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    Intake Form: Health Declaration For Travellers

    Uploaded by

    HekiXam
    This document is an intake form for a health declaration that travellers must complete truthfully and keep with them throughout their journey. It asks travellers questions about whether they have been diagnosed with or exposed to COVID-19, and whether they are experiencing symptoms. If any questions are answered yes, the traveller will not be permitted to board. It collects passenger information like flight number and name. The traveller must sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Intake Form: Health Declaration For Travellers

    Uploaded by

    HekiXam
    159 views1 page
    This document is an intake form for a health declaration that travellers must complete truthfully and keep with them throughout their journey. It asks travellers questions about whether they have been diagnosed with or exposed to COVID-19, and whether they are experiencing symptoms. If any questions are answered yes, the traveller will not be permitted to board. It collects passenger information like flight number and name. The traveller must sign and date the form.

    Original Description:

    For travelling abroad

    Original Title

    Dutch Health Declaration

    Copyright

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    This document is an intake form for a health declaration that travellers must complete truthfully and keep with them throughout their journey. It asks travellers questions about whether they have been diagnosed with or exposed to COVID-19, and whether they are experiencing symptoms. If any questions are answered yes, the traveller will not be permitted to board. It collects passenger information like flight number and name. The traveller must sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    159 views1 page

    Intake Form: Health Declaration For Travellers

    Uploaded by

    HekiXam
    This document is an intake form for a health declaration that travellers must complete truthfully and keep with them throughout their journey. It asks travellers questions about whether they have been diagnosed with or exposed to COVID-19, and whether they are experiencing symptoms. If any questions are answered yes, the traveller will not be permitted to board. It collects passenger information like flight number and name. The traveller must sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Intake form

    Health declaration for travellers


    Answer the following questions truthfully and keep your completed health declaration form close at hand while travelling. You will
    need it throughout the course of your journey and when you reach your final destination. You must show this form when boarding.
    In addition, airport staff and the designated health authorities at the airport may ask to see it. This data is collected as part of the
    public health measures taken in response to the COVID-19 pandemic and, pursuant to Dutch legislation, may be processed by the
    health authorities. All travellers aged 12 and older are required to complete this form.

    1 Please select ‘yes’ or ‘no’ in response to the following questions.


    1.1 Have you (or the person for whom you are completing this form) been diagnosed as currently having a lung infection
    or coronavirus infection (COVID-19), or is there suspicion that you might have either of these? n Yes n N0

    1.2 Should you (or the person for whom you are completing this form) currently be in quarantine because you were in
    contact with someone infected with coronavirus, whether a close contact or someone you were informed about through
    the CoronaMelder app, and you are not fully vaccinated? n n Yes n N0

    1.3 Have you (or the person for whom you are completing this form) experienced any of the following symptoms in the past 24 hours?
    In case you have tested negative for COVID-19 after the development of the symptoms, this question can be answered with ‘no’

    Cold symptoms (such as congestion, runny nose, sneezing or sore throat) n


    n Yes n No

    Cough n
    n Yes n No

    Shortness of breath n
    n Yes n No

    Raised temperature or fever n


    n Yes n No

    Sudden loss of smell and/or taste (without congestion) n


    n Yes n No

    If you answered ‘yes’ to any of the above questions, under the transport agreement you are not permitted to board.

    2 Passenger information
    2.1 Flight number

    2.2 Surname and first and middle initial(s)

    2.3 Date of birth (ddmmyyyy)

    3 Signature
    Completed truthfully on

    3.1 Date (ddmmyyyy)

    Signature

    Signature

    VWS_DCo_2020.11

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