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Ipc Health Declaration Form

This document is a health declaration form that collects personal information and health details from travelers. It asks for a traveler's name, date of birth, flight details, and whether they have been in contact with COVID-19 cases or have symptoms. It also requests a signature and date to verify the truthfulness of the responses.

Uploaded by

tsubaki mahiro
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We take content rights seriously. If you suspect this is your content, claim it here.
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114 views1 page

Ipc Health Declaration Form

This document is a health declaration form that collects personal information and health details from travelers. It asks for a traveler's name, date of birth, flight details, and whether they have been in contact with COVID-19 cases or have symptoms. It also requests a signature and date to verify the truthfulness of the responses.

Uploaded by

tsubaki mahiro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

HEALTH DECLARATION FORM

You must attach this declaration with other IPC requirements.

Personal Information
Name:
Date of Birth:
Date of Flight: (Arrival and Departure)
Flight Number: (Arrival and Departure)

YES NO
1 Have you been in close contact with a confirmed case/s of COVID-19?
2 Have you been in close contact with persons in quarantine/probable
case of COVID-19
3 Do you have the following signs and symptoms within the YES NO
last 14 days?
Fever
Cough
Runny Nose
Sore Throat
Shortness of breath
4 Have you undergone COVID-19 detection testing? If yes, kindly attach
the result.
5 Are you fully vaccinated? If yes, kindly attach the certification.

Completed truthfully on: __/__/____ (mm/dd/yyyy) Time: __:__

Signature over printed name

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