海峡两岸直航人员进出港检疫.doc

海峡两岸直航人员进出港检疫 进/出港健康申明卡 根据有关法律法规规定，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 舱位(车厢号) 座位号 1.在中国大陆期间能联系到您的电话 2.过去7天内您到过的国家(地区)和城市 3.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 4.您如有以下症状，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 □其它症状或传染病 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： HEALTH DECLARATION FORM ON ENTRY/EXIT For Passengers of Cross-Straits Direct Transportation According to the relevant laws and regulations, for the health of you and others, please fill in the form truly and completely. False information may cause legal consequences. Name Sex: □Male □Female Date of Birth Nationality/Region Passport No. Destination Flight (boat/train/bus) No. Cabin No._______ Seat No. 1. The telephone number by which you can be contacted when you stay in Mainland China 2. Please list the countries/regions and cities (towns) where you’ve been in the last 7 days 3. Did you have close contact with patients of flu or with flu-like symptoms in the last 7 days? □Yes □No 4.If you have the following symptoms, please mark “√” in the corresponding “□” □Fever □Cough □Sore throat □Muscle and joint pain □Stuffy nose □Headache □Diarrhoea □Vomiting □Runny nose □Breath difficulty □Other symptoms or Infectious diseases I declare that all the information given in this form is true and correct. Signature: Date: For quarantine official only Temperature ℃ Signature