0920-1287 U.S. Traveler Health Declaration England/Ireland Fillabl

Form Approved
OMB Control No.0920-1287
Exp 09/30/2020

UNITED STATES
TRAVELER HEALTH DECLARATION

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 the novel coronavirus (COVID-19) pandemic. 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 a country for which the United States has applied entry restrictions due to the 2019 Novel Coronavirus
(COVID-19) needs to fill out a form1.
Arrival airport code:
Other
SFO
SEA
ORD
MIA
LAX
JFK
IAD
HNL
EWR
DTW
DFW
BOS
ATL

Other port of entry:

IN THE PAST 14 DAYS WERE YOU IN HUBEI PROVINCE, CHINA? Yes

No

IN THE PAST 14 DAYS HAVE YOU BEEN TO ANY OF THE OTHER COUNTRIES OR GEOGRAPHIC REGIONS LISTED
ON THE BOTTOM OF THIS FORM?
Yes
No
Family name:

First (given) name:

Birth date (Day/Month/Year):

Sex:

Male

Airline:
AerAl
Aerolineas
Aeroflot-SU
Aeromexico-AM
Air
Airasia
Alaska
All
Alitalia-AZ
American
Asiana
Austrian
British
Avianca-AV
Cathay
Champlain
China
Chinese
Compass
Condor
COPA
Corsair
Delta
El
Egyptair-MS
DreamJet-B0
Emirates
Endeavor
Envoy
Ethiopian
Etihad
EVA
Eurowings-EW
Fiji
French
Finnair-AY
Hainan
Hawaiian
Hong
Horizon
Iberia
Japan
Interjet-4O
Jazz
Jetblue
Jetstar
Kenya
KLM
Korean
Kuwait
LATAM
LOT
Mesa
Lufthansa-LH
Nordic
Norwegian
Philippine
Openskies-LV
Porter
Qantas
Qatar
Republic
Royal
SATA
Saudi
Scandanavian
Sichuan
Singapore
Sky
SkyWest
South
Swis
TAP
Turkish
Ukaine
United
Uzbekistan
Virgin
Viva
Volaris
Vuela
Xiamen
WestJet-WS
Other
Nippon
Canada-AC
China-CA
France-AF
India-AI
New
Tahiti
Airway/Air
Lingus-EI
Regional
Polish
Portugal-TP
Columbia-VH
Airways-BR
Israel-LY
Aviation-QK
Royal
Air
Airlines-DL
Kong
Airlines-YV
Lineas
Airways-QR
Airline-OO
Air
Jordanian-RJ
Atlantic
Australia
Arabian
Aviacion
Airlines-CI
Cargo
Southern
Internacional
African
Airlines-PD
Airlines-JL
Airway-BA
Air-MQ
Compangia
Airways-EY
Airways-KQ
Regional
Airlines-UA
Airlines-AS
Airways-JQ
Airways-KU
X-D7
(Mexico)-Y4
Airlines-OZ
Bee-BF
International
Pacific-CX
Airlines-HU
International-SS
Airways-B6
Air
Airways-QF
Airlines-TK
Flugdienst-DE
Airlines-LA
Airlines-MF
Air-QX
Zealand-NZ
Lines-LX
Airlines-3U
Airlines-OS
Eastern
Airways-YX
Nui-TN
Airlines-EK
Airlines-OO
Maroc-AT
Airlines-HA
Airlines-ET
Airlines-AA
Airlines-CP
Air-9E
Airlines-PR
Airways-NH
Airlines-SQ
Argentinas-AR
Lines-KE
Enterprises
Air-DI
Air
Dutch
Airlines-LO
Airways-HY
Airlines-HX
Airlines-CK
Aereas-IB
Airlines-KV
Airways-SA
Pacific
Airways-VS
Shuttle-DY
Airlines-SV
Airlines
Volaris
Airlines-VA
Airlines-CZ
Airlines-FI
Airlines-MU
Airlines-KL
Panamena
Azores
Airlines-PS
Limited-FJ
Systems
(Costa
Commutair-C5
Airlines-S4
Rica)-Q6
de(SAS)-SK
Avicacion-CM
U.S. Destination
Address or hotel name:
City:

Female

Date of US arrival (Day/Month/Year):

Flight number:

Seat number(s):

State:

WY
WV
WI
WA
VT
VI
VA
UT
TX
TN
SD
SC
RMI
RI
PW
PR
PA
OR
OK
OH
NY
NV
NM
NJ
NH
NE
ND
NC
MT
MS
MP
MO
MN
MI
ME
MD
MA
LA
KS
IN
IL
ID
IA
HI
GU
GA
FM
FL
DE
DC
CT
CO
CA
AZ
AS
AR
AL
AK
Telephone number in US:

E-mail address:

Mobile? Yes

No

TODAY OR IN THE PAST 24 HOURS, HAVE YOU HAD ANY OF THE FOLLOWING SYMPTOMS?
SYMPTOM

YES / NO

Fever (100.4° F / 38° C or higher), felt feverish, or had chills?

Yes

No

New or worsening persistent (frequent or continuing) cough?

Yes

No

New or worsening difficulty breathing?

Yes

No

QUESTIONS FOR SCREENER
Measured temperature:
Does traveler have visible signs of cough or shortness of breath or being obviously unwell?
Traveler was:

Released

Yes

No

Referred for public health risk assessment

Completed by:

People’s Republic of China (mainland), Schengen Area (Austria, Belgium, Czech Republic, Denmark, Estonia,
Finland, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta,
Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, Monaco, San Marino,
and Vatican City), Iran, Ireland, United Kingdom
1

SAVE
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 0920-1287.

CS 314673_D 03/16/2020 Version 3.0