TRAVELER DISCLOSURE AND ATTESTATION TO THE UNITED STATES OF AMERICA

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OMB Control No: 0920-1474
Expiration Date: 3/31/2027
ATTACHMENT A
TRAVELER DISCLOSURE AND ATTESTATION
TO THE UNITED STATES OF AMERICA
All airlines or other aircraft operators covered by the Order must provide the following
disclosure and attestation form to all persons intending to board any aircraft destined for the
United States from a foreign country and confirm completion of the disclosure and attestation
form prior to embarkation.
TRAVELER ATTESTATION REQUIREMENT:
I ______________________________________ [name of traveler or authorized representative,
the “Attestee”] have read the following disclosure pertaining to not having been present in the
Democratic Republic of the Congo in the past 21 days. Presence in the Democratic Republic of
the Congo means any physical presence, including entering or traveling through the country by
air (excluding overflights), land, or sea. Presence also includes connecting through an airport in
the Democratic Republic of the Congo, even if the traveler did not disembark the plane or leave
the airport.
Check exactly one of the options below:
[ ] I attest that I have not been present in the Democratic Republic of the Congo in the past 21
days prior to boarding a flight to the United States.
[ ] On behalf of [____________________________] (the Attestee), for whom I am authorized to
act, I attest that such person has not been present in the Democratic Republic of the Congo in the
past 21 days preceding boarding a flight to the United States.
Airline or aircraft operator personnel may assist with data entry but do not attest on behalf of the
Attestee.
I attest that I have responded truthfully and understand that willfully providing false or
misleading information may lead to criminal fines and imprisonment under 18 U.S.C. § 1001,
and that I may be subject to criminal penalties under 42 U.S.C. § 271 and 42 C.F.R. §71.2, in
conjunction with 18 U.S.C. §§ 3559 and 3571 for failure to comply with these requirements.
Printed Name of Traveler or Authorized Representative:
___________________________________________
Signature: ___________________________________________
Date: _________________________

OMB Control No: 0920-1474
Expiration Date: 3/31/2027
AIRLINE AND AIRCRAFT OPERATOR DISCLOSURE REQUIREMENT:
As required by United States federal law, all airlines or other aircraft operators must, for all
travelers on flights departing for the United States from a foreign country, collect and retain for
at least 42 days a completed traveler attestation on behalf of the U.S. Centers for Disease Control
and Prevention (CDC) and provide the attestation to the U.S. Government upon request. All
airlines or other aircraft operators must not board any traveler who has failed to complete and
present such an attestation.
Each individual must provide a separate attestation. Unless otherwise permitted by law, a parent
or other authorized representative should attest on behalf of a traveler under 18 years old. An
individual may attest on behalf of another traveler for whom the individual is authorized to
submit the required information (for example, adult member of the same traveling party, travel
companion, or travel agent). An authorized representative may also act on behalf of any person
who is unable to act on their own behalf (e.g., by reason of age, or physical or mental
impairment). An airline or aircraft operator employee or agent who assists with data entry or
submission at the direction of the traveler or authorized representative does not, solely by
providing such assistance, become the authorized representative or provide the attestation on the
traveler’s behalf.
Under United States federal law, each traveler must present either a printed or digital copy of this
attestation. The information provided must be accurate and complete to the best of the
individual’s knowledge. Failure to provide this attestation, or submitting false or misleading
information, could result in delay of travel, denial of boarding, or denial of boarding on future
travel. Any traveler 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 (providing for fines and/or imprisonment of up to one year). Willfully
providing false or misleading information may lead to criminal fines and imprisonment under,
among others, 18 U.S.C. § 1001. The U.S. Department of Justice may seek to prosecute
individuals who knowingly and willfully submit false attestations in violation of 18 U.S.C. §
1001.
Translations of this attestation approved by CDC will be made available online. In the event of
any inconsistency between the English text of this attestation and any translation, the English
text controls.
Privacy Act Statement
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 persons arriving by aircraft
into the United States. Failure to provide this information may prevent you from boarding the
plane. CDC may use this information to help prevent the introduction, transmission, and spread
of communicable diseases by performing contact tracing investigations, notifying exposed
individuals and public health authorities, and other appropriate public health interventions,
including the implementation of travel restrictions.

OMB Control No: 0920-1474
Expiration Date: 3/31/2027
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. 09-200171, 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 Health, 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.