出入境健康申明卡

：中华人民共和国出入境检验检疫出/入境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，将依据有关法律法规追究相关责任。姓名性别：□男□女出生日期____年____月国籍（地区）和城市护照（入台证、台胞证、回乡证、通行证）号码航班（船、车次）号舱位(车厢）号座位号1.7天内是否离开中国大陆？□是，请填写在中国大陆期间的行程预计离开日期月日，目的地所乘交通工具的航班（船、车次）号□否，请填写在7天内的行程继续旅行乘坐的航班（船、车次）号日期2.在中国大陆详细联系地址联系电话3.过去7天内您居住或到过的国家（地区）和城市：4.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□5.您如有以下症状和疾病，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□乏力□其它症状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：体温（检疫人员填写）：____________ºC检疫人员签名：HEALTHDECLARATIONFORMONENTRY/EXITEntry-ExitInspectionandQuarantineoftheP.R.ChinaAccordingtotherelevantlawsandregulations,forthehealthofyouandothers,pleasefillintheformtrulyandcompletely.Falseinformationmaycauselegalconsequences.NameSex:□Male□FemaleDateofBirth__________________Nationality/Region_______________________PassportNo.__________________ThedestinationFlight(boat/train/bus)No._______________CabinNo.____________SeatNo._____________1.IfyouleaveMainlandChinain7days,pleasefillinyouritineraryandyourDepartureDate/(mm/dd),thedestinationcountryandtheflight(boat/train/bus)No..IfyouwillstayinMainlandChina,pleasefillinyouritineraryforthenext7days,theflight(boat/train/bus)No.anddateofyournexttrip.2.Yourcontactingdetailsforthenext7daysinChina:youraddressandyourtelephonenumber(residentialorbusinessormobileorhotel).Contactinformationforthepersonwhowillbestknowwhereyouareforthenext7days,incaseofemergencyortoprovidecriticalhealthinformationtoyou,pleaseprovidethenameofaclosepersonalcontactoraworkcontact.ThismustNOTbeyou.NameTel.No.3.Pleasedescribethecountriesandcities(towns)whereyoustayedinthelast7days:.4.Didyouhaveclosecontactpatientsoffluorwithflu-likesymptomsinthelast7days?Yes□No□5.Ifyouhavethefollowingsymptomsanddiseases,pleasemark“√”inthecorresponding“□”□Fever□Cough□Sorethroat□Muscleandjointpain□Stuffynose□Headache□Diarrhoea□Vomiting□Runnynose□Breathdifficulty□Fatigue□OthersymptomsIdeclarethatalltheinformationgiveninthisformistrueandcorrect.SignatureofpassengerDate:_______________Temperature(forquarantineofficialonly):______________℃Signatureofquarantineofficial:_________________________