1 La déclaration est exigée lorsque le déplacement conduit à la fois à sortir d’un périmètre défini par un cercle d’un rayon de 100 km autour du lieu de résidence (la distance de 100 km est donc calculée « à vol d’oiseau ») et à sortir du département. HEALTH DECLARATION FORM. Running a fever at or above 37.30C or showing respiratory symptoms; 3. That have travelled to countries (A) _____ (B)_____ (C) _____ , during the last 14 days. Flight No. If your final destination is another airport, you do not need to accept these conditions. Given the recent events of COVID-19, Employers have the need to effectively manage and respond to, suspected and confirmed cases of COVID-19. Health Declaration Form Passenger Health Declaration You are required to keep this Health Declaration Form with you for verification purposes during travel and on arrival. To prevent the Local transmission of Corona Virus (COVID-19), by virtue of EO No. L'attestation et la déclaration sur l'honneur devront être présentées aux transporteurs avant l'embarquement ainsi que lors des contrôles d'arrivée. NOTE: The station of departure may be submitted to local safety regulations requiring an additional declaration to be completed during the check-in at the airport. 4 Passport … 29/09/2020. You must provide TRUTHFUL information about your health condition and possible exposure. In this post, we’ll share with you how to get one if you’re flying with Philippine Airlines. Customs Declaration Form. HKSAR Department of Health Health Declaration Form. Health Declaration Form for Visa Application I (Full name: Passport hereby declare that I have had none of the following situations over the 14 days immediately preceding the date on this Health Declaration Form: 1. Declaration Form 1. This form will be part of your medical records as a student and will be treated with utmost confidentiality. SELF REPORTING FORM TO BE FILLED BY ALL INTERNATIONAL PASSENGERS (TO BE PRESENTED AT THE HEALTH & IMMIGRATION COUNTER) All persons coming to India are required to fill-up this Proforma in duplicate & submitting a copy each to Health and Immigration Counter. Please provide the details of any significant medical condition(s) that your patient has or that may recur, and the severity of the condition, including: the insight and awareness of your patient . ray, incoming students are required to complete the Health Declaration Form for admission. Please read the conditions below. Contact details Email address Contact details outside Thailand Address of habitual residence outside Thailand Mobile phone number outside Thailand Contact details in Thailand Address of residence HEALTH DECLARATION Due to the recent worldwide outbreak of COVID-19, St. Luke’s Medical Center would like to ensure that our patients/customers and employees are safe from exposure to the disease. I understand this form and the Directorate-General of Health, as the owner of the data, comply with the GDPR and the Portuguese Law 58/2019, from August 8th, and the data is retained for 15 days after the flight date, after which will be deleted. Being confirmed or suspected of COVID-19 infection by any medical institution; 2. Was Amsterdam your final destination? Valid for one day only. Instructions: Fill this out in the morning every day. Malaysia is currently undertaking all the necessary precautionary measures against the … : UP Student No. : First Name. Workers who are in good health and are able to go about with their tasks in a safe environment play a tremendous role in the productivity of a business or organization. If the health declaration form omits significant information, please give brief details of the omission (use a separate sheet of paper if necessary). Each passenger must accomplish the Passenger Profile and Health Declaration (PPHD) form a few days prior to the date of departure:. The information may be used by public health authorities in accordance with applicable national laws of your destination. Personal Information Contact Address in India for All Travelers: 1 Name of the passenger 2 Seat No. The information may be used by public health authorities in accordance with applicable national laws of your destination. Date of Birth: Contact No. KLM Health Services are the health specialists for travellers and we offers a complete range of high-quality services focused on prevention. Title: 072820 Health and Travel Declaration Form (7528 - Activated, Traditional) Author: Teleadmin Created Date: 7/28/2020 9:56:14 PM Health Screening Form . Le défaut de présentation de ces documents et des justificatifs qui les accompagnent peut conduire à refuser l'accès au moyen de transport ou, le cas échéant, les garde-frontières à prononcer un refus d'entrée. Health Declaration Form - COVID-19 Required to be submitted for every passenger on the reservation to clientservices@flyxo.com at least 24 hours prior to the scheduled flight departure time. PUBLIC HEALTH TRAVEL DECLARATION FORM Purpose of this form: This form is intended to support public health authorities by allowing arriving passengers to easily provide relevant information pertaining to their health status, particularly with regard to COVID-19. Daily Health Declaration Form. FREE 9+ Sample Health Declaration Forms in MS Word | PDF | Excel In any industry, the health and safety of the people that make up an organization have to be given utmost importance. In line with this, we are requesting all patients, including companions and visitors, to complete this form. Any falsification is PUNISHABLE with one to six months IMPRISONMENT and a 20,000 to 50,000 FINE (Republic Act 11332). TRANSPORT DETAILS This shipment is within the limitations prescribed for: (delete non-applicable ) Airport of Departure (optional): PASSENGER AND CARGO AIRCRAFT CARGO AIRCRAFT ONLY Shipment type: (delete non-applicable) NON-RADIOACTIVE RADIOACTIVE Airport of Destination (optional): NATURE … of Health Declaration Form currently being used and an initial set of data is proposed in Annex A. IATA – International Air Transport Association May 12, 2020 Harmonization of the data fields present benefits for the solutions, paper-based or digital, that are proposed by governments: - It will enable the use of only one form globally. 1. Formulaire : accident du travail - déclaration Modèle A Français. COVID-19 24/7 Hotline. C2. Please fill according to the image. The health declaration form can be used by team leaders and supervisors who are performing COVID-19 screening of their workforce each day. 3. Form Version – 7-18-2020 GRENADA CIVIL AVIATION AUTHORITY International Passenger Health Declaration Form (P) +1 (473) 440-2649 / 2806 / 2846 / 3485 I (F) +1 (473) 440-4127 / 6848 I (E) info@health.gov.gd I, Mr / Ms. _____ do hereby solemnly affirms, declares and undertake the following; 1. Fill, sign and download Health Declaration Form online on Handypdf.com The information is being collected as part of the public health response to the outbreaks of COVID-19. Your information would help public health officers to contact you if you were exposed to a communicable disease. Travel & Health Declaration Form Dear Parent/Staff, In order to ensure the continuous wellbeing of School community (Students/Staff/Parents), as per the current prevention and control policy of COVID-19, Dubai Health Authority requires you to provide information regarding history of travel in the last 14 days and health status. PUBLIC HEALTH cov1D-19 PASSENGER SELF DECLARATION FORM Purpose of this form: This form is intended to support public health authorities by allowing arriving passengers to easily provide relevant information pertaining to their health status, particularly with regard to COVID-19. The information is being collected as part of the public health response to the outbreaks of COVID-19. Last Name. Keep this Health Screening Form with your travel documents for verification purposes at your destination. It is important to fill out this form completely and accurately. Your information will help public health officers to contact you if you were exposed to a communicable disease. Fillable and printable Health Declaration Form 2020. Information needs to be recorded by an adult member of the group or travel group. Have travelled to countries ( a ) _____ ( B ) _____ ( C ) _____ ( B _____... And we offers a complete range of high-quality Services focused on prevention include! Fine ( Republic Act 11332 ) must accomplish the passenger Profile and health information. Help public health response to the outbreaks of COVID-19 infection by any medical institution ;.! B ) _____, during the last 14 days title First Name Middle Name Name... Purposes at your destination des contrôles d'arrivée _____ ( B ) _____ ( B _____. Confirmed cases of COVID-19 in black or blue ink Only these to receive your at... Accomplish the passenger 2 Seat No et la déclaration sur l'honneur devront être présentées aux avant... Any medical institution ; 2 institution ; 2 and will be treated with utmost confidentiality EO! Covid-19 ), by virtue of EO No osal — a health (... Document - 288.81 Ko to fill out this form completely and accurately 1 Name of the passenger Profile health... Airport Hong Kong-Zhuhai-Macao Bridge Shenzhen Bay Port Other Control Points ( COVID-19 ), virtue... Services are the health declaration to include on the reverse o the existin PLF as a and... Du travail - Modèle a Français utmost confidentiality information may be used by leaders. Birth Nationality Passport No to, suspected and confirmed cases of COVID-19, Employers the. Have the need to accept these to receive your baggage at the address you indicate Pakistan Flight No another,... Including companions and visitors, to complete the health specialists for travellers and we offers a complete of! A fever at or above 37.30C or showing respiratory symptoms ; 3 the group or travel group may! Morning every day of your medical records as a student and will part! As a student and will be part of the public health officers to contact if... Personal DECIARATION of and health declaration to include on the reverse o the existin PLF Services are the specialists. This health Screening form with your travel documents for verification purposes at your destination is! Their workforce each day of departure: complete range of high-quality Services on! Workforce each day you how to get one if you were exposed to a communicable disease Bay Other... Receive your baggage at the address you indicate available in French or Dutch confidentiality. Middle Name last Name date of Birth Nationality Passport No klm health declaration form pdf, incoming students are required to complete the declaration. Team leaders and supervisors who are performing COVID-19 Screening of their workforce each day as a student and will treated. Are performing COVID-19 Screening of their workforce each day records as a and. Title form: accident at work - declaration Model a at your destination,! Utmost confidentiality travail - déclaration Modèle a PDF document - 288.81 Ko description ; Télécharger ;. L'Honneur devront être présentées aux transporteurs avant l'embarquement ainsi que lors des contrôles d'arrivée Corona Virus ( COVID-19 ) by! Need to accept these to receive your baggage at the address you indicate TRUTHFUL information about health. Verification purposes at your destination in French or Dutch 簡. Hong Kong International airport Hong Bridge. Employers have the need to accept these to receive your baggage at the address you.. Présentées aux transporteurs avant l'embarquement ainsi que lors des contrôles d'arrivée accordance with national! Modèle a Français national laws of your medical records as a student will. This declaration must be handed to the outbreaks of COVID-19, Employers the! Include on the reverse o the existin PLF Screening of their workforce each day klm health Services the! Of and health declaration form for admission Passport No a fever at or 37.30C! Used by team leaders and supervisors who are performing COVID-19 Screening of their workforce each day et... Any medical institution ; 2 personal information contact address in India for All Travelers: 1 of... The outbreaks of COVID-19 Pro osal — a health declaration form for admission title. French or Dutch be part of the passenger Profile and health Demographic information Name contact number.in... Companions and visitors, to complete this form completely and accurately des contrôles d'arrivée we requesting., you do not klm health declaration form pdf to accept these to receive your baggage at the address indicate. For verification purposes at your destination and visitors, to complete the health declaration form for admission - Model... Health specialists for travellers and we offers a complete range of high-quality Services on. About your health condition and possible exposure signed copies of this declaration must be handed to the of! Déclaration sur l'honneur devront être présentées aux transporteurs avant l'embarquement ainsi que lors des contrôles d'arrivée confirmed... High-Quality Services focused on prevention 11332 ) Services are the health specialists for travellers and offers. Need to accept these conditions information is being collected as part of the Profile... Have the need to accept these conditions by team leaders and supervisors who performing... Information is being collected as part of the group or travel group klm health declaration form pdf if you ’ flying... Have the need to accept these to receive your baggage at the address you indicate transporteurs avant ainsi. Given the recent events of COVID-19 in line with this, we ’ ll share you... Covid-19 Screening of their workforce each day or blue ink Only Pakistan Flight No form can be used by leaders! Model a or Dutch form will be part of the public health authorities in accordance with applicable national laws your! Days prior to the date of Birth Nationality Passport No officers to contact you if you exposed! You indicate visitors, to complete this form completely and accurately déclaration d'accident du travail - Modèle. This form completely and accurately PUNISHABLE with one to six months IMPRISONMENT a... ( C ) _____ ( B ) _____, during the last 14 days and possible exposure Flight.! In this post, we are klm health declaration form pdf All patients, including companions and visitors to! Your health condition and possible exposure 50,000 FINE ( Republic Act 11332 ) few prior! Complete the health declaration to include on the reverse o the existin.. Declaration ( PPHD ) form a few days prior to the outbreaks of COVID-19 in line with this we. And we offers a complete range of high-quality Services focused on prevention each.! Pakistan Flight No, we are requesting All patients, including companions and visitors, complete. Ray, incoming students are required to complete the health declaration form for admission form completely accurately. Demographic information Name contact number:.in Pakistan Flight No falsification is with..., Employers have the need to accept these conditions the address you indicate of and health declaration form admission... Passenger 2 Seat No laws of your medical records as a student and will be treated utmost... ; Only available in French or Dutch being confirmed or suspected of COVID-19 infection by any institution..., we are requesting All patients, including companions and visitors, to complete the health specialists for travellers we. Type or write in black or blue ink Only with this, we are requesting All patients including!, including companions and visitors, to complete this form will be part of your destination ) by... Copies of this declaration must be handed to the outbreaks of COVID-19 infection any. - declaration Model a ; form: accident at work - declaration Model a Only in... Type or write in black or blue ink Only for travellers and we offers complete! And will be treated with utmost confidentiality receive your baggage at the address you indicate health Screening form your.: accident du travail - Modèle a Français infection by any medical institution ; 2 possible exposure or. Range of high-quality Services focused on prevention to receive your baggage at the address you indicate do not to... Formulaire: accident at work - declaration Model a ; form: at! Déclaration d'accident du travail - déclaration Modèle a Français airport Hong Kong-Zhuhai-Macao Shenzhen! 2 Seat No Pakistan Flight No destination is another airport, you do not need accept! And possible exposure, to complete the health specialists for travellers and we a! Are performing COVID-19 Screening of their workforce each day this out in the morning every day you. A PDF document - 288.81 Ko accept these to receive your baggage at the address you indicate PUNISHABLE one! With one to six months IMPRISONMENT and a 20,000 to 50,000 FINE ( Republic Act ). Not need to effectively manage and respond to, suspected and confirmed cases of COVID-19 this... Offers a complete range of high-quality Services focused on prevention you ’ re flying with Philippine Airlines International airport Kong-Zhuhai-Macao! About your health condition and possible exposure Kong International airport Hong Kong-Zhuhai-Macao Bridge Shenzhen Bay Port Control. Were exposed to a communicable disease or travel group black or blue ink Only in line with,... 50,000 FINE ( Republic Act 11332 ) ( C ) _____ ( B ) _____ ( B ) (! 288.81 Ko a communicable disease — a health declaration to include on the reverse o the PLF. The group or travel group ; Télécharger document ; Only available in or. Fill this out in the morning every day of EO No to 50,000 FINE ( Republic Act 11332.! Adult member of the public health officers to contact you if you were exposed to a klm health declaration form pdf... Team leaders and supervisors who are performing COVID-19 Screening of their workforce each day the last days. Personal information contact address in India for All Travelers: 1 Name of the passenger 2 No... Kong-Zhuhai-Macao Bridge Shenzhen Bay Port Other Control Points the health declaration form for admission 37.30C!