TRAVELER HEALTH DECLARATION FORM – National Institute of Health

Ebola Diclaration 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:

Taariikhda Dhalashada/ Date of Birth

Jinsiyadda / Nationality:

Lambarka baasaboorka/Aqoonsiga / Passport/ID No.:

Taleefan / Phone:

Jinsiga/ Sex

Lab/ Male

Dhadig/ Female

Cinwaanka Soomaaliya/ Address in Somalia

Ciwaanka/ Email:

2. Macluumaadka Safarka / Travel Information

Dalka laga soo safray/ Country of departure:

Lambarka duulimaadka/gaari/markab / Flight/vehicle/vessel No.:

Goobta laga soo galay / Point of entry:

Dalalka la sii maray / Countries transited:

Taariikhda imaanshaha / Date of arrival:

Kursiga haddii jiro / Seat No. if any

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

Qandho / Fever:

Haa/ Yes

Maya/ No

Shuban / Diarrhea:

Haa/ Yes

Maya/ No

Madax-xanuun / Headache:

Haa/ Yes

Maya/ No

Cunaha oo xanuuna / Sore throat:

Haa/ Yes

Maya/ No

Xanuun aan caadi ahayn / Unusual illness:

Haa/ Yes

Maya/ No

Matag / Vomiting:

Haa / Yes

Maya / No

Tabar-darro daran / Severe weakness:

Haa/ Yes

Maya/ No

Murqo-xanuun / Muscle pain:

Haa/ Yes

Maya/ No

Dhiig-bax aan la garanayn / Unexplained bleeding:

Haa/ Yes

Maya/ No

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

6. Caddeynta Caafimaadka Dadweynaha / Public Health Declaration

Waxaan caddeynayaa in macluumaadka kor ku xusan uu yahay run oo dhameystiran. Waxaan oggolahay inaan la shaqeeyo Adeegyada Caafimaadka Xuduudaha, baaritaanka heerkulka, qiimeynta caafimaadka iyo tilmaamaha hay’adaha masuulka ah. / I declare that the information provided is true and complete. I agree to cooperate with Port Health Services, temperature screening, health assessment and public health instructions.

Magaca Socdaalaha / Traveler Name:

Saxiix / Signature:

Taariikhda / Date issue

Taleefan Degdeg ah / Emergency Phone:

EBOLA OUTBREAK TRAVELER HEALTH DECLARATION

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

6. Caddeynta Caafimaadka Dadweynaha / Public Health Declaration

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