Health Declaration Form
2020/08/12

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 37.3ÂșC 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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