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Self Declaration Health Form

This 3 sentence summary provides the key information from the self-declaration health form: The self-declaration health form requires travelers to confirm that they are not residing in a containment zone, experiencing any COVID-19 symptoms, under quarantine, or have tested positive for COVID-19 in the last two months. It also states that travelers must provide contact information, agree to contact health authorities if symptoms develop, and understand they may face penalties for traveling without meeting eligibility criteria.

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Daulath Alikhan
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276 views1 page

Self Declaration Health Form

This 3 sentence summary provides the key information from the self-declaration health form: The self-declaration health form requires travelers to confirm that they are not residing in a containment zone, experiencing any COVID-19 symptoms, under quarantine, or have tested positive for COVID-19 in the last two months. It also states that travelers must provide contact information, agree to contact health authorities if symptoms develop, and understand they may face penalties for traveling without meeting eligibility criteria.

Uploaded by

Daulath Alikhan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SELF-DECLARATION HEALTH FORM

It is mandatory, as per the Government of India guidelines,


to give a declaration to the following effect:

i) I/we am/are not residing in any containment zone.


ii) I/we am/are not are suffering from any fever/cough/any
respiratory distress.
iii) I/we am/are not under quarantine.
iv) If I/we develop any of the above-mentioned symptoms. I shall
contact the concerned health authorities immediately.
v) I/we have not tested COVID-19 positive in the last two months.
vi) I/we am/are eligible to travel as per the extant norms.
vii) I shall make my mobile number/contact details available to the
airlines whenever required by them.
viii) I understand that if I undertake the air journey without meeting
the eligibility criteria, I would be liable to penal action.
Ix) I am/we are fully aware of the state requirements.

Name(s):
PNR number:
Flight number: Seat number:
Origin: Destination:

Mobile number:
E-mail ID:

Address at the destination:

Destination pin code:

Signature:

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