GHS-HDF

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First name*

Last name*

Sex*

Male

Female

Date of birth*

Nationality*

Occupation*

Are you in transit ?*

Yes

Country of departure*

Date of departure*

Date of arrival*

Country 1

Country 2

Country 3

Country(ies) visited on the last 14 days starting from the latest.

Country 1

Country 2

Country 3

Country 4

Country 5

Purpose of visit *

Resident

Study

Business

Family Visit

Diplomatic

Medical

Transit

Conference

Tourism

Passport No.*

Airline*

Specify airline*

Flight/Vessel, Vehicle No.*

Seat No.*

Contact address in Ghana (Location)*

Telephone No. of contact person in Ghana*

Telephone No. in Ghana*

Contact No. overseas*

Have you had close contact with sick person(s) (persons with fever, cough and difficulty in breathing) in the past 14 days ? *

Yes

Please tick if you have any of the underlisted signs and symptoms.

Please tick to consent to the information provided. *

Submit

KINDLY FILL THIS FORM

Guardian Name

Guardian Passport No.

Guardian Relationship

Country(ies) visited before this trip starting from the latest.

Country(ies) visited on the last 14 days starting from the latest.

Purpose of visit *

Have you had close contact with sick person(s) (persons with fever, cough and difficulty in breathing) in the past 14 days ? *

Please tick if you have any of the underlisted signs and symptoms.

Fever *

Cough *

Headache *

Bodily Weakness *

Sore throat *

Sneezing *

Runny nose *

Others

Vaccination status *

Type of vaccine *

Number of doses *

Date of first dose *

Date of second dose *

Name of accredited lab where pre-departure COVID-19 PCR test was done *

Please tick to consent to the information provided. *