Public Health Passenger Locator Form 1 PDF
Public Health Passenger Locator Form 1 PDF
Public Health Passenger Locator Form 1 PDF
suspect a communicable disease onboard a flight. Your information will help public health officers to contact you if you were exposed to
a communicable disease. It is important to fill out this form completely and accurately. Your information is intended to be held in
accordance with applicable laws and used only for public health purposes. ~Thank you for helping us to protect your health.
One form should be completed by an adult member of each family. Print in capital (UPPERCASE) letters. Leave blank boxes for spaces.
FLIGHT INFORMATION: 1. Airline name 2. Flight number 3. Seat number 4. Date of arrival (yyyy/mm/dd)
2 0
PERSONAL INFORMATION: 5. Last (Family) Name 6. First (Given) Name 7. Middle Initial 8. Your sex
Male Female
PHONE NUMBER(S) where you can be reached if needed. Include country code and city code.
9. Mobile 10. Business
11. Home 12. Other
13. Email address
PERMANENT ADDRESS: 14. Number and street (Separate number and street with blank box) 15. Apartment number
16. City 17. State/Province
18. Country 19. ZIP/Postal code
TEMPORARY ADDRESS: If you are a visitor, write only the first place where you will be staying.
20. Hotel name (if any) 21. Number and street (Separate number and street with blank box) 22. Apartment number
23. City 24. State/Province
EMERGENCY CONTACT INFORMATION of someone who can reach you during the next 30 days
27. Last (Family) Name 28. First (Given) Name 29. City
30. Country 31. Email
32. Mobile phone 33. Other phone
34. TRAVEL COMPANIONS – FAMILY: Only include age if younger than 18 years
Last (Family) Name First (Given) Name Seat number Age <18
(1)
(2)
(3)
(4)
35. TRAVEL COMPANIONS – NON‐FAMILY: Also include name of group (if any)
Last (Family) Name First (Given) Name Group (tour, team, business, other)
(1)
(2)