中华人民共和国出入境检验检疫

附件：

中华人民共和国出入境检验检疫

出/入境健康申明卡

根据《中华人民共和国国境卫生检疫法》有关规定，为了您和他人的健康，请如实逐项填报，如有隐瞒或虚假填报，将依据有关法律追究相关责任。

姓名性别：□男□女

出生日期_______年______月国籍/地区

护照（回乡证、通行证）号码目的地

航班（船、车次）号座位号_____

1. 在中国7天内的行程

继续旅行乘坐的航班（船、车次）号日期

中国境内详细联系地址

真实有效的联系电话

2. 如7天内离开中国，请填写离开日期月日，目的地国家

所乘交通工具的航班（船、车次）号

3. 过去7天内您到过的国家和城市：

4.过去7天内您是否与流感或有流感样症状的患者有过密切接触？

是□否□

5. 您如有以下症状和疾病，请在“□”中划“√”

□发热□咳嗽□嗓子痛（喉咙痛）□肌肉痛和关节痛□鼻塞

□头痛□腹泻□呕吐□流鼻涕□呼吸困难□乏力

□其它症状

我已阅知本申明卡所列事项，并保证以上申报内容正确属实。

旅客签名：

日期：

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HEALTH DECLARATION FORM ON ENTRY/EXIT

Entry-Exit Inspection and Quarantine of the P.R.China

According to the FRONTIER HEALTH AND QUARANTINE LAW OF THE PEOPLE'S REPUBLIC OF CHINA,for your and others’ health,please fill in the form truly and completely. False information of intent will be followed with legal consequences.

Name Sex: □Male □Female

Date of Birth__________________ Nationality/Region_______________

Passport No. ___________________ The destination

Flight(boat/ train/bus)No.____________Seat No. ____________

1.The itinerary of the next 7 days in China

Vechile of your next trip,Flight(boat/ train/bus)No. Date

Contact address of the next 7 days in China.

Contact telephone number （Residential or Business or Mobile or Hotel）

Contact information for the person who will best know where you are for the next 7days,in case of emergency or to provide critical health information to you ,please provide the name of

a close personal contact or a work contact. This must NOT be you.

Name Telephone No.

2.If you leave China in 7 days, please fill in the Departure Date / （mm/dd）

The destination country，Flight(boat/ train/bus)No.

3.Please describe the countries and cities(towns) where you stayed within the last 7 days?

4.Have you had close contact with patients of flu or person with flu-like symptoms within the

last 7 days? Yes□No□

5.If you have the symptoms and diseases Please mark with “√” in the corresponding “□”

□Fever □Cough □Sore throat □Muscle and joint pain □Stuffy nose

□Headache □Diarrhoea □V omiting □Runny nose □Breath difficulty □Fatigue □Other symptoms

I declare that all the information given in this form is true and correct.

Signature of passenger Date:_______________

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