0920-1181 Public Health Passenger Locator Form_DOMESTIC

Public Health Passenger Locator Form: To protect your health, public health officers need you to complete this form whenever
they suspect a communicable disease on board a flight. Your information will help public health officers to contact you if you were
exposed to a communicable disease. It is important to fill out this form completely and accurately. Your information is intended to
be held in accordance with privacy laws and used only for public health purposes.
~Thank you for helping us to protect your health.
One form should be completed by an adult member of each family. Print in capital (uppercase) letters. Leave blank boxes for spaces.

FLIGHT INFORMATION: 1. Airline name

2. Flight number 3. Seat number 4. Date of arrival (dd/mm/yyyy)
2 0

PERSONAL INFORMATION: 5. Last (Family) Name

6. First (Given) Name

7. Middle Initial

8. How do you describe yourself (mark all that apply)?
Female

Male

Transgender

Non-binary Use a different term [free-text]

Prefer not to answer/Decline

PHONE NUMBER(S) where you can be reached if needed. Include country code and city code.
9· Mobile
l0. Business
ll. Home

12. Other

13. Email address
15. Apartment number

PERMANENT ADDRESS: 14. Number and street (Separate number and street with blank box)
16. City

17. State/Providence

18. Country

19. ZIP/Postal code

TEMPORARY ADDRESS: If you are a visitor, write only the first place where you will be staying.
20. Hotel name (if any)
21. Number and street (Separate number and street with blank box)

22. Apartment number

23. City

24. State/Providence

25. Country

26. ZIP/Postal code

EMERGENCY CONTACT INFORMATION of someone who can reach you during the next 30 days
27. Last (Family) Name
28. First (Given) Name
30. Country
32. Mobile phone

29. City

31. Email
33. Other phone

34. TRAVEL COMPANIONS - FAMILY: Only include age if younger than 18 years
Last (Family) Name
First (Given) Name
(1)
(2)
(3)
(4)
35. TRAVEL COMPANIONS - NON-FAMILY: Also include name of group (if any)
Last (Family) Name
First (Given) Name
(1)
(2)

Seat number

Age <18

Group (tour, team, business, other)