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    Self Reporting Form Details For International Arriving Passengers

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    أبو عبداالرحمن
    The document contains a self-reporting form for three international passengers arriving from Maldives to India. It includes passenger details like name, date of birth, flight information, contact details, medical details, and travel history. The passengers agree to undergo a 14-day mandatory quarantine - 7 days of paid institutional quarantine followed by 7 days of home isolation with health monitoring.

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    © All Rights Reserved
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    Self Reporting Form Details For International Arriving Passengers

    Uploaded by

    أبو عبداالرحمن
    18 views4 pages
    The document contains a self-reporting form for three international passengers arriving from Maldives to India. It includes passenger details like name, date of birth, flight information, contact details, medical details, and travel history. The passengers agree to undergo a 14-day mandatory quarantine - 7 days of paid institutional quarantine followed by 7 days of home isolation with health monitoring.

    Original Title

    1609462013225731

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    The document contains a self-reporting form for three international passengers arriving from Maldives to India. It includes passenger details like name, date of birth, flight information, contact details, medical details, and travel history. The passengers agree to undergo a 14-day mandatory quarantine - 7 days of paid institutional quarantine followed by 7 days of home isolation with health monitoring.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views4 pages

    Self Reporting Form Details For International Arriving Passengers

    Uploaded by

    أبو عبداالرحمن
    The document contains a self-reporting form for three international passengers arriving from Maldives to India. It includes passenger details like name, date of birth, flight information, contact details, medical details, and travel history. The passengers agree to undergo a 14-day mandatory quarantine - 7 days of paid institutional quarantine followed by 7 days of home isolation with health monitoring.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Self Reporting form details for international arriving passengers

    Applications are being accepted on behalf of the Ministry of Health and Family Welfare, Government of India

    PASSENGER DETAILS

    Registration Number
    @
    SR01012130045

    Name Date of Birth


    LEELAA MOHAMED 28/11/1978

    Flight Number Seat Number


    Q22706 WNQGN

    PNR Number Nationality


    Maldives

    Passport Number Passport Copy Uploaded


    LA24E7775 Yes

    Date of Arrival Country of Origin


    01/01/2021 Maldives

    City of Origin First Airport of Entry


    MALE' Cochin Airport

    First Airport of Entry State/Union Territories Final Destination - House Number


    Kerala AMRITA HOSPITAL

    Final Destination Street/Village Final Destination Tehsil


    PONEKKARA

    Final Destination State/Union Territories Final Destination District/City


    Kerala PONEKKARA

    Final Destination Pincode Contact Number


    682041 +919895029596

    Alternate Contact Number Email ID


    ajuvad1020@gmail.com

    Fever Diabetes
    No No

    Cough Hypertension
    No No

    Respiratory Distress Bronchial Asthma


    No No
    Cancer
    No

    Unde Immunosuppresive Therapy


    No

    Post Transplant Patients


    No

    Details of the Cities / Countries visited in last 14 days? How many passengers are travelling?
    None 3

    CO PASSENGER DETAILS

    Passenger 2 @

    Name Date of Birth


    MOHAMED SHAKIR 01/05/1976

    Flight Number Seat Number


    Q22706 5WNQGN

    PNR Number Nationality


    Maldives

    Passport Number Passport Copy Uploaded


    LA24E7776 Yes

    Date of Arrival Country of Origin


    01/01/2021 Maldives

    City of Origin First Airport of Entry


    MALE' Cochin Airport

    First Airport of Entry State/Union Territories Final Destination - House Number


    Kerala AMRITA HOSPITAL

    Final Destination Street/Village Final Destination Tehsil


    PONEKKARA

    Final Destination State/Union Territories Final Destination District/City


    Kerala PONEKKARA

    Final Destination Pincode Contact Number


    682041 +919895029596

    Alternate Contact Number Email ID


    ajuvad1020@gmail.com

    Fever Diabetes
    No No
    Cough Hypertension
    No No

    Respiratory Distress Bronchial Asthma


    No No

    Cancer
    No

    Unde Immunosuppresive Therapy


    No

    Post Transplant Patients


    No

    Details of the Cities / Countries visited in last 14 days?


    NONE

    Passenger 3 @

    Name Date of Birth


    SHAMMAA MOHAMED 05/01/2001

    Flight Number Seat Number


    Q22706 5WNQGN

    PNR Number Nationality


    Maldives

    Passport Number Passport Copy Uploaded


    RF61D2414 Yes

    Date of Arrival Country of Origin


    01/01/2021 Maldives

    City of Origin First Airport of Entry


    MALE' Cochin Airport

    First Airport of Entry State/Union Territories Final Destination - House Number


    Kerala AMRITA HOSPITAL

    Final Destination Street/Village Final Destination Tehsil


    PONEKKARA

    Final Destination State/Union Territories Final Destination District/City


    Kerala PONEKKARA

    Final Destination Pincode Contact Number


    682041 +919895029596

    Alternate Contact Number Email ID


    ajuvad1020@gmail.com
    Fever Diabetes
    No No

    Cough Hypertension
    No No

    Respiratory Distress Bronchial Asthma


    No No

    Cancer
    No

    Unde Immunosuppresive Therapy


    No

    Post Transplant Patients


    No

    Details of the Cities / Countries visited in last 14 days?


    NONE

    I/We have agreed to the following terms:

    I agree to the guidelines issued by Ministry of Health & Family Welfare.

    The above information is correct and in case of any wrong information and non-cooperation, I will be liable for action
    under the law. I also agree to the terms & conditions.

    I would undergo mandatory quarantine for 14 days i.e. 7 days paid institutional quarantine at my own cost, followed by 7
    days isolation at home with self-monitoring of health.

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