TRAVELER’S HEALTH DECLARATION/QUESTIONNAIRE

TRAVELER’S HEALTH DECLARATION/QUESTIONNAIRE
To be completed prior to boarding by all persons. One form per person.
Date *

Month Day Year
Date
DEP Airport *
ARR Airport *
Name (as it appears on Passport/Driver’s License/Birth Certificate) *
TO ASSIST US IN PROTECTING THE HEALTH AND SAFETY OF PASSENGERS AND CREW ON THIS FLIGHT, WE REQUIRE YOU TO ANSWER THE FOLLOWING QUESTIONS?
1. Have you traveled outside of the United States in the last 14 days? *

YES NO
If you answered YES above, please list the countries you traveled to in the space below.
2. Have you, or any person listed above, had close contact with, or helped care for, anyone suspected or diagnosed with COVID-19, or who is currently subject to health monitoring for possible exposure to COVID-19? *

YES NO
3. Do you have a fever (100.4 F° / 38 C° or higher), feel feverish, or have chills, a cough, or difficulty breathing? *

YES NO
4. Have you ever tested positive for COVID-19? *

YES NO
Please list date of last positive test result

Month Day Year
If you have answered YES to any of the questions above, you may be denied boarding, or may have to quarantine at your destination depending on local regulations. If you answered YES to question 4 above, your postive test must have been more than 14 days prior to your date of travel.
5. Have you been fully vaccinated for COVID-19?

YES NO
If you answered YES above, please provide the date of your last shot and show vaccination card to crew upon request.

Month Day Year
I certify that the above declaration is true and correct and understand that any dishonest answers may have serious public health implications.
Signature of Traveler: *

Clear
Date *

Month Day Year
Signature of Parent/Guardian if traveler is under 18 years of age:

Clear
Date:
Should be Empty:

TRAVELER’S HEALTH DECLARATION/QUESTIONNAIRE

TO ASSIST US IN PROTECTING THE HEALTH AND SAFETY OF PASSENGERS AND CREW ON THIS FLIGHT, WE REQUIRE YOU TO ANSWER THE FOLLOWING QUESTIONS?