Liberia Traveller Health Declaration

Section 1: Traveler Information

Full name (as on passport) *

Sex *

Male Female

Date of birth *

Nationality *

If other, specify

Occupation *

Purpose of travel (in country) *

If other, specify

Passport / travel document no. *

Date of entry *

Mode of entry into the country *

Air Sea Ground crossing

Country of departure *

Flight / vessel / vehicle no. *

Seat no.

Countries visited/transited in last 21 days *

Traveler address (in Liberia) *

Closest landmark to address *

Phone no. (reachable in Liberia) *

Email (optional)

Section 3: Exposure & Risk Assessment (Past 21 Days)

Had contact with a sick or confirmed VHF case? *

Yes No

Handled dead bodies or visited a health facility? *

Yes No

Participated in large gatherings, funerals, or visited an outbreak area? *

Yes No

Touched blood, vomit, stool, urine, saliva, sweat, or other body fluids of a sick person? *

Yes No

If yes to any, provide details

Section 4: Emergency Details

Emergency contact name

Emergency contact phone

Section 5: Consent

I declare that the information provided is true and complete. I consent to the Ministry of Health and the National Public Health Institute of Liberia (NPHIL) collecting and using this information for public health purposes, including contact tracing and follow-up, in line with Liberia's public health regulations and the International Health Regulations (2005). Any attempt to provide false/fake information shall be subjected to the laws of Republic of Liberia.

I agree and confirm the above *

Section 1: Traveler Information

Section 2: Signs & Symptoms

Section 3: Exposure & Risk Assessment (Past 21 Days)

Section 4: Emergency Details

Section 5: Consent