‘As required by United States federal law, all airlines or other airerat operators my the U'S. Government, COMBINED PASSENGER DISCLOSURE AND ATTESTATION TO THE UNITED STATES OF AMERICA collect the passenger attestation on bebalf of This combined passenger disclosure and attestation fulls the requirements of US. Centers for Disease Contol and Prevention (Ci ‘Order: Requirement for Proo of Negative COVID-19 Test Result or Recovery from COVID-19 for All Airline Passengers Arriving nto the United States and Order Implementing Presidential Proclamation on Advancing the Safe Resumption of Global Travel During the COVID. 19 Pandemic. s drecied by the CDC and the Transporation Security Administration (TSA), through Security Directive 1544-21-03 and [Emergency Amendment 1546-21-02, and consistent with CDC's Order implementing te Presidential Proclamation, al rine oroter aircraft ‘operators must provide the following dsclosres to all passengers prior to thei boarding a flight oma frcign country tothe United States. The information provided below must be accurate and complet tothe best ofthe individual's knowledge, Under United States federal law, the applicable portion ofthe atesaton must be completed for each passenger age two or older andthe atestation must be provided tothe atin or ireratdperator prior to boarding sight to the United State fam foreign coun. Failure fo complete and preset ‘he applicable portion ofthe attestation, or submiting false or misleading information, could result in delay of travel, denial of boarding, of denial of boording on future travel, or pat the passenger or other individuals a sk of harm, including serous bodily injury or death. Any passenger who fails to comply with these requirements may be subject o criminal penalties, Wilflly proving fale or misleading information tray lead 1a criminal fines and imprisonment under, among oer, 18 US.C.§ 1001, Providing this information ean help protect you, your Friends and family, your communities, andthe United States. CDC appreciates your cooperation Tam attesting on (Select one): [CT my behalf [UT behalf of | d Serer ee Ce tenn kee Cen ce Caen keke d PASSENGERS 2 YEARS OR TO BE COMPLET SELECT ONLY ONE: T/A. NEGATIVE PRE_DEPARTURE TEST RESULT arest that Ihave, othe person Lam attesting on bebalf of has, received a negative pre-departure test result fr COVID- 19, The test was a vial test that was conducted on a specimen collected no more thas I ealendar day before the flight's departure TB. DOCUMENTATION OF RECOVERY FROM COVID-19 [atest that Ihave, othe person I am attesting on behalf of has, tested positive for COVID-19 and havethas beet cleared for travel by a licensed healtheare provider or public health offical, The test was a viral test that was conducted ona specimen collected no more than 90 days before the flight's departure Di |C. HUMANITARIAN EXEMPTION Taltest that Ihave, or the person T am attesting on behalf of has, received a humanitarian exemption tothe testing requirement, as dstermined by CDC and documented by an official U.S. Government letter ICTION 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 YEARS OR OLDER CT ONLY ON! T/A. FULLY VACCINATED COVERED INDIVIDUALS [attest that I am, or the person I am attesting on bebalf oF, fully vaccinated against COVID-19, Proceed to signature tine and sign the form Ty B.NOT FULLY VACCINATED COVERED INDIVIDUALS [attest that Iam, oF the person I am attesting on bebalf is, not Fully vaccinated and attest that lam, 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 ofthe following exceptions and have made arrangements as liste forthe exception. Check only one exception below as applicable, Then check boxes for all arrangements for that exception and proceed to signature (© | Diplomat and Official Foreign Government Travel 15 To be tested with a COVID-19 viral test 3-5 days after arriving inthe United States unless Iithey have documentation of having recovered from COVID-19 inthe past 90 days; 10 To sel-quarantine fora full 7 calendar days, even ifthe test result of the post-arrval viral testis negative, except during periods when myiteir attendance is required to carry out the purposes of the diplomatic or official forsign government travel (eg, to ltend official meetings or events) unless Iithey have documentation of having recovered from COVID-19 in the past 90 days, 1 To selfisolate ifthe result of the postatrval viral testis positive or i COVID-19 symptoms develop. Form continues on reverse 22PPIII>‘Child 2 to 17 vears of age: or Participant in certain COVID-19 vaccine trials as determined by CDC 1 To be tested with a COVID-19 viral test 3-5 day’ after arriving in the United States unless Uthey have documentation of having recovered from COVID-19 inthe past 90 days, 1 To selligolate if the result of the post-atrival viral testis positive or if COVID-19 symptoms develop. 'O | Medical contraindication to an accepted COVID-19 vaccine as determined by CDC 15 To be tested with a COVID-19 viral test 3-5 days after arriving inthe United States, unless Uthey have documentation of having recovered from COVID-19 inthe past 90 days, To self quarantine fora full 7 calendar days, even ifthe test result of the post-arrival viral testis negative, unless they have documensation of having recovered from COVID-19 inthe past 90 days ‘To selPiolate ifthe result ofthe post-arrival viral test is positive or if COVID-19 symptoms develop, ‘Humanitarian or emergency exception as determined by CDC and documented by an official U.S. Government letter; or lid 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; or (O | Sea crew member traveling pursuant toa C-1 and D nonimmigrant visa To be tested with a COVID-19 viral test 3-5 days after arriving in the United States unless they have documentation of having recovered from COVID-19 inthe past 90 days. To selE-quarantine fora full 7 calendar days, even ifthe test sult of the post-arrval viral testis negative, unless Iithey have documentation of having recovered from COVID-19 inthe past 90 days. To self-solat if the result ofthe post-arrival viral tests positive or if‘ COVID-19 symptoms develop. ‘To become fully vaccinated against COVID-19 within 60 days of arriving inthe United States, or as soon thereafter as is medically appropriate, if intending to stay inthe United States for more than 60 days, (© | Berson whose entry isin the U.S, National Interest To be tested with a COVID-19 viral test 3-5 day’ after arriving in the United States unless Vthey have documentation of having recavered from COVID-19 inthe past 90 days 5 To self-quarantine fora full 7 calendar days, even ifthe test result of the post-arrval viral testis negative, except during periods when attendance is required to carry out the purposes ofthe travel forthe U.S, national interest (ee, fo attend official meetings or events) unless Vthey have documentation of having recovered from COVID-19 in the past 90 days 1 To selfisolate if the result of the post-atrval viral testis positive or if COVID-19 symptoms develop. To become fully vaccinated against COVID-19 within 60 days of arriving in the United States, or as soon thereafter as is medically appropriate, if intending to stay inthe United States for more than 60 days, Signature 2 V ol1/22 bate * This means any passenger covered bythe Proclamation and this Orde: a noacitzen (other than a U'S.lawfl permanent resident or US. atonal) whois «nonimmigrant seeking o enter the United Sates bya ave. This term doesnot apply to erew members of silines or other aircraft operators if such crewmembers and operstors adhere to all industy standard protocols for the prevention of COVID-19, a set forth in clevant guidance fr erewmember health issued by the CDC or by the Fedral Aviation Adminstration in coordination withthe CDC. oo 0° Privacy Act Statement for Travelers Relat to the Requirement to Provide Proof of Negative COVID-19 Test Result The United States Centers for Disease Contol and Prevention (CDC) requires airlines and oler aircraft operators ta collect this information pursuant to 42 CFR. §§ 71.20 and 71.3100), a8 authorized by 42 U.S.C § 264, Providing this information is mandatory for ll passengers friving by aircraft into the United States, Failure to provide this information may prevent you fom boarding the plane. Additionally, passengers ‘willbe required to atest to providing complete and aecurste information, and failure todo 80 may lead to other eonsequences, including eriminal penalties. CDC will use this information to help prevent the intodeson,tansmission, and spreed of communicable diseases by performing ‘contact acing investigations and notifying exposed individuals and public health authorities; and for health education, treatment, prophylaxis, or other appropriate public health intervention, including the implementation of travel restrictions. The Privacy Act of 1974, 5 U.S.C. §$82a, governs the collection and us of his information, The information maintained by CDC will be covered by CDC's System of Records No, 09-20-0171, Quarantne- and Traveler-Related Activities, Tchuding Records for Contact Tracing Investigation and Notification under 42 CFR. Parts 70 and 71, See 72 Fed, Reg. 70867 (Dee, 13, 2007), a8 amended by 76 Fe, Reg. 4435 (Jan, 25,2011) and 83 Fed. Reg. 6591 (Feb. 14,2018). CDC will only disclose information ffom the system outside tbe CDC and the US. Department of Health and Human Servess as the Privacy Act permits, including in accordance withthe routine uses published fortis sytem in ‘he Federal Register, and as authorized by law. Suck lawful purposes may include, but are not limited o, sharing identifiable information with state and local public health depatmens, and other cooperating authorities. CDC and cooperating authorities wil retain, use, delete, oF otherwise destay the designated inforeation in accordance with feral law and the System of Records Notice (SORN) sa forth above. You tay cone! the system manager at dgmapolcyoticeiede go’ or by mailing Poliy Office, Division of Global Migration and Quarantine, (Centers for Disease Contol and Prevention, 1600 Clifion Road NE, MS Hi6-4, Atlanta, GA 30528, if you have questions about CDC's use of your data