OMB Control No.: 0920-1318
Expiration date: 5/31/2022
NON-US CITIZEN NON-IMMIGRANT ATTESTATION
As required by United States federal law, all airlines or other aircraft operators must collect the passenger attestation on behalf of the
U.S. Government.
COMBINED PASSENGER DISCLOSURE AND ATTESTATION TO THE UNITED STATES OF AMERICA
This combined passenger disclosure and attestation fulfills the requirements of U.S. Centers for Disease Control and Prevention (CDC) Orders: Requirement for Proof of
Negative COVID-19 Test Result or Recovery from COVID-19 for All Airline Passengers Arriving in the United States and Order Implementing Presidential
Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic. As directed by the CDC and the Transportation Security
Administration (TSA), including through a forthcoming Security Directive, to be issued after consultation with CDC, and consistent with CDC’s Order implementing the
Presidential Proclamation, all airline or other aircraft operators must provide the following disclosures to all passengers prior to their boarding a flight from a foreign
country to the United States.
The information provided below must be accurate and complete to the best of the individual’s knowledge. Under United States federal law, each passenger must complete
the applicable portion of the attestation and provide it to the airline or aircraft operator prior to boarding a flight to the United States from a foreign country. Failure to
complete and present the applicable portion of the attestation or submitting false or misleading information, could result in delay of travel, denial of boarding, denial of
boarding on future travel, or put the passenger or other individuals at risk of harm, including serious bodily injury or death. Any passenger who fails to comply with these
requirements may be subject to criminal penalties. Willfully providing false or misleading information may lead to criminal fines and imprisonment under, among others,
18 U.S.C. § 1001. Providing this information can help protect you, your friends and family, your communities, and the United States. CDC appreciates your cooperation.
Privacy Act Statement for Travelers Relating to the Requirement to Provide Proof of a Negative COVID-19 Test Result
The United States Centers for Disease Control and Prevention (CDC) requires airlines and other aircraft operators to collect this information pursuant to 42 C.F.R. §§
71.20 and 71.31(b), as authorized by 42 U.S.C. § 264. Providing this information is mandatory for all passengers arriving by aircraft into the United States. Failure to
provide this information may prevent you from boarding the plane. Additionally, passengers will be required to attest to providing complete and accurate information,
and failure to do so may lead to other consequences, including criminal penalties. CDC will use this information to help prevent the introduction, transmission, and
spread of communicable diseases by performing contact tracing investigations and notifying exposed individuals and public health authorities; and for health education,
treatment, prophylaxis, or other appropriate public health interventions, including the implementation of travel restrictions.
The Privacy Act of 1974, 5 U.S.C. § 552a, governs the collection and use of this information. The information maintained by CDC will be covered by CDC’s System of
Records No. 09-20-0171, Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation and Notification under 42 C.F.R. Parts 70
and 71. See 72 Fed. Reg. 70867 (Dec. 13, 2007), as amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018). CDC will only disclose
information from the system outside the CDC and the U.S. Department of Health and Human Services as the Privacy Act permits, including in accordance with the
routine uses published for this system in the Federal Register, and as authorized by law. Such lawful purposes may include, but are not limited to, sharing identifiable
information with state and local public health departments, and other cooperating authorities. CDC and cooperating authorities will retain, use, delete, or otherwise
destroy the designated information in accordance with federal law and the System of Records Notice (SORN) set forth above. You may contact the system manager at
dgmqpolicyoffice@cdc.gov or by mailing Policy Office, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road
NE, MS H16-4, Atlanta, GA 30329, if you have questions about CDC’s use of your data.
SECTION 1: Passenger Attestation Requirement Relating to Proof of Negative COVID-19 Test Result or Recovery
from COVID-19
TO BE COMPLETED BY/FOR EACH PASSENGERS 2 YEARS AND OLDER:
[ ] I attest that I am/have… [ ] On behalf of [ ], I attest that this person is/has…
[[SELECT ONE CATEGORY ONLY]]
1.
[ ] fully vaccinated against COVID-19 and received a negative pre-departure test result for COVID-19. The test was a viral test that
was conducted on a specimen collected from me no more than 1 day before the flight’s departure.
2.
[ ] not fully vaccinated against COVID-19 and received a negative pre-departure test result for COVID-19. The test was a viral test
that was conducted on a specimen collected from me no more than 1 day before the flight’s departure.
3.
[ ] tested positive for COVID-19 and have/has been cleared for travel by a licensed healthcare provider or public health official.
The test was a viral test that was conducted on a specimen collected from me no more than 90 days before the flight’s departure.
4.
[ ] between 2 and 17 years of age, is not fully vaccinated against COVID-19, and received a negative pre-departure test result for
COVID-19. The test was a viral test that was conducted on a specimen collected from the person no more than 1 days before the
flight’s departure and this person is traveling with a fully vaccinated parent or guardian.
5.
[ ] received a humanitarian or emergency exemption to the testing requirement or the documentation of recovery, as determined by
CDC and documented by an official U.S. Government letter.
Forms continues on reverse
SECTION 2: Passenger Attestation Requirement Relating to Presidential Proclamation on Advancing the Safe
Resumption of Global Travel During the COVID-19 Pandemic
TO BE COMPLETED BY/FOR EVERY COVERED INDIVIDUAL
2
:
[ ] I attest that I am/have… [ ] On behalf of [ ], I attest that this person is/has…
[[SELECT ONE CATEGORY ONLY]]
1.
[ ] fully vaccinated against COVID-19 (proceed to Signature below to complete the Attestation).
2.
[ ] not fully vaccinated and attest that I am, or the person I am attesting on behalf of is, excepted from the requirement to present
Proof of Being Fully Vaccinated Against COVID-19 based on one of the following (check only one box, as applicable):
□
Diplomatic and Official Foreign Government Travel (complete sections 3 and 4 and sign the form).
□
Child under 18 years of age (complete section 3 and sign the form OR have parent/legal guardian complete and sign on behalf
of a person under 18 years of age).
□
Participant in certain COVID-19 vaccine trials as determined by CDC (complete section 3 and sign the form).
□
Medical contraindication to an accepted COVID-19 vaccine as determined by CDC (complete section 3 and sign the form below).
□
Humanitarian or emergency exception as determined by CDC and documented by an official U.S. Government letter (complete
sections 3 and 4 and sign the form).
□
Valid nonimmigrant visa holder (excluding B-1 or B-2 visas) and citizen of a Foreign Country with Limited COVID-19 Vaccine
Availability as determined by CDC (complete sections 3 and 4 and sign the form to).
□
Member of U.S. Armed Forces or spouse or child (under 18 years of age) of a member of U.S. Armed Forces (sign the form).
□
Sea crew member traveling pursuant to a C-1 and D nonimmigrant visa (complete sections 3 and 4 and sign the form).
□
Person whose entry is in the U.S. national interest as determined by the Secretary of State, the Secretary of Transportation, the
Secretary of Homeland Security, or their designees (complete sections 3 and 4 and sign the form).
3.
[ ] I attest that I made, or the person I am attesting on behalf of has made or has had made on their behalf, the following arrangements
(must check all boxes).
□
to be tested with a COVID-19 viral test 1 day after arriving in the United States, unless documented to have
recovered from COVID-19 in the past 90 days.
□
to self-quarantine for a full 7 days, even if the test result to my post-arrival viral test is negative, unless documented
to have recovered from COVID-19 in the past 90 days: and
□
to self-isolate if the result of the post-arrival viral test is positive or if COVID-19 symptoms develop.
4.
Do you, or the person you are attesting on behalf of, intend to stay in the United States for more than 60 days?
□
YES (complete statement below and then sign form)
□
NO (skip statement below and sign form)
[ ] If YES, I attest that I agree, or the person I am attesting on behalf of agrees, to be vaccinated and have/has arranged to
become fully vaccinated against COVID-19 within 60 days of arriving in the United States, or as soon thereafter as is medically
appropriate.
Print Name
Signature
Date
2
This means any passenger covered by the Proclamation and this Order: a noncitizen (other than a U.S. lawful permanent resident or
U.S. national) who is a nonimmigrant seeking to enter the United States by air travel. This term does not apply to crew members of
airlines or other aircraft operators if such crewmembers and operators adhere to all industry standard protocols for the prevention of
COVID-19, as set forth in relevant guidance for crewmember health issued by the CDC or by the Federal Aviation Administration in
coordination with the CDC.
OMB Control No.: 0920-1318
Expiration date: 5/31/2022
US CITIZEN OR US IMMIGRANT (RESIDENT) ATTESTATION
As required by United States federal law, all airlines or other aircraft operators must collect the passenger attestation on behalf of the
U.S. Government.
COMBINED PASSENGER DISCLOSURE AND ATTESTATION TO THE UNITED STATES OF AMERICA
This combined passenger disclosure and attestation fulfills the requirements of U.S. Centers for Disease Control and Prevention (CDC) Orders: Requirement for Proof of
Negative COVID-19 Test Result or Recovery from COVID-19 for All Airline Passengers Arriving in the United States and Order Implementing Presidential
Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic. As directed by the CDC and the Transportation Security
Administration (TSA), including through a forthcoming Security Directive, to be issued after consultation with CDC, and consistent with CDC’s Order implementing the
Presidential Proclamation, all airline or other aircraft operators must provide the following disclosures to all passengers prior to their boarding a flight from a foreign
country to the United States.
The information provided below must be accurate and complete to the best of the individual’s knowledge. Under United States federal law, each passenger must complete
the applicable portion of the attestation and provide it to the airline or aircraft operator prior to boarding a flight to the United States from a foreign country. Failure to
complete and present the applicable portion of the attestation or submitting false or misleading information, could result in delay of travel, denial of boarding, denial of
boarding on future travel, or put the passenger or other individuals at risk of harm, including serious bodily injury or death. Any passenger who fails to comply with these
requirements may be subject to criminal penalties. Willfully providing false or misleading information may lead to criminal fines and imprisonment under, among others,
18 U.S.C. § 1001. Providing this information can help protect you, your friends and family, your communities, and the United States. CDC appreciates your cooperation.
Privacy Act Statement for Travelers Relating to the Requirement to Provide Proof of a Negative COVID-19 Test Result
The United States Centers for Disease Control and Prevention (CDC) requires airlines and other aircraft operators to collect this information pursuant to 42 C.F.R. §§
71.20 and 71.31(b), as authorized by 42 U.S.C. § 264. Providing this information is mandatory for all passengers arriving by aircraft into the United States. Failure to
provide this information may prevent you from boarding the plane. Additionally, passengers will be required to attest to providing complete and accurate information,
and failure to do so may lead to other consequences, including criminal penalties. CDC will use this information to help prevent the introduction, transmission, and
spread of communicable diseases by performing contact tracing investigations and notifying exposed individuals and public health authorities; and for health education,
treatment, prophylaxis, or other appropriate public health interventions, including the implementation of travel restrictions.
The Privacy Act of 1974, 5 U.S.C. § 552a, governs the collection and use of this information. The information maintained by CDC will be covered by CDC’s System of
Records No. 09-20-0171, Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation and Notification under 42 C.F.R. Parts 70
and 71. See 72 Fed. Reg. 70867 (Dec. 13, 2007), as amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018). CDC will only disclose
information from the system outside the CDC and the U.S. Department of Health and Human Services as the Privacy Act permits, including in accordance with the
routine uses published for this system in the Federal Register, and as authorized by law. Such lawful purposes may include, but are not limited to, sharing identifiable
information with state and local public health departments, and other cooperating authorities. CDC and cooperating authorities will retain, use, delete, or otherwise
destroy the designated information in accordance with federal law and the System of Records Notice (SORN) set forth above. You may contact the system manager at
dgmqpolicyoffice@cdc.gov or by mailing Policy Office, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road
NE, MS H16-4, Atlanta, GA 30329, if you have questions about CDC’s use of your data.
SECTION 1: Passenger Attestation Requirement Relating to Proof of Negative COVID-19 Test Result or Recovery
from COVID-19
TO BE COMPLETED BY/FOR EACH PASSENGER 2 YEARS AND OLDER:
[ ] I attest that I am/have… [ ] On behalf of [ ], I attest that this person is/has…
[[SELECT ONE CATEGORY ONLY]]
1.
[ ] fully vaccinated against COVID-19 and received a negative pre-departure test result for COVID-19. The test was a viral test that
was conducted on a specimen collected from me no more than 1 day before the flight’s departure.
2.
[ ] not fully vaccinated against COVID-19 and received a negative pre-departure test result for COVID-19. The test was a viral test
that was conducted on a specimen collected from me no more than 1 day before the flight’s departure.
3.
[ ] tested positive for COVID-19 and have/has been cleared for travel by a licensed healthcare provider or public health official.
The test was a viral test that was conducted on a specimen collected from me no more than 90 days before the flight’s departure.
4.
[ ] between 2 and 17 years of age, is not fully vaccinated against COVID-19, and received a negative pre-departure test result for
COVID-19. The test was a viral test that was conducted on a specimen collected from the person no more than 1 day before the
flight’s departure and this person is traveling with a fully vaccinated parent or guardian.
5.
[ ] received a humanitarian or emergency exemption to the testing requirement or the documentation of recovery, as determined by
CDC and documented by an official U.S. Government letter.
Print Name
Signature
Date
