Intake form

Health declaration for travellers

Answer the following questions truthfully and keep your completed health declaration form close at hand while travelling. You will
need it throughout the course of your journey and when you reach your final destination. You must show this form when boarding.
In addition, airport staff and the designated health authorities at the airport may ask to see it. This data is collected as part of the
public health measures taken in response to the COVID-19 pandemic and, pursuant to Dutch legislation, may be processed by the
health authorities. All travellers aged 12 and older are required to complete this form.

1 Please select ‘yes’ or ‘no’ in response to the following questions.

1.1 Have you (or the person for whom you are completing this form) been diagnosed as currently having a lung infection
or coronavirus infection (COVID-19), or is there suspicion that you might have either of these? n Yes n N0

1.2 Should you (or the person for whom you are completing this form) currently be in quarantine because you were in
contact with someone infected with coronavirus, whether a close contact or someone you were informed about through
the CoronaMelder app, and you are not fully vaccinated? n n Yes n N0

1.3 Have you (or the person for whom you are completing this form) experienced any of the following symptoms in the past 24 hours?
In case you have tested negative for COVID-19 after the development of the symptoms, this question can be answered with ‘no’

Cold symptoms (such as congestion, runny nose, sneezing or sore throat) n

n Yes n No

Cough n
n Yes n No

Shortness of breath n
n Yes n No

Raised temperature or fever n

n Yes n No

Sudden loss of smell and/or taste (without congestion) n

n Yes n No

If you answered ‘yes’ to any of the above questions, under the transport agreement you are not permitted to board.

2 Passenger information
2.1 Flight number

2.2 Surname and first and middle initial(s)

2.3 Date of birth (ddmmyyyy)

3 Signature
Completed truthfully on

3.1 Date (ddmmyyyy)

Signature

Signature

VWS_DCo_2020.11