HDF-IBHM-2020-V1

HEALTH DECLARATION FORM FOR PASSENGER AND CREW

1 Name of the passenger/Crew
2 Nationality
3 Date of Birth
4 Sex Male M Female F
5 Passport No.
6 Date of Arrival
7 Length of Stay
8 Place of residency (city/state/country)
9 Name of the Vessel
10 Cabin Number
11 Email Address
12 Contact Number
13 Address in Maldives
14 Purpose of stay (Tick)
Holiday/cruise Business Official Visit/Friends/Relatives
Transit Conference Employment Others
16 Have you travelled from or transited in a Yellow fever endemic country within the last 6 days Yes No
17 Have you been vaccinated for yellow fever 10 days prior to your arrival date Yes No
Note: If you have answered “Yes" to #16 and “No” to #17, then you will need a document that explains why you
18 have been exempted from getting vaccinated for yellow fever. If you do not have such a document, you may be put
under surveillance for a duration of 6 days.
19 Did you have any of the following symptoms within the last 14 days
Symptom Tick (YES/NO) Yes No If "Yes", date of onset
a Fever
b Cough
c Runny nose
d Breathing difficulty
e Sore throat
Note: If you have selected “Yes” for any of the Covid-19 symptoms,
1. You will be assessed by a doctor upon arrival and be tested for Covid-19 (for which you may have to pay for)
2. If you test positive you may be isolated in your destination resort or in a government isolation facility for a period
between 14 to 24 days. (You may have to pay for the additional days of your isolation in the resort or government facility).
You will be responsible for any additional fees (penalties) incurred as a result of your delay in departure.
20 Countries that you have travelled to or transited in the last 14 days
a Arrival date DD MM YYYY Departure date DD MM YYYY
b Arrival date DD MM YYYY Departure date DD MM YYYY
c Arrival date DD MM YYYY Departure date DD MM YYYY
d Arrival date DD MM YYYY Departure date DD MM YYYY
e Arrival date DD MM YYYY Departure date DD MM YYYY
Deliberately providing false information is a legal offense under the Public Health Act 7/2012 and violators will be
prosecuted or a fine will be imposed.

21 I, hereby declare that the information given below is true to the best of my knowledge Sign

For further enquiries call the 7337970 / 1676 (COVID-19 HOTLINE)