Request for Contact Tracing

Request Form for
Passenger Contact Tracing
To

From

Airline name:

Requesting:

Address:

Address:

Tel.:

Tel.:

Fax:

Fax:

E-mail:

E-mail:

In accordance with the International Health Regulations (IHR) and our national regulation:
(Please specify the legal authority that allows you to make that request and may supersede any Data Protection Legislation)

We are making enquiries because we have been advised that your airline
(Name of your airline)

Please select one of the two scenarios below and fill out the information required based upon your choice:
1. Has carried a passenger with the following communicable disease, or
2. Has carried a passenger who was exposed to:

1

Has carried a passenger with the following communicable disease:
(Name of disease. For example: active TB)

Passenger name:
Flight number:

Seat number:

Date of departure:

Origin:

Transit destination:

Final destination:

(if any)

(DD/MM/YY)

We need the names and contact information for the passengers sitting in:

(Number of rows)

2

Has carried a passenger who was exposed to:
(Name of hazard)

On the following flight(s):
Flight number:

Date of travel:

Origin:

Transit destination:

(DD/MM/YY)
(if any)

Final destination:

We need the names and contact information for the passengers sitting in:
(Number of rows)

Comments:

Signed: Position:
Name: Date:
IMPORTANT NOTES:
All data provided pursuant to this form shall be treated as confidential. In some countries, e-mail may not be considered as a legal document.