Health Declaration Form

________ (month) ____ (day) _________ (year)

ID/Passport Contact
Name
No. No.:

Permanent/temporary
address in Shanghai

Departed from Hubei Province (□ Yes □ No) □ Train No.

If yes, indicate the date of departure. □ Flight No.
□ For people from Wuhan: □ Coach No. and Plate No.
□ For people from other cities of Hubei: □ Private Car Plate No.

Stopped along the way (□ Yes □ No) Names of

If yes, indicate the stops. people traveling
□ For people from Wuhan: together and
□ For people from other cities of Hubei: their contact
□ For people from places other than Hubei: numbers

Body temperature

My current health conditions:

□ cough □ expectoration □ runny nose □ sore throat □ chest pain/tightness
other symptom(s)
□ none of the above symptoms

I undertake that the information provided above is true and accurate, or I

shall be responsible for all consequences and legal liabilities arising therefrom.

Date: