GOVERNMENT OF INDIA MINISTRY OF HEALTH & FAMILY WELFARE, SELF REPORTING FORM FOR ALL TRAVELLERS ARRIVING FROM 2019-nCoV affected countries (TO BE PRESENTED AT THE HEALTH/IMMIGRATION COUNTER) ‘All persons to India are required to fill-up this proforma. You ate requested to provide the following information to safeguard your own health. Personal Information Contact Address in India for All Travellers T | Name of the 7 1 | House Number SREE RRESHAP passenger/Crew | MONEE SH PH NDUASA Mm, CHANITHeOI, [2 |ShipName [wt 304 Latesty| 2 | Street/ Village RropALa reer Waca(P) 3 | Passports No. [sia 7664 3_| Tehsil : 4 | Date of Arrival 4 | District/ City ema | 5 | Port of origin of a 5 | State | Journey kerara | 6 | Port of final | Pin _ | destination l L Salsos 7_ | Residence Number Fane 8 | Mobile Number G2995225571 9 [Email ID mance shachuI8@ (PART-A) I) _ Details of the cities / countries visited in last 28 days? ketteyam [keLian / Jenne II) Are you suffering from any of the following symptoms** « Fever Yes No! © Cough Yes Noe © Respiratory distress Yes No Signature of the passenger ** If answer to any of the above questions “Yes”, please inform to the Port Health Officer for preliminary screening. In case you develop symptoms such as fever and cough within 28 days of leaving this port, restrict your outdoor movement and contact MoHFWs 24 hour’s helpline number 011-23978046. Call operator will tell you whom to contact further. *To give details of travel itinerary, Flight details, Departure date and time & Hotel stay if so:-Declaration of travel History of (past 28 days) annexure! Name Mancéest- 22 IndosNo. = _OF NL 2R4R ost sign off date Ai\osl 202 Passport No. S116 2664 Last signoff port / country eae F Details / addr if place visited | Frie lotel, Social gathering, Hospitals: peer Contact details (phone | ae _ Is / adress of place visited (Home, Friend, Hotel, Socal gathering. Hosp ipesoofs} you ret etc) eh no.) of personts) met 1 tnleoze Kae dice rior, Tra 1010 (e's) koltod neleap |4s 34060278 2 |raulocoe nual nuchv unas tua Teeeaeep- Aver | acema 4449424081 | / we, do hereby declare that above particulars of information and facts stated are true, correct and complete to the best of my knowledge and belle. Place bate: kounn Manz sn ¢ 2 Wed sale Name / SignBREATHING [covaw sone ate Leen Bag] Feverwvm [naman | MUMMIABBE ) oreicuLTY ny om vn shal 3 N Nv nm MN I) Mavcesa Pe ie