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Health Declaration Form
2020/07/27

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:

  1. Being confirmed or suspected of COVID-19 infection by any medical institution;

  2. Running a fever at or above 37.3ºC or showing respiratory 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 People’s Republic of China should I conceal any health condition that might cause the spread of quarantinable infectious diseases or give rise to serious risks of such spread.

  Signature:                                                    Date: ____/____/_____(Day/Month/Year)

 

  To be completed by consular officers of the Chinese Embassy or Consulate:

  The Chinese Embassy/Consulate has examined the COVID-19 negative 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 ____/____/_____.

  Seal:                                                             Date: ____/____/_____(Day/Month/Year)

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