Entry-Exit Inspection and Quarantine of the P.R.China
According to the FRONTIER HEALTH AND QUARANTINE LAW OF THE PEOPLE'S REPUBLIC OF CHINA, for your and others' health, please fill in the form truly and completely. False information of intent will be followed with legal consequences.
Name Sex: □Male □Female
Date of Birth__________________ Nationality/Region_______________
Passport No. ___________________ The destination
Flight(boat/ train/bus)No.____________ Seat No. ____________
1. The itinerary of the next 7 days in China
Vechile of your next trip, Flight(boat/ train/bus)No. Date
Contact address of the next 7 days in China.
Contact telephone number （Residential or Business or Mobile or Hotel）
Contact information for the person who will best know where you are for the next 7days,in case of emergency or to provide critical health information to you ,please provide the name of a close personal contact or a work contact. This must NOT be you.
Name Telephone No.
2. If you leave China in 7 days, please fill in the Departure Date / （mm/dd）
The destination country ，Flight(boat/ train/bus)No.
3. Please describe the countries and cities(towns) where you stayed within the last 7 days?
4. Have you had close contact with patients of flu or person withflu-like symptomswithin the last 7 days? Yes □ No □
5. If you have the symptoms and diseases Please mark with “√” in the corresponding “□”
□Fever □Cough □Sore throat □Muscle and joint pain □Stuffy nose
□Headache □Diarrhoea □Vomiting □Runny nose □Breath difficulty □Fatigue
I declare that all the information given in this form is true and correct.
Signature of passenger Date:_______________
Temperature (for quarantine official only):______________ºC
Signature of quarantine official : _____________________
(Source: General Administration of Quality Supervision,Inspection and Quarantine of the People's Republic of China)