Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697804145709.pdf (India)
Ministry of Health and Family Welfare Government of India SELF REPORTING FORM FOR ALL TRAVELLERS ARRIVING from 2019-nCoV affected countries* (TO BE PRESENTED AT THE HEALTH/IMMIGRATION COUNTER) All persons coming to India from 2019-nCoV affected countries are required to fill-up this proforma.

You are requested to provide the following information to safeguard your own health.

Personal Information Contact Address in India for All Travellers: 3.

Flight No.

1 4 5 6 7 Name of the passenger Seat No.


Passport No.

Date of Arrival Port of origin of Journey Port of final destination 1 House Number Street/ Village Tehsil District/ City State Pin Residence Number Mobile Number E mail ID (PART-A) a.

During your visit to China, what all cities did you visit in last 14 days?

_______________ b.
_______________ b.

Are you suffering from any of the following symptoms**  Fever Yes No  Cough Yes No  Respiratory distress Yes No Signature of the passenger *CHINA, ANY OTHER COUNTRY AS NOTIFIED BY W.H.O.

FOR LOCAL TRANSMISSION.

(https://www.who.int/emergencies/diseases/novel- coronavirus-2019/situation-reports/) **If answer to any of the above questions is “yes”, please present yourself to the Airport Health counter for preliminary screening.
In case you develop symptoms such as fever and cough within 28 days of leaving this airport, restrict your outdoor movement and contact MoHFW’s 24 hours helpline number 011-23978046.

Call operator will tell you whom to contact further.

In the meanwhile, keep yourself isolated in your house/room.
Ministry of Health and Family Welfare Government of India SELF REPORTING FORM FOR ALL TRAVELLERS ARRIVING from 2019-nCoV affected countries* (TO BE PRESENTED AT THE HEALTH/IMMIGRATION COUNTER) All persons coming to India from 2019-nCoV affected countries are required to fill-up this proforma.

You are requested to provide the following information to safeguard your own health.

Personal Information Contact Address in India for All Travellers: 3.

Flight No.

1 4 5 6 7 Name of the passenger Seat No.


Passport No.

Date of Arrival Port of origin of Journey Port of final destination 1 House Number Street/ Village Tehsil District/ City State Pin Residence Number Mobile Number E mail ID (PART-A) a.

During your visit to China, what all cities did you visit in last 14 days?
_______________ b Are you suffering from any of the following symptoms**  Fever Yes No  Cough Yes No  Respiratory distress Yes No Signature of the passenger *CHINA, ANY OTHER COUNTRY AS NOTIFIED BY W.H.O.

FOR LOCAL TRANSMISSION.

(https://www.who.int/emergencies/diseases/novel- coronavirus-2019/situation-reports/) **If answer to any of the above questions is “yes”, please present yourself to the Airport Health counter for preliminary screening.
In case you develop symptoms such as fever and cough within 28 days of leaving this airport, restrict your outdoor movement and contact MoHFW’s 24 hours helpline number 011-23978046.

Call operator will tell you whom to contact further.

In the meanwhile, keep yourself isolated in your house/room.