Arrival Health Declaration Form
Supplementary Arrival Card
MINISTRY OF HEALTH AND MEDICAL SERVICES Due to outbreaks of novel coronavirus (2019-n-COV) in China, the Fijian Ministry of Health &Medical Services is collecting additional information from each arriving passenger regarding their current health status.
Your complete and accurate completion and information will help keep Fiji and our visitors safe and healthy.
Please complete all sections of this form using blue or black pen. A separate card must be completed for every passenger including children. Please print clearly, answering in English, using capital letters.
Mark check boxes with a “tick”, like this:
Bula! Please find advice regarding novel coronavirus (2019-nCOV) for travelers arriving into Fiji.
The virus is a new strain of coronavirus that has not been previously identified in humans.
Coronaviruses are a large family of respiratory viruses that can cause diseases ranging from the common cold to the Middle-East Respiratory Syndrome and the Severe Acute Respiratory Syndrome (SARS).
How can you catch 2019-nCOV? Whilst many details about the virus are yet to be determined, it has been identified that it can spread from human to human. Therefore, it is recommended that individuals reduce their general risk of respiratory infections while travelling in or from affected areas by practicing good hand and cough hygiene.
What are the symptoms? Common signs include respiratory symptoms, fever, cough, shortness of breath, and breathing difficulties. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death.
Family Name/
Surname Given/
First names Passport number Country of residence
Nationality Date of
Birth (DD/MM/YY) Flight/ship
number Overseas port
where you boarded this flight/ship
Seatnumber
Do you have any of the following symptoms, or have you, in the past 14 days?
Fever Cough
Difficulty breathing
If you have any of these symptoms, and have a travel history of visiting China, please visit our health office before immigration.
MORE INFORMATION ON NOVEL CORONAVIRUS
If you have been to China in the last 14 days and develop any of the symptoms after leaving the air/seaport, immediately contact one of the numbers listed below. If you need to
see a doctor please call ahead before visiting to reduce the risk of infecting other patients.
Central 2219905 Eastern 2219906 Western 2219907 Northern 2219908
Please list ALL the countries AND cities you have visited in the last 14 days If visiting, date of departure from Fiji (DD/MM/YY)
Have you come into contact with someone confirmed or
suspected of having 2019-nCOV in the last 14 days? Yes No Unsure
Phone contact in Fiji Email contact in Fiji
Address of stay in Fiji
Have you visited a healthcare facility in China in the last
14 days? Yes No Unsure
For the latest information, visit the Fiji Ministry
of Health website: www.health.gov.fj For more information regarding 2019-nCOV:
https://www.who.int/emergencies/diseases/
novel-coronavirus-2019/advice-for-public Yes No Have you been in China in the last 14 days?
DECLARATION
I declare that the details I have given are true and correct and complete in every respect.
Signature: Date:
MINISTRY OF HEALTH & MEDICAL SERVICES USE
