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Public Health Travel Declaration Form Template

Streamline Your Travel Health Compliance Efforts

Keeping track of travelers' health information can be a challenge, especially in our fast-paced environment. This public health travel declaration form template is designed for organizations and institutions needing to ensure compliance with health regulations while making the process effortless for travelers. With this template, you can easily collect essential health details, monitor compliance with regulations, safeguard public health, and streamline your data collection process-all in a user-friendly format. Start using the live template today to simplify your health monitoring efforts.

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Full name
Date of birth
Nationality or citizenship
Passport or national ID number
Email address
Mobile phone number (include country code)
Address while in destination (accommodation name and full address)
Emergency contact full name
Emergency contact phone number
Emergency contact relationship
Spouse/Partner
Parent/Guardian
Child
Sibling
Relative
Friend
Employer
Other
Please Specify:
Arrival date
Mode of travel
Air
Sea
Land
Carrier/flight/vessel/train/bus number
Seat or cabin number
Country of departure immediately before arrival
Countries visited in the past 14 days (list all, with dates if known)
Purpose of travel
Resident returning
Visitor/Tourism
Work/Business
Study
Transit
Diplomatic/Official
Other
Please Specify:
In the past 10 days, have you experienced any of the following symptoms? Select all that apply.
In the past 14 days, have you had close contact with someone who was ill with a contagious respiratory infection?
Yes
No
Not sure
Prefer not to say
In the past 10 days, have you tested positive for COVID-19, influenza, or a similar respiratory virus?
Yes, confirmed positive
Suspected/awaiting result
No
Prefer not to say
Are you currently under any isolation or quarantine order?
Yes
No
Not sure
Vaccination status relevant to destination requirements
Up to date per destination requirements
Partially vaccinated
Not vaccinated
Prefer not to say
Not applicable
I declare that the information provided in this form is true and complete to the best of my knowledge.
Yes
No
I agree to comply with applicable public health guidance and entry requirements.
Yes
No
Typed full name (serves as signature)
Date of declaration
I consent to be contacted by public health authorities if follow-up is required.
Yes
No
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Paper art illustration depicting a travel declaration form with health symbols and travel-related icons in a creative layout

When to use this form

Use this form when screening travelers entering facilities, events, or jurisdictions to reduce the spread of communicable disease. It helps public health teams, airports, universities, and employers collect travel history, symptoms, vaccination, and exposure details. Example scenarios: pre-arrival checks for international students, cruise disembarkation screening, conference registration, or returning to work after overseas travel. Responses help you triage who may need testing, isolation, or follow-up. Pair it with the Contact tracing form to quickly reach close contacts if exposure is reported. If testing is needed, create orders using the Medical requisition form.

Must Ask Public Health Travel Declaration Questions

  1. What countries or regions did you visit and what were your travel dates, including layovers, in the last 14 days?

    This shows geographic risk and whether current advisories or local rules apply. It also defines the monitoring window so you can time testing or follow-up.

  2. Do you currently have any symptoms such as fever, cough, sore throat, shortness of breath, loss of taste or smell, vomiting, or diarrhea?

    Symptoms drive immediate triage and help you prioritize who needs testing or isolation now. If severe signs are reported, prepare an Emergency room admission form to speed care.

  3. In the past 14 days, did you have close contact with someone diagnosed with a communicable disease?

    Close contact indicates higher risk and the need for targeted outreach. A clear yes/no with the exposure date helps you schedule monitoring efficiently.

  4. What is your vaccination status and the date of your most recent dose or negative test?

    This can change requirements and prevent unnecessary holds for low-risk travelers. Dates and document type help you verify compliance quickly.

  5. Where can we reach you for the next 14 days (phone, email, and local address)?

    Accurate contact details enable timely notifications if risks emerge. It also supports follow-up during the full incubation period.

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