☐ I have received written instructions on how to self-isolate and can find more information 3. It is important to fill out this form completely and accurately. Self‐Declaration of Emergency Disaster Assistance Application Applicant name (print): _____ Third‐party verification and documentation is necessary for certifying that duplication of benefits will not occur as a result of funds being utilized for COVID‐19 relief. PUBLIC HEALTH COVID-19 PASSENGER SELF DECLARATION FORM Pro osal — a health declaration to include on the reverse o the existin PLF. COVID-19 SELF-DECLARATION FOR GUESTS / CONTRACTORS ON ARRIVAL DISCLAIMER It should be noted that the information provided in this publication is provided as general and illustrative information only. Declaration of Self-Isolation Declaration (applies to you and all those travelling with you): ☐ I understand I am required by law to self-isolate upon my arrival to Newfoundland and Labrador if I do not meet the verified exemptions in Section 2. Attachment A: Self-Certification Form JASON E. BAILEY Brigadier General, USAF Commander "Return With Honor" EXAMPLE EXAMPLEEXAMPLE NOTE: The Italian side of both the self-declaration form and the MFR MUST be completed. Do you have any of the following Flu like symptoms (Please tick anyone option ) : Date of Birth (DD/MM/YY) / / Name of the candidate (In Capital Letters) Mobile Number Father’s Name (In Capital Letters) Email-id Travelling From (City / Town Name) Travelling To (City / Town Name) 1. [FORM] DECLARATION UNDER PENALTY OF PERJURY FOR . Your information would help public health officers to contact you if you were exposed to a communicable disease. 2. THE CENTERS FOR DISEASE CONTROL AND PREVENTION’S TEMPORARY . HALT IN EVICTIONS TO PREVENT FURTHER SPREAD OF COVID-19 . Have you had any symptoms of COVID-19 in the last 14 days (e.g. Have you returned from travel abroad (including USA) in the last 14 days? SELF DECLARATION FORM TO BE FILLED BY ALL INTERNATIONAL PASSENGERS (TO BE PRESENTED AT THE HEALTH & IMMIGRATION COUNTER) All persons coming to India are required to fill up the Proforma in duplicate & submitting a copy each to Heath and Immigration Counter Personal Information Contact Address in India for All Travellers: (Part-A) a. Self-Declaration Form Precautions Against COVID-19 Please answer the following questions: 1. I certify under penalty of perjury, pursuant to 28 U.S.C. PUBLIC HEALTH cov1D-19 PASSENGER SELF DECLARATION FORM Purpose of this form: This form is intended to support public health authorities by allowing arriving passengers to easily Whether you’re an employer or manage HR for a company, this free Coronavirus Self-Declaration Form allows members of your staff to confirm if they have coronavirus, so they can proceed to seek medical treatment and prevent further contamination in your workplace. Your information is intended to be A coronavirus self-declaration form is used by individuals infected with COVID-19 to report their medical status. Self Declaration Form – COVID-19 Application Form No. YES NO . § 1746, that the foregoing are true and correct: 5. Health Declaration Form To protect your health, public health officers need you to complete this form. YES NO . You can choose the option to encrypt the responses with JotForm to ensure the privacy of responses from our customers. 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