0920-1318 Combined Passenger Disclosure And Attestation To The Uni

ATTACHMENT A: COMBINED PASSENGER DISCLOSURE AND ATTESTATION
TO THE UNITED STATES OF AMERICA
This combined passenger disclosure and attestation fulfills the requirements of U.S. Centers for Disease
Control and Prevention (CDC) Orders: Requirement for Proof of Negative COVID-19 Test Result or
Recovery from COVID-19 for All Airline Passengers Arriving into the United States and Order
Implementing Presidential Proclamation on Advancing the Safe Resumption of Global Travel During the
COVID-19 Pandemic. 1 As directed by the CDC and the Transportation Security Administration (TSA),
including through a forthcoming Security Directive, to be issued after consultation with CDC, and
consistent with CDC’s Order implementing the Presidential Proclamation, all airline or other aircraft
operators must provide the following disclosures to all passengers prior to their boarding a flight from a
foreign country to the United States.
The information provided below must be accurate and complete to the best of the individual’s knowledge.
Under United States federal law, each passenger must complete the applicable portion of the attestation and
provide it to the airline or aircraft operator prior to boarding a flight to the United States from a foreign
country. Failure to complete and present the applicable portion of the 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. 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.
AIRLINE AND AIRCRAFT OPERATOR DISCLOSURE REQUIREMENTS:
As required by United States federal law, all airlines or other aircraft operators must collect the passenger
attestation on behalf of the U.S. Government.
All airlines and other aircraft operators must additionally confirm one of the following for each passenger
– 2 years and older––prior to their boarding a flight to the United States from a foreign country:
1. A negative result for a Qualifying Test for Fully Vaccinated for those passengers who provide proof
of being fully vaccinated,
2. A negative result for a Qualifying Test for Not Fully Vaccinated, or
3. Documentation of recovery from COVID-19 in the form of a positive COVID-19 viral test on a
sample taken no more than 90 days prior to departure and clearance to travel.

These requirements (e.g. proof of negative COVID-10 test result and proof of being fully vaccinated against COVID-19)do not
apply to crew members of airlines or other aircraft operators if they are traveling for the purpose of operating the aircraft, or
repositioning (i.e., on “deadhead” status), provided their assignment is under an air carrier’s or operator’s occupational health and
safety program that follows applicable industry standard protocols for the prevention of COVID-19 as set forth in relevant Safety
Alerts for Operators (SAFOs) issued by the Federal Aviation Administration (FAA).
1

Public reporting burden of this collection of information is estimated to average X 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 XXXX-XXXX

Form
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX

As directed by the TSA, including through a forthcoming security directive, all airlines and other aircraft
operators must additionally confirm one of the following for each noncitizen who is a nonimmigrant
passenger prior to their boarding a flight to the United States from a foreign country:
1. Proof of being Fully Vaccinated Against COVID-19
2. Proof of being excepted from the requirement to be Fully Vaccinated Against COVID-19.
SECTION 1:
Passenger Attestation Requirement Relating to Proof of Negative COVID-19 Test Result or Recovery
from COVID-19
TO BE COMPLETED BY ALL PASSENGERS:
1. [ ] I attest that I am fully vaccinated against COVID-19 and 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 no
more than 3 days before this flight’s departure.
[ ] On behalf of [_____________________], I attest that this person is fully vaccinated against COVID19 and received a negative pre-departure test result for COVID-19. The test was a viral test that was
conducted on a specimen collected from the person no more than 3 days before the flight’s departure.
2. [ ] I attest that I am not fully vaccinated against COVID-19 and 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
no more than 1 day before the flight’s departure.
[ ] On behalf of [_____________________], I attest that this person is not fully vaccinated against
COVID-19 and 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 the person no more than 1 day before the flight’s
departure.
3. [ ] I attest that I tested positive for COVID-19 and have been cleared for travel by a licensed healthcare
provider or public health official. The test was a viral test that was conducted on a specimen collected
from me no more than 90 days before the flight’s departure.
[ ] On behalf of [___________], I attest that this person tested positive for COVID-19 and has been
cleared for travel by a licensed healthcare provider or public health official. The test was a viral test
that was conducted on a specimen collected from the person no more than 90 days before the flight’s
departure.
4. [ ] On behalf of [_____________________], I attest that this person is between 2 and 17 years of age,
is not fully vaccinated against COVID-19, and received a negative pre-departure test result for COVID19. The test was a viral test that was conducted on a specimen collected from the person no more than
3 days before the flight’s departure and this person is traveling with a fully vaccinated parent(s) or
guardian(s).
5. [ ] I attest that I have received a humanitarian or emergency exemption to the testing requirement or
the documentation of recovery, as determined by CDC and documented by an official U.S. Government
letter.

Form
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX

[ ] On behalf of [__________________], I attest that this person has received a humanitarian or
emergency exemption to the testing requirement or the documentation of recovery, as determined by
CDC and documented by an official U.S. Government letter.

Form
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX

SECTION 2:
Passenger Attestation Requirement Relating to Presidential Proclamation on Advancing the Safe
Resumption of Global Travel During the COVID-19 Pandemic
TO BE COMPLETED BY EVERY COVERED INDIVIDUAL: 2
1. [ ] I attest that I am fully vaccinated against COVID-19 (sign the form to complete the Attestation).
[ ] On behalf of [___________], I attest that this person is fully vaccinated against COVID-19 (sign the
form to complete the Attestation).
2. [ ] I am not fully vaccinated and attest that I am excepted from the requirement to present Proof of
Being Fully Vaccinated Against COVID-19 based on one of the following (check only one box, as
applicable):
Diplomatic and Official Foreign Government Travel (complete sections 3 and 5, unless as
determined by CDC, these requirements cannot be completed consistent with the purposes of the
official government travel, and sign the form to complete the Attestation).
Child under 18 years of age (complete section 4 and sign the form to complete the Attestation OR
have parent/legal guardian complete section 4 and sign on behalf of a person under 18 years of
age).
Participant in certain COVID-19 vaccine trials as determined by CDC (complete section 4 and sign
the form to complete the Attestation).
Medical contraindication to an accepted COVID-19 vaccine as determined by CDC (complete
section 3 and sign the form below to complete the Attestation).
Humanitarian or emergency exception as determined by CDC and documented by an official U.S.
Government letter (complete sections 3 and 5 below and sign the form to complete the Attestation).
Valid nonimmigrant visa holder (excluding B-1 or B-2 visas) and citizen of a Foreign Country with
Limited COVID-19 Vaccine Availability as determined by CDC (complete sections 3 and 5 below
and sign the form to complete the Attestation).
Member of the U.S. Armed Forces or spouse or child (under 18 years of age) of a member of the
U.S. Armed Forces (sign the form to complete the Attestation).
Sea crew member traveling pursuant to a C-1 and D nonimmigrant visa (complete sections 3 and 5
below and sign the form to complete the Attestation).
Person whose entry is in the U.S. national interest as determined by the Secretary of State, the
Secretary of Transportation, the Secretary of Homeland Security, or their designees (complete
sections 3 and 5 below and sign the form to complete the Attestation).
[ ] On behalf of [___________], I attest that this person is excepted from the requirement to present
Proof of Being Fully Vaccinated Against COVID-19 based on one of the following (check only one box,
as applicable):

2

This means any passenger covered by the Proclamation and this Order: a noncitizen (other than a U.S. lawful
permanent resident or U.S. national) who is a nonimmigrant seeking to enter the United States by air travel. This
term does not apply to crew members of airlines or other aircraft operators if such crewmembers and operators
adhere to all industry standard protocols for the prevention of COVID-19, as set forth in relevant guidance for
crewmember health issued by the CDC or by the Federal Aviation Administration in coordination with the CDC.

Form
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX

Diplomatic and Official Foreign Government Travel (complete sections 3 and 5, unless as
determined by CDC, these requirements cannot be completed consistent with the purposes of the
official government travel, and sign the form to complete the Attestation).
Child under 18 years of age (complete section 4 and sign the form to complete the Attestation).
Participant in certain COVID-19 vaccine trials as determined by CDC (complete section 4 and sign
the form to complete the Attestation).
Medical contraindication to an accepted COVID-19 vaccine as determined by CDC (complete
section 3 and sign the form below to complete the Attestation).
Humanitarian and emergency exception as determined by CDC and documented by an official U.S.
Government letter (complete sections 3 and 5 below and sign the form to complete the Attestation).
Valid nonimmigrant visa holder (excluding B-1 or B-2 visas) and citizen of a Foreign Country with
Limited COVID-19 Vaccine Availability as determined by CDC (complete sections 3 and 5 below
and sign the form to complete the Attestation).
Member of the U.S. Armed Forces or spouse or child (under 18 years of age) of a member of the
U.S. Armed Forces (sign the form to complete the Attestation).
Sea crew member traveling pursuant to a C-1 and D nonimmigrant visa (complete sections 3 and 5
below and sign the form to complete the Attestation).
Person whose entry is in the U.S. national interest as determined by the Secretary of State, the
Secretary of Transportation, the Secretary of Homeland Security, or their designees (complete
sections 3 and 5 below and sign the form to complete the Attestation).
3. [ ] I attest that I have made the following arrangements (must check all boxes).
To be tested with a COVID-19 viral test 3-5 days after arriving in the United States, unless I have
documentation of having recovered from COVID-19 in the past 90 days;
To self-quarantine for a full 7 days, even if the test result to my post-arrival viral test is negative,
unless I have documentation of having recovered from COVID-19 in the past 90 days; and
To self-isolate if the result of the post-arrival viral test is positive or if I develop COVID-19
symptoms.
[ ] On behalf of [___________], I attest that such person is excepted from the requirement to present
Proof of Being Fully Vaccinated Against COVID-19 and has made or has had the following
arrangements made on their behalf (must check all boxes).
Testing with a COVID-19 viral test 3-5 days after arriving in the United States, unless such person
has documentation of having recovered from COVID-19 in the past 90 days;
Self-quarantine for a full 7 days, even if the test result to the person’s post-arrival viral test is
negative, unless such person has documentation of having recovered from COVID-19 in the past
90 days; and
Self-isolation if the result of the person’s post-arrival viral test is positive or if the person develops
COVID-19 symptoms.
4. [ ] I attest that I have made the following arrangements (must check all boxes).
To be tested with a COVID-19 viral test 3-5 days after arriving in the United States, unless I have
documentation of having recovered from COVID-19 in the past 90 days; and
To self-isolate if the result of the post-arrival viral test is positive or if I develop COVID-19
symptoms.

Form
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX

[ ] On behalf of [___________], I attest that such person is excepted from the requirement to present
Proof of Being Fully Vaccinated Against COVID-19 and has made or has had the following
arrangements made on their behalf (must check all boxes).
Testing with a COVID-19 viral test 3-5 days after arriving in the United States, unless such person
has documentation of having recovered from COVID-19 in the past 90 days; and
Self-isolation if the result of the person’s post-arrival viral test is positive or if the person develops
COVID-19 symptoms.
5. Do you, or the person you are attesting on behalf of, intend to stay in the United States for more than
60 days?
YES (complete statement below and then sign form)
NO (skip statement below and sign form)
[ ] If YES, I attest that I agree to be vaccinated and have arranged to become fully vaccinated against
COVID-19 within 60 days of arriving in the United States, or as soon thereafter as is medically
appropriate.
[ ] If YES, on behalf of [___________], I attest that such person agrees to be vaccinated and has
arranged to become fully vaccinated against COVID-19 within 60 days of arriving in the United States,
or as soon as thereafter as is medically appropriate.

___________________________________________ Print Name
___________________________________________ Signature
_________________________Date

Form
OMB Control No.: XXXX-XXXX
Expiration date: XX/XX/XXXX

Privacy Act Statement for Travelers Relating to the Requirement to Provide Proof of a Negative
COVID-19 Test Result
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, Quarantineand 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 H164, Atlanta, GA 30329, if you have questions about CDC’s use of your data.