Attestation -Proof of Negative Covid-19 Test Result or D

ATTACHMENT A:

PROOF OF NEGATIVE COVID-19 TEST RESULT OR DOCUMENTATION OF RECOVERY FOR AIR PASSENGERS FROM THE PEOPLE’S REPUBLIC OF CHINA

NOTICE TO AIRLINES AND AIRCRAFT OPERATORS

This passenger disclosure and attestation fulfills the requirements of U.S. Centers for Disease Control and Prevention (CDC) Order: Requirements for Negative Pre-Departure COVID-19 Test Result or Documentation of Recovery from Covid-19 for All Airline or Other Aircraft Passengers Traveling to the United States from the People’s Republic of China.¹,²

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.³

As required by the Order, all airlines and other aircraft operators must provide this disclosure to all air passengers who are ages 2 years and older⁴ who have an itinerary that includes the United States and are boarding:

1. an aircraft in the People’s Republic of China, or

2. an aircraft at a Designated Airport if the passenger has been in the People’s Republic of China in the past 10 calendar days. Designated Airports include Incheon International Airport (ICN) in Seoul, Republic of Korea; Toronto Pearson International Airport (YYZ) in Canada; and Vancouver International Airport (YVR) in Canada.

This requirement does not apply to passengers transiting through an airport in the People’s Republic of China en route from another country to the United States. It also does not apply to passengers who have been in the People’s Republic of China for less than 24 hours.

The airline must identify which passengers are subject to the requirements of this Order and confirm that each such passenger, prior to boarding the aircraft, has presented paper or digital documentation reflecting:

1. A negative result for a COVID-19 viral test taken no more than 2 days before the departure of the flight from an airport in the People’s Republic of China or a Designated Airport ; or

2. Documentation of Recovery from COVID-19 in the form of:

• A positive viral test result for COVID-19 conducted on a sample collected more than 10 calendar days but fewer than 91 calendar days before the departure of the flight from an airport in the People’s Republic of China or a Designated Airport;

or

• A positive viral test result for COVID-19 conducted on a sample taken 10 or fewer calendar days before the flight AND a signed letter from a licensed healthcare provider or public health official stating that the passenger’s symptoms began more than 10 calendar days before the departure of the flight from an airport in the People’s Republic of China or a Designated Airport; or

3. A Humanitarian Exception in the form of a letter from the U.S. Government

OMB Control No.: 0920-XXXX

PROOF OF NEGATIVE COVID-19 TEST RESULT OR DOCUMENTATION OF RECOVERY FOR AIR PASSENGERS FROM THE PEOPLE’S REPUBLIC OF CHINA⁵

PASSENGER DISCLOSURE AND ATTESTATION

The information provided below must be accurate and complete to the best of the person’s knowledge. Under United States federal law, the attestation must be completed for each air passenger 2 years of age or older who has an itinerary that includes the United States and is boarding an aircraft in the People’s Republic of China; or is boarding an aircraft at a Designated Airport and has been in the People’s Republic of China in the last 10 calendar days. 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, or denial of boarding on future travel, or put the passenger or other people 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 other provisions, 18 U.S.C. § 1001. Providing this information can help protect you, your friends and family, your communities, and the United States. The U.S. Centers for Disease Control and Prevention (CDC) appreciates your cooperation.

One attestation form must be filled out for each air passenger 2 years of age or older with an itinerary that includes the United States prior to boarding

1. an aircraft in the People’s Republic of China; or

2. an aircraft at a Designated Airport if the passenger has been in the People’s Republic of China in the last 10 days. Designated Airports include Incheon International Airport (ICN) in Seoul, the Republic of Korea; Toronto Pearson International Airport (YYZ) in Canada; and Vancouver International Airport (YVR) in Canada.⁶

The air passenger or the person acting on behalf of the air passenger as a legal representative, such as a parent or guardian, must check A, B, or C and sign the attestation.

I, ­­­­­­­ am attesting on (Select one):

PRINT FIRST AND LAST NAME

My own behalf Behalf of: ____________________________________

PRINT FIRST AND LAST NAME

1. A. NEGATIVE PRE-DEPARTURE TEST RESULT

 I attest that I have (or the person I am attesting on behalf of has) received a negative test

result for COVID-19. The test was a viral test that was done on a sample taken from me (or the person) no more than 2 calendar days before my (or the person’s) flight’s departure.

2. B. DOCUMENTATION OF RECOVERY FROM COVID-19

 I attest that I have (or the person I am attesting on behalf of has) met the criteria for documentation of

recovery by:

• testing positive for COVID-19 that was done on a sample taken from me (or the person) more than 10 calendar days but fewer than 91 calendar days before my (or the person’s) flight’s departure;

or

• developing COVID-19 symptoms more than 10 full calendar days before my (or the person’s) flight’s departure if my (or the person’s) positive viral test was done on a sample taken from me (or the person) 10 or fewer calendar days before my (or the person’s) flight.

1. C. HUMANITARIAN EXCEPTION

 I attest that I have (or the person I am attesting on behalf of has) received a humanitarian exception to

the requirement to show a negative COVID-19 test result or documentation of recovery, documented by a letter provided by the U.S. Government.

___________________________________________ Print Name

___________________________________________ Signature

_________________________Dated

Privacy Act Statement for Air Passengers from People’s Republic of China Relating to the Requirement to Provide Proof of a Negative COVID-19 Test Result or Documentation of Recovery

The U. S. 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 2 years and older boarding an aircraft into the United States from the People’s Republic of China, or from Designated Airports if they have been in the People’s Republic of China in the last 10 days. 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.

The Privacy Act of 1974, 5 U.S.C. § 552a, governs the collection and use of this information about citizens of the United States and aliens lawfully admitted for permanent residence. 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.

1 This requirement (i.e., proof of negative COVID-19 test or recovery) does not apply to crewmembers of airlines or other aircraft operators on official duty assigned by the airline or aircraft operator that involves operation of the aircraft or repositioning of crew (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 consistent with relevant CDC guidance. See the Order and CDC’s website for more information about applicability and exceptions.

2 People’s Republic of China includes the Special Administrative Regions of Hong Kong and Macau.

3 This attestation does not need to be completed by or on behalf of children under 2 years of age. The airline or other aircraft operator may permit them to board an aircraft without an attestation.

4 This Order applies to any passenger 2 years of age or older, regardless of citizenship or vaccination status.

5 People’s Republic of China includes the Special Administrative Regions of Hong Kong and Macau.

6 This requirement excludes persons transiting through an airport in the People’s Republic of China en route to the United States from another country. This Order also excludes persons who have been in the People’s Republic of China for less than 24 hours.

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. Comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, may be submitted to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.