Ebola Virus Diclaretion Form

EVD Declaration form

FOOMKA CADDEYNTA CAAFIMAADKA SOCDAALAHA TRAVELER HEALTH DECLARATION FORM

Wasaaradda Caafimaadka iyo Adeegga Bulshada Machadka Caafimaadka Qaranka/

Ministry of Health - National Health Institute of Somalia

1. Macluumaadka Socdaalaha/ Traveler Information

Magaca oo dhameystiran/ Full name:

Lambarka baasaboorka/Aqoonsiga / Passport/ID No.:

Cinwaanka Soomaaliya/ Address in Somalia

Dagmada/ District

Magaalada/ City

Damiin/ Contact person

Teleefan/ Phone

Jinsiyadda/ Nationality:

Taariikhda Dhalashada/ Date of Birth

Taleefan/ Phone:

Ciwaanka/ Email:

Jinsiga/ Sex

Lab/ male

Dhadig/ Female

2. Macluumaadka Safarka / Travel Information

Dalka laga soo safray/ Country of departure:

Goobta laga soo galay/ Point of entry:

Taariikhda imaanshaha/ Date of arrival:

Dalalka la sii maray/ Countries transited:

3. Taariikhda Safarka 21-kii Maalmood ee Ugu Dambeeyay / Travel History in the Last 21 Days

Ma tagtay ama ma sii martay meel Ebola ka jiro ama khatar sare leh? / Have you visited or transited through an Ebola-affected/high-risk area?

Haa/ Yes

Maya/ No

Haddii HAA, sheeg dalka/magaalada / If YES, specify country/city:

4. Baaritaanka Calaamadaha / Symptoms Screening

Calaamad / Symptom

5. Taariikhda La-kulanka Khatar Caafimaad / Exposure History

21-kii maalmood ee ugu dambeeyay, ma dhacday inaad: / In the last 21 days, have you:

La kulantay qof looga shakisan yahay ama laga xaqiijiyay Ebola? / Had contact with a suspected or confirmed Ebola case?

Haa/ Yes

Maya/ No

Taabatay dhiig ama dheecaan jirka ka yimid qof xanuunsan? / Had contact with blood or body fluids of a sick person?

Haa/ Yes

Maya/ No

Ka qaybgashay aas ama taabatay meyd meel cudurku ka jiro? / Attended a funeral or touched a body in an affected area?

Haa/ Yes

Maya/ No

Ka shaqeysay/booqatay xarun caafimaad oo lagu hayo kiisaska Ebola? / Worked in or visited a health facility managing Ebola cases?

Haa/ Yes

Maya/ No

Contact

TRAVELER HEALTH DECLARATION FORM

FOOMKA CADDEYNTA CAAFIMAADKA SOCDAALAHA TRAVELER HEALTH DECLARATION FORM

Wasaaradda Caafimaadka iyo Adeegga Bulshada Machadka Caafimaadka Qaranka/

Ministry of Health - National Health Institute of Somalia

1. Macluumaadka Socdaalaha/ Traveler Information

2. Macluumaadka Safarka / Travel Information

3. Taariikhda Safarka 21-kii Maalmood ee Ugu Dambeeyay / Travel History in the Last 21 Days

4. Baaritaanka Calaamadaha / Symptoms Screening

5. Taariikhda La-kulanka Khatar Caafimaad / Exposure History

Thank You

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