A- Health Declaration Form B- Health Declaration Form

ස ෞඛ්‍ය ප්‍රකාශ඾ ස ෝරමය / ස ෞඛ්‍ය ප්‍රකාශ඾ ස ෝරමය /

Ministry of Health / ස ෞඛ්‍ය අමශත්යශාං඾ය / Ministry of Health / ස ෞඛ්‍ය අමශත්යශාං඾ය /
Sri Lanka /ශ්‍රී ඼ාංකාශල/ Sri Lanka /ශ්‍රී ඼ාංකාශල/
Office Copy/ කාශර්යශ඼ පිට ත් / Traveller’s Copy/ ගේ පිට ත්/ டிரரவல்லரின் நைல்
Please fill the form accurately and completely in English
Please fill the form accurately and completely in English
(If there are children below 15 years, need to be filled by parent/guardian)
(If there are children below 15 years, need to be filled by parent/guardian)
ය නිලැරදිල සහ ස ය නිලැරදිල සහ ස
( 15 ට දරුලන් සිටියි නම්, ඔවුන්ගේ විස්තර / )
( 15 ට දරුලන් සිටියි නම්, ඔවුන්ගේ විස්තර / )
஧டியங் கள஭ து஬் லினநாகவுந் முழுளநனாகவுந் ஆங் கி஬த்தி஬் ஥ிப஧்஧வுந்
஧டியங் கள஭ து஬் லினநாகவுந் முழுளநனாகவுந் ஆங் கி஬த்தி஬் ஥ிப஧்஧வுந்
(15 யனதுக்குக் குள஫யா஦ கும஥் ளதக஭் இரு஥் தா஬் , ப஧஫் ற஫ாப் / ஧ாதுகாய஬ப் ஥ிப஧் ஧ றயண்டுந் )
(15 யனதுக்குக் குள஫யா஦ கும஥் ளதக஭் இரு஥் தா஬் , ப஧஫் ற஫ாப் / ஧ாதுகாய஬ப் ஥ிப஧் ஧ றயண்டுந் )
1) Name with Initials / ස / :
1) Name with Initials / ස / :
…………………………………………………………………………………….………………… ……………………………………………………,,,,…………………………….……………
2) Sex/ ස්තී‍්ර - (√): 3) Country of beginning of this travel/ ස ය
කළ ට/ 2) Sex/ ස්තී‍්ර - (√): 3) Country of beginning of this travel
Female/ ස්තී‍්ර / பெண்
: Female/ ස්තී‍්ර / பெண் ස ය කළ ට
Male/ / ஆண் ………………………………………… :

4) Passport No/ බ ත්‍ර / 5) Flight No./ .: Male/ / ஆண்

.: …………………………
……………………….. 4) Passport No/ බ ත්‍ර /
……..…………………….. 5) Flight No./
.: .:
6) Were you diagnosed of having COVID-19 when you were in overseas/ ඔබ ගතල
ගකොවිඩ්-19 ගරෝගය සෑදී COVID-19 ……..…………………….. ……………………………………...
? (√):
6) Address in Sri Lanka/ / :
Yes/ඔ / No/නැ / Don’t know ගනොදනී/ பெரியரது
7) Have you got any of the following symptoms currently/ ඔබට ට හ …………………..……………..………….…………………………..…………………………
/ ? (√) 7) Telephone No. in Sri Lanka/ ථ
Symptom/ Yes/ No/නැත/ இ஬் ள஬ இலங்கையில் பெரகலபெசி எண் : ……………………..………..…....
Fever/ උ
Sore throat/ උගුගේ ආසාදනය/
For office use only/ ේයා ත
Cough/ කැස්ස/ Temperature of the traveller / Name of the Officer of Health Office/
Runny nose/ ගසොටු දියර ගැලීම/ උ ගසෞඛ්‍ය කාේයා඼ගේ නි඼ධාරියාගේ නම/
சுகாதாப அலுய஬க அலுய஬பி஦் ப஧னப்
Shortness of breath/ ස ගැනීගම් අපහසුල/
Diarrhoea/බඩ එළිය යෑම/
………………..oC / oF
…………………………………………….
Any other/ :……………………………………………………………………………………………… Signature/ ස / :
Date / / திகதி: ……/……/………
8) Address in Sri Lanka/ / : (dd/mm/yyyy) ……..……………………..
…………………..……………..………….…………………………..………………………………
9) Telephone No. in Sri Lanka/ ථ
இலங்கையில் பெரகலபெசி எண் : ……………………..……..……..….... For Immigration only/ආ න කටයුතු /
Signature/ ස /
: ……………………...…….. Date / / திகதி : …..…/…..…/…….…
(dd/mm/yyyy) Entry grant/
For office use only/ ත අනුමැතිය / Signature/ ස / : ……..……………..…………..
Temperature of the traveller / Name of the Officer of Health Office/ ගසෞඛ්‍ය Date / / திகதி : ……/……/………
උ කාේයා඼ගේ නි඼ධාරියාගේ නම/ சுகாதாப அலுய஬க (dd/mm/yyyy)
/ அலுய஬பி஦் ப஧னப்
………..…………………………………..
…………….. o
.C / F o