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PASSENGER DISCLOSURE AND ATTESTATION

TO THE UNITED STATES OF AMERICA

Full Name

Email Address

Date of Birth

ATTACHMENT A: 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 into the United States and Order Implementing Presidential Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic.1 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.

AIRLINE AND AIRCRAFT OPERATOR DISCLOSURE REQUIREMENTS:

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.

All airlines and other aircraft operators must additionally confirm one of the following for each passenger – 2 years and older––prior to their boarding a flight to the United States from a foreign country:

A negative result for a Qualifying Test for Fully Vaccinated for those passengers who provide proof of being fully vaccinated,
A negative result for a Qualifying Test for Not Fully Vaccinated, or
Documentation of recovery from COVID-19 in the form of a positive COVID-19 viral test on a

sample taken no more than 90 days prior to departure and clearance to travel.

As directed by the TSA, including through a forthcoming security directive, all airlines and other aircraft operators must additionally confirm one of the following for each noncitizen who is a nonimmigrant passenger prior to their boarding a flight to the United States from a foreign country:

1 These requirements (e.g. proof of negative COVID-10 test result and proof of being fully vaccinated against COVID-19)do not apply to crew members of airlines or other aircraft operators if they are traveling for the purpose of operating the aircraft, or repositioning (i.e., on “deadhead” status), provided their assignment is under an air carrier’s or operator’s occupational health and safety program that follows applicable industry standard protocols for the prevention of COVID-19 as set forth in relevant Safety Alerts for Operators (SAFOs) issued by the Federal Aviation Administration (FAA).

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1318

Form OMB Control No.: 0920-1318 Expiration date: 05/31/2022

Proof of being Fully Vaccinated Against COVID-19
Proof of being excepted from the requirement to be Fully Vaccinated Against COVID-19.

SECTION 1:

Passenger Attestation Requirement Relating to Proof of Negative COVID-19 Test Result or Recovery from COVID-19

TO BE COMPLETED BY ALL PASSENGERS:

Check one of the options that applies:

I attest that I am fully vaccinated against COVID-19 and have 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 3 days before this flight’s departure.

I attest that this person is 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 3 days before the flight’s departure.

I attest that this person is not fully vaccinated against COVID-19 and has 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.

I attest that I tested positive for COVID-19 and have 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.

I attest that this person tested positive for COVID-19 and 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 the person no more than 90 days before the flight’s departure.

I attest that this person is 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 3 days before the flight’s departure and this person is traveling with a fully vaccinated parent(s) or guardian(s).

I attest that I have 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.

I attest that this person has 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.

SECTION 2:

Form OMB Control No.: 0920-1318 Expiration date: 05/31/2022

Passenger Attestation Requirement Relating to Presidential Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic

TO BE COMPLETED BY EVERY COVERED INDIVIDUAL:2

5. Do you, or the person you are attesting on behalf of, intend to stay in the United States for more than 60 days?

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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.

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