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

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 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?

Mainland CHINA YES NO If yes, last date in mainland China:_____/______/______ (DD/MM/YY)

HUBEI PROVINCE, CHINA YES NO If yes, last date in Hubei Province, China: _____/_____/____(DD/MM/YY)

IRAN YES NO If yes, last date in Iran:_____/______/______ (DD/MM/YY)

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 No

Released 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 0920-1287.

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Cohen, Nicole (Nicky) (CDC/OID/NCEZID)
File Modified	0000-00-00
File Created	2021-01-14