PASSENGER ATTESTATION FORM

[ ] I attest that I have recovered from COVID-19 in the last 3 months (90 days), or the time period specified in current CDC guidance, after having previously.

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PASSENGER ATTESTATION FORM
I (name of passenger or authorized representative) have read the disclosure pertaining to my obligation to obtain a negative pre-departure test result for COVID-19 or to having recovered from COVID-19 after previous SARS-CoV-2 infection and being cleared to travel in order to board an aircraft departing from a foreign country and arriving in the United States.
Check one of the options that applies
[ ] I attest that I have received a negative pre-departure test result for COVID-19. The test was a viral test that was conducted on a specimen collected from me during the 3 calendar days preceding the flight's departure.
[ ] I attest that I have recovered from COVID-19 in the last 3 months (90 days), or the time period specified in current CDC guidance, after having previously tested positive for SARS-CoV-2 and have been cleared for travel by a licensed healthcare provider or public health official.
[ ] On behalf of [__________], I attest that such person has received a negative pre-departure test result for COVID-19. The test was a viral test that was conducted on a specimen collected from that person during the 3 calendar days preceding the flight's departure.
[ ] On behalf of [___________], I attest that such person has recovered from COVID-19 in the last 3 months (90 days), or the time period specified in current CDC guidance, after having previously tested positive for SARS-CoV-2 and has been cleared for travel by a licensed healthcare provider or public health official.
______________________________________ __ Name/Signature/Flight Number(KE )
_________________________Date (DD/MM/YYYY)
Refer to the back page (Privacy Act Statement)
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Privacy Act Statement
The United States Centers for Disease Control and Prevention (CDC) requires airlines and other aircraft operators to collect this information pursuant to 42 C.F.R. §§ 71.20 and 71.31(b), as authorized by 42 U.S.C. § 264. Providing this information is mandatory for all passengers arriving by aircraft into the United States. Failure to provide this information may prevent you from boarding the plane. Additionally, passengers will be required to attest to providing complete and accurate information, and failure to do so may lead to other consequences, including criminal penalties. CDC will use this information to help prevent the introduction, transmission, and spread of communicable diseases by performing contact tracing investigations and notifying exposed individuals and public health authorities; and for health education, treatment, prophylaxis, or other appropriate public health interventions, including the implementation of travel restrictions. The Privacy Act of 1974, 5 U.S.C. § 552a, governs the collection and use of this information. The information maintained by CDC will be covered by CDC's System of Records No. 09-20-0171, Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation and Notification under 42 C.F.R. Parts 70 and 71. See 72 Fed. Reg. 70867 (Dec. 13, 2007), as amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018). CDC will only disclose information from the system outside the CDC and the U.S. Department of Health and Human Services as the Privacy Act permits, including in accordance with the routine uses published for this system in the Federal Register, and as authorized by law. Such lawful purposes may include, but are not limited to, sharing identifiable information with state and local public health departments, and other cooperating authorities. CDC and cooperating authorities will retain, use, delete, or otherwise destroy the designated information in accordance with federal law and the System of Records Notice (SORN) set forth above. You may contact the system manager at dgmqpolicyoffice@cdc.gov or by mailing Policy Office, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H16-4, Atlanta, GA 30329, if you have questions about CDC's use of your data.
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