Health Declaration Form for Visa Application

Full Name: __________________________________________

Passport Number: __________________________________

I hereby declare that I have had none of the following situations over the 14 days immediately preceding the date on this Health Declaration Form:

• ☐ Being confirmed or suspected of COVID-19 infection by any medical institution
• ☐ Running a fever at or above 37.3°C or showing respiratory symptoms
• ☐ Coming into contact with confirmed or suspected COVID-19 cases
• ☐ Coming into contact with patients with a fever or respiratory symptoms
• ☐ Staying in a community or hotel reporting confirmed or suspected COVID-19 cases
• ☐ At least two people in my office or family are running a fever or showing respiratory symptoms
• ☐ Taking medicine for a fever or a cold
• ☐ Visiting public spaces (hospitals, theaters, restaurants, etc.) or group activities without protective measures

I declare the truthfulness and accuracy of the statements above. If any of the above situations occur before departure, I will cancel my trip.

I acknowledge and accept responsibility under the laws and regulations of the People's Republic of China if I conceal any relevant health condition.

Signature of Applicant: __________________________________________

Date: ______________________________