Scribd
Upload
655 views1 page

Public Health Passenger Locator Form PDF

This document is a public health passenger locator form that collects contact information from travelers. The information will be used to contact travelers if they were potentially exposed to a communicable disease during their flight. It is important to fill out the form completely and accurately to help public health officers protect health. Personal information will be kept private and used only for public health purposes.

Uploaded by

Hari Dimoshi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
655 views1 page

Public Health Passenger Locator Form PDF

This document is a public health passenger locator form that collects contact information from travelers. The information will be used to contact travelers if they were potentially exposed to a communicable disease during their flight. It is important to fill out the form completely and accurately to help public health officers protect health. Personal information will be kept private and used only for public health purposes.

Uploaded by

Hari Dimoshi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Public Health Passenger Locator Form:  To protect your health, public health officers need you to complete this form whenever they 

suspect a communicable disease onboard a flight. Your information will help public health officers to contact you if you were exposed to  
a communicable disease. It is important to fill out this form completely and accurately.  Your information is intended to be held in  
accordance with applicable laws and used only for public health purposes.                    ~Thank you for helping us to protect your health.                  
One form should be completed by an adult member of each family.  Print in capital (UPPERCASE) letters. Leave blank boxes for spaces. 
FLIGHT INFORMATION:          1. Airline name                                                               2. Flight number     3. Seat number      4. Date of arrival (yyyy/mm/dd)  
2 0                     

PERSONAL INFORMATION:    5. Last (Family) Name                          6. First (Given) Name                                        7. Middle Initial     8. Your sex  
Male  Female 

PHONE NUMBER(S) where you can be reached if needed. Include country code and city code. 
9. Mobile   10. Business 

11. Home  12. Other 

13. Email address  

PERMANENT ADDRESS:     14. Number and street  (Separate number and street with blank box)                                                15. Apartment number 

16. City                                                                                17. State/Province                                            

18. Country                                                               19. ZIP/Postal  code                                          

TEMPORARY ADDRESS:  If you are a visitor, write only the first place where you will be staying. 
20. Hotel name (if any)                       21. Number and street (Separate number and street with blank box)                 22. Apartment number 

23. City                                                                                  24. State/Province                                            

25. Country                                                                          26. ZIP/Postal code                                          

EMERGENCY CONTACT INFORMATION of someone who can reach you during the next 30 days 
27. Last (Family) Name                                                                          28. First (Given) Name                                         29. City                    

30. Country                                                                                                                                31. Email 

32. Mobile phone                                                                                  33. Other phone 

34. TRAVEL COMPANIONS – FAMILY:  Only include age if younger than 18 years 
Last (Family) Name                                                                                   First (Given) Name                                                            Seat number      Age <18  
(1) 

(2) 

(3) 

(4) 

35. TRAVEL COMPANIONS – NON‐FAMILY:  Also include name of group (if any) 
Last (Family) Name                                                                                First (Given) Name                                                  Group  (tour, team, business, other) 

(1) 

(2) 

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy