chronological / date wise sequences is .......................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
6. My itenarary for travel in Rajasthan in chronological / date wise sequences is ...............
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
7. My last 02 month travel history is
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
8. I have / do not have symptoms like :-
Fever - Yes/No (If yes, Date of onset ......................)
Cough - Yes/No (If yes, Date of onset ......................)
Sore throat - Yes/No (If yes, Date of onset ......................)
Cold - Yes/No (If yes, Date of onset ......................)
Difficulty in breathing - Yes/No (If yes, Date of onset ......................)
Others.................................................... (If yes, Date of onset ......................)

Sign with Name of Guest / Tourist

Sign with Name of Hotel Staff who received declaration form along with hotel seal
 Office of the Chief Health Medical Officer, Jaipur –II
Mini Swasthya Bhawan, Sethi Colony, Jaipur
Phone No: - 0141- 2605858, E Mail- idspjp2@gmail.com

Declaration by Hotels

I ................................................................. (Name) competent authority of Hotel/ Resort/ Guest

house/ Holiday Home.......................................................................... (Name), Jaipur hereby
declare that :
1. Masks are available in sufficient quantity and are being provided to tourists and hotel
staff.
2. All tourists have been requested to avoid visit to dense populated and public places.
3. Following are the names and contact number of hotel staff who came in contact with
tourists(who are foreign nationals or had visited abroad in last 2 months)
4. Following is the line list of the active contacts (people who were in close contact with the
suspect tourist. (Additional sheet can be enclosed in given format if needed),

Name / Father’s Name, Age Sex Address Mobile No

5. Following is the list of places in Jaipur/ out of Jaipur in Rajasthan where suspected tourist
had visited (Additional sheet can be enclosed in given format if needed).

Name / Father’s Name, Age Sex Address Mobile No

6. Copy of passport of foreign national or valid ID of Indian National is enclosed

Sign with Name of Hotel Staff

Along with hotel seal