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

Ebola Prepareness

Workshop on Enhancing one Health Approach in Emergency preparedness and Response

Workshop on Enhancing one Health Approach in Emergency preparedness and Response

Workshop on Enhancing one Health Approach in Emergency preparedness and Response

Workshop on Enhancing one Health Approach in Emergency preparedness and Response

Workshop on Enhancing one Health Approach in Emergency preparedness and Response

Workshop on Enhancing one Health Approach in Emergency preparedness and Response

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

Ebola Virus Declaration form

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