Required Information	Details ( mandatory () fields)*
Flight Details	Mode of transport* : Arrival Vessel/Flight No.: Seat No.: Date of arrival : PORT OF ENTRY LIST* :
Travel Itinerary	Original port/ country of departure: Name of port: Name of country : Name of city : (N/A)* Other, please specify: Departure Vessel/Flight No. : Date of departure : Do you have any transit? *: Port/ Country of Transit (1): Name of port: Name of country: Vessel/Flight No.: Date of arrival: Port/ Country of Transit (2): Name of port: Name of country: Vessel/Flight No.: Date of arrival: Port/ Country of Transit (3): Name of port: Name of country: Vessel/Flight No.: Date of arrival:
Personal details	Name (as it appears in your passport): Last Name/ Surname : First Name : Middle Name: Sex : Nationality : Occupation : Date of birth : Passport # *:
Contact details	Overseas residential address: House/ Flat No.: Street/Village: District: City/County : Province: Country : Residential address in Papua New Guinea: Sec No.: Lot No.: Street/Village: Province : District : Phone# 1 : Phone# 2 : Email address: Quarantine related information: Select the option that best describes you : Aircraft crew Sea vessel crew None of these After your most recent departure from Papua New Guinea, did you disembark from the aircraft? Will you be disembarking from the vessel on arrival in Papua New Guinea? Where will you be completing your quarantine period? Quarantine address: Click on Pg2 tab to submit form*

Upon arrival in PNG, if you are worried about or developed symptoms, please call COVID-19 Hotline : 1800200.

Questions on health status and travel history

1. Have you lived, travelled or visited countries with Covid-19 confirmed cases in the last 14 days prior to your travel? *

If Yes, please specify the name of country recently visited:

If Yes, which city or province did you spend most of your time in?

How long have you been in the city or province (state number of days)?

2. Have you had close contact with a confirmed case of COVID-19 in the LAST 14 DAYS PRIOR TO ARRIVAL? *

If yes, specify date and place:

3. Are you a health care worker? *

If yes, have you cared for patients with respiratory infections; or have you worked in an environment where patients with respiratory illness were cared for in the 14 DAYS PRIOR TO ARRIVAL?

If yes, specify date and health facility name:

4. Do you have cough? *

If Yes, when did the cough begin?

5. Do you have fever? *

If Yes, when did the fever begin?

Temperature in degree Celsius (if checked):

6. If your answer is 'Yes' to question 4 or 5, did you get any treatment?

If Yes, please provide details of the treatment:

7. Has anyone traveling with you developed a fever and/or cough in the LAST 14 DAYS? *

If Yes, how many family members and/or friends:

Please provide details of treatment, if any:

8. Has been vaccinated? *

Date last vaccinated:

Upon arrival in PNG, if you are worried about or developed symptoms, please call COVID-19 Hotline : 1800200.

I hereby confirm that the above information is accurate.

Steps to follow:

Step 1 ->	Step 2 ->	Step 3 ->	Step 4 ->	Step 5
Fill in the form	Check correctness of information	Submit form	Save barcode in your device	Show barcode at the airport / seaport

Notice for all the passengers:
1. Health declaration form is mandatory to fill-up by all the passengers who travel to PNG.
2. Please save the barcode to show as proof of online form submission at check-in/check-out counters.
3. This is a request from PNG government in emergency response to Covid-19. So any false information will be subject to punishment.
4. Kindly check the accuracy and completeness of information in health declaration form before submission.

Contact us: Outbreaks and Health Emergencies, National Department of Health,PO Box: 807 WAIGANI,Port Moresby, Papua New Guinea.|
© Copyright 2020 by NDOH. All Rights Reserved. | Best viewed in Google Chrome, 1360*768 Resolution)

Government of Papua New Guinea

Health Declaration Form

Original port/ country of departure:

Port/ Country of Transit (1):

Port/ Country of Transit (2):

Port/ Country of Transit (3):

Name (as it appears in your passport):

Overseas residential address:

Residential address in Papua New Guinea:

Quarantine related information:

Contact us: Outbreaks and Health Emergencies, National Department of Health,PO Box: 807 WAIGANI,Port Moresby, Papua New Guinea.|
© Copyright 2020 by NDOH. All Rights Reserved. | Best viewed in Google Chrome, 1360*768 Resolution)

Government of Papua New Guinea

Health Declaration Form

Original port/ country of departure:

Port/ Country of Transit (1):

Port/ Country of Transit (2):

Port/ Country of Transit (3):

Name (as it appears in your passport):

Overseas residential address:

Residential address in Papua New Guinea:

Quarantine related information:

Contact us: Outbreaks and Health Emergencies, National Department of Health,PO Box: 807 WAIGANI,Port Moresby, Papua New Guinea.| © Copyright 2020 by NDOH. All Rights Reserved. | Best viewed in Google Chrome, 1360*768 Resolution)

Contact us: Outbreaks and Health Emergencies, National Department of Health,PO Box: 807 WAIGANI,Port Moresby, Papua New Guinea.|
© Copyright 2020 by NDOH. All Rights Reserved. | Best viewed in Google Chrome, 1360*768 Resolution)