0920-1287 US Traveler Health Declaration - Brazil - Paper Format

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 coronavirus disease 2019 (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 COVID-19 needs to fill out a form¹.

Arrival airport (name or airport code):

in the past 14 DAYS HAVE YOU BEEN TO ANY OF THE COUNTRIES OR GEOGRAPHIC REGIONS LISTED ON THE BOTTOM OF THIS FORM? YES NO

Family name: ..…………….…………………………………………………. First (given) names: …………………..…………………………..……….………………………

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

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?
New or worsening persistent (frequent or continuing) cough?
New or worsening difficulty breathing?

QUESTIONS FOR SCREENER

Measured Temperature

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: ______________________________________________________________________________________

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Brazil, Iran, Ireland, People’s Republic of China (excluding the Special Administrative Regions of Hong Kong and Macau), 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), United Kingdom (England, Northern Ireland, Scotland, Wales)

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