Passenger Disclosure And Attestation

Form
OMB Control No.: 0920-1318
Expiration date: 05/31/2021

ATTACHMENT A
PASSENGER DISCLOSURE AND ATTESTATION
TO THE UNITED STATES OF AMERICA
All airlines or other aircraft operators covered by the Order must provide the following
disclosure to their passengers and collect the attestation prior to embarkation.

AIRLINE AND AIRCRAFT OPERATOR DISCLOSURE REQUIREMENT:
As required by United States federal law, all airlines or other aircraft operators must confirm either
a negative COVID-19 test result or recovery from COVID-19 and clearance to travel and collect
a passenger attestation on behalf of the U.S. Centers for Disease Control and Prevention (CDC)
for certain passengers on aircraft departing from a foreign country and arriving in the United States.
Each individual 2 years of age or older must provide a separate attestation. Unless otherwise
permitted by law, a parent or other authorized individual should attest on behalf of a passenger
aged 2 to 17 years. An individual may attest on behalf of another passenger for whom the
individual is authorized to submit the required information (for example, immediate family
member(s), legal guardian, or travel agent), if that person is unable to attest on his or her own
behalf (e.g., because of physical or mental impairment).
The information provided must be accurate and complete to the best of the individual’s knowledge.
Under United States federal law, each passenger must provide this attestation. Failure to provide
this attestation, or submitting false or misleading information, could result in delay of travel, denial
of boarding, denial of boarding on future travel, or put the passenger or other individuals at risk of
harm, including serious bodily injury or death. Any passenger who fails to comply with these
requirements may be subject to criminal penalties under, among others, 42 U.S.C. § 271 and 42
C.F.R. § 71.2, in conjunction with 18 U.S.C. §§ 3559 and 3571. Willfully providing false or
misleading information may lead to criminal fines and imprisonment under, among others, 18
U.S.C. § 1001. Providing this information can help protect you, your friends and family, your
communities, and the United States. CDC appreciates your cooperation.

PASSENGER ATTESTATION REQUIREMENT:
I [name of passenger or authorized representative] have read the disclosure pertaining to my
obligation to obtain a negative pre-departure test result for COVID-19 or to having recovered from
COVID-19 after previous SARS-CoV-2 infection and being cleared to travel in order to board an
aircraft departing from a foreign country and arriving in the United States.
Check one of the options that applies:
Public reporting burden of this collection of information is estimated to average 2 hours 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 0920-1318

[ ] I attest that I have received a negative pre-departure test result for COVID-19. The test was a
viral test that was conducted on a specimen collected from me during the 3 calendar days preceding
the flight’s departure.

[ ] I attest that I have recovered from COVID-19 in the last 3 months (90 days), or the time period
specified in current CDC guidance, after having previously tested positive for SARS-CoV-2 and
have been cleared for travel by a licensed healthcare provider or public health official.

[ ] On behalf of [___________], I attest that such person has received a negative pre-departure test
result for COVID-19. The test was a viral test that was conducted on a specimen collected from
that person during the 3 calendar days preceding the flight’s departure.

[ ] On behalf of [___________], I attest that such person has recovered from COVID-19 in the last
3 months (90 days), or the time period specified in current CDC guidance, after having previously
tested positive for SARS-CoV-2 and has been cleared for travel by a licensed healthcare provider
or public health official.

___________________________________________

_________________________Date

Privacy Act Statement
The United States Centers for Disease Control and Prevention (CDC) requires airlines and other
aircraft operators to collect this information pursuant to 42 C.F.R. §§ 71.20 and 71.31(b), as
authorized by 42 U.S.C. § 264. Providing this information is mandatory for all passengers arriving
by aircraft into the United States. Failure to provide this information may prevent you from
boarding the plane. Additionally, passengers will be required to attest to providing complete and
accurate information, and failure to do so may lead to other consequences, including criminal
penalties. CDC will use this information to help prevent the introduction, transmission, and spread
of communicable diseases by performing contact tracing investigations and notifying exposed
individuals and public health authorities; and for health education, treatment, prophylaxis, or other
appropriate public health interventions, including the implementation of travel restrictions.
The Privacy Act of 1974, 5 U.S.C. § 552a, governs the collection and use of this information. The
information maintained by CDC will be covered by CDC’s System of Records No. 09-20-0171,
Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation
and Notification under 42 C.F.R. Parts 70 and 71. See 72 Fed. Reg. 70867 (Dec. 13, 2007), as

amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018). CDC will
only disclose information from the system outside the CDC and the U.S. Department of Health
and Human Services as the Privacy Act permits, including in accordance with the routine uses
published for this system in the Federal Register, and as authorized by law. Such lawful purposes
may include, but are not limited to, sharing identifiable information with state and local public
health departments, and other cooperating authorities. CDC and cooperating authorities will retain,
use, delete, or otherwise destroy the designated information in accordance with federal law and
the System of Records Notice (SORN) set forth above. You may contact the system manager at
[email protected] or by mailing Policy Office, Division of Global Migration and
Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H16-4,
Atlanta, GA 30329, if you have questions about CDC’s use of your data.