Health Declaration Form
I(Full name:------- Passport number:------）
hereby declare that I have had none of the following situations in the 14 days immediately preceding the date on this Health Declaration Form:
Being confirmed or suspected of COVID-19 infcction by any medical institution:
2. Running a fever at or above 37.3C or showing respiralory symptoms:
3. Coming into contact with confirmed or suspected CovID-19 cases:
4. Coming into contact with patients with a fever or respiratory symptoms;
5. Staying in a community or hotel reporting confirmed or suspected COVID-19 cases;
6. At least two persons in my office or family running a fever or showing respiratory symptoms;
7. Taking medicine for fever or cold;
8. Visiting public spaces like hospitals, theaters. restaurants and leisure facilities or taking part in group activities without taking protective measures like wearing a mask 。
I declare the truthfulness and veracity of the statements above and the COVID-19 negative certificate I have provided. If any of the above- mentioned situations happens to me before leaving for China, I shall cancel the trip.
I acknowledge and accept the responsibilities under this Declaration pursuant to the relevant laws and regulations of the e People's Republic of China should I conceal any health condition thatmight cause the spread of quarantinable infectious diseases or give rise to
serious risks of such spread.
Signature: Date: 14/10/2020(Day/Month/Year)
To be completed by consular officers of the Chinese Embassy :
The Chinese Embassy has examined the COVID-19 ncgative certificate (No Issuance date ) provided by the declarant.
Used for the sole purpose of pre-boarding screening by airlines, this health declaration form is valid until---
Date: )Day/Month/Year)
