EBOLA OUTBREAK TRAVELER HEALTH DECLARATION

To protect your health and the health of others, please complete this form honestly and accurately.
This information is collected for public health purposes in response to the Ebola outbreak. The information will be used by Port Health Services (PHS) and other public health authorities.

Ebola outbreak Traveler Health Declaration Form

1. TRAVELER INFORMATION

PORT HEALTH SERVICES (PHS)

Last (Family) Name

First (Given) Name

Nationality:

Passport Number:

Date of Birth (DD/MM/YYYY);

Gender

Male

Female

Other

Occupation:

Country of Residence:

Phone Number (Including Country Code):

Home Address:

Address in Somalia (where you will be staying for the next 21 days):

Emergency Contact in Somalia (Name):

Relationship:

Phone Number:

2. TRAVEL HISTORY (EBOLA RISK AREAS) - last 21 days (3 weeks)

Have you been in, or transited through, or visited any of the following countries/areas in the last 21 days?

Democratic Republic of the Congo (DR Congo)

Option 5

Guinea

Liberia

Sierra Leone

Uganda

Yes

Guinea

Yes

Liberia

Yes

Sierra Leone

Yes

Other Countries / areas with ongoing Ebola outbreak

Yes

If Yes, specify countries/areas and dates of visit:

3. HEALTH SCREENING QUESTIONS

A. Current Symptoms - today or in the past 48 hours, have you had any of the following symptoms?

Fever

Yes

Vomiting

Yes

Diarrhea

Yes

B. Risk Exposure - in the last 21 days (3 week), have you

1. Lived in the same household or had direct contact with a person sick with Ebola or a person who died from Ebola?

Yes

2. Visited a health care facility or laboratory in a country with an Ebola outbreak?

Yes

3. Had direct contact with blood, body fluids or tissues of a person suspected or confirmed eith Ebola?

Yes

4. Attended a funeral or had contact with the body of a person who died in a country with an Ebola outbreak?

Yes

5. Had contact with wild animals (bats, Primates) in a country with an Ebola outbreak?

Yes

EBOLA OUTBREAK TRAVELER HEALTH DECLARATION

To protect your health and the health of others, please complete this form honestly and accurately.
This information is collected for public health purposes in response to the Ebola outbreak. The information will be used by Port Health Services (PHS) and other public health authorities.

1. TRAVELER INFORMATION

2. TRAVEL HISTORY (EBOLA RISK AREAS) - last 21 days (3 weeks)

3. HEALTH SCREENING QUESTIONS

Our Services

Recent Post

EBOLA OUTBREAK TRAVELER HEALTH DECLARATION

To protect your health and the health of others, please complete this form honestly and accurately. This information is collected for public health purposes in response to the Ebola outbreak. The information will be used by Port Health Services (PHS) and other public health authorities.

1. TRAVELER INFORMATION

2. TRAVEL HISTORY (EBOLA RISK AREAS) - last 21 days (3 weeks)

3. HEALTH SCREENING QUESTIONS

To protect your health and the health of others, please complete this form honestly and accurately.
This information is collected for public health purposes in response to the Ebola outbreak. The information will be used by Port Health Services (PHS) and other public health authorities.