HEALTH DECLARATION FORM ON ENTRY/EXIT

                                                          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

Other symptoms                                                           

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)

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