0920-20HF US Traveler Health Declaration Paper

UNITED STATES
TRAVELER HEALTH DECLARATION

Form Approved
OMB Control No.0920-XXXX
Exp XX/XX/XXXX

Providing the following information to the Centers for Disease Control and Prevention is required under Title 42 Code of Federal
Regulations Section 71.20, and is being collected as part of the public health response to a new coronavirus first identified in China.
The information will be used by U.S. public health authorities and other international, federal, state, or local agencies for public
health purposes.

Each traveler coming from Iran or the People’s Republic of China, (“mainland China”) needs to fill out one form.
Mainland China does not include travelers coming from the Special Administrative Regions of Hong Kong, Macau, and
the island of Taiwan.
Arrival airport code:
IN THE PAST 14 DAYS HAVE YOU BEEN IN ANY OF THE FOLLOWING LOCATIONS?

YES
MAINLAND CHINA
HUBEI PROVINCE, CHINA YES

NO
NO

If yes, last date in mainland China:_____/______/______ (DD/MM/YY)
If yes, last date in Hubei Province, China: _____/_____/____(DD/MM/YY)

YES

NO

If yes, last date in Iran:_____/______/______ (DD/MM/YY)

IRAN

Family name: ..…………….…………………………………………………. First (given) names: …………………..…………………………..……….………………………
Country of residence………………………………… Citizenship:……………………………….…………… Passport number ………….………………………………
Birth date: _____ /_____ / _____ (Day/Month/Year)

Sex: Male

Female

Date of US arrival: ____ /____ /____ (Day/Month/Year) Airline: ……………….…… Flight number:………….…… Seat number(s): …………………
U.S. destination: Address or hotel name: ………………………………………………………………………………………….……………………………………………………
………………………………………………………….……………… City: ……………………………………..…………................................. State: ……………………….........
E-mail address: ………………………………............... Telephone number in US:.................................................... Mobile? Yes

No

IN THE PAST 14 DAYS, HAVE YOU HAD CONTACT WITH A PERSON KNOWN TO BE INFECTED WITH THE NOVEL
CORONAVIRUS (COVID-2019)?

YES

NO

If yes, date contact occurred: _____/_____/_____ (Day/Month/Year)
TODAY OR IN THE PAST 24 HOURS, HAVE YOU HAD ANY OF THE FOLLOWING SYMPTOMS?
YES

NO

Fever (100.4° F / 38° C or higher), felt feverish, or had chills?
Cough?
Difficulty breathing?
MEASURED TEMPERATURE:

QUESTIONS FOR SCREENER
Does traveler have visible signs of cough or shortness of breath or being obviously unwell? Yes
Released

No

Referred for public health risk assessment

Completed by: ______________________________________________________________________________________
Time start: ……………………………… Time end: ………………………………

Translator needed? Yes

No

This data collection is mandatory. Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control
Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.