Passenger Disclosure and Attestation - English

OMB Control No.: 0920-1318
Expiration date: 5/31/2021

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,
, 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.

Select one of the options that applies:
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.

Signature

Date (mm/dd/yyyy)

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

CS322196_A

02/1/2021

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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.

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