Passenger Disclosure And Attestation Form

OMB Control Number: 0920-XXXX

Expiration Date: XX/XX/XXXX

PASSENGER DISCLOSURE AND ATTESTATION

TO THE UNITED STATES OF AMERICA

All airlines covered by the Order must provide the following disclosure to passengers and collect the attestation prior to embarkation.

AIRLINE DISCLOSURE REQUIREMENT:

As required by United States federal law, all airlines are required to confirm a negative COVID-19 test result and collect a passenger attestation on behalf of the U.S. Centers for Disease Control and Prevention (CDC) for certain passengers on aircraft departing from the United Kingdom and arriving in the United States.

Each individual 2 years of age or older must provide a separate attestation. A parent or other legal guardian must attest on behalf of a passenger aged 2 to 17 years. An individual may attest on behalf of another passenger for whom the individual is authorized to submit the required information (for example, immediate family member(s), legal guardian, or travel agent), if that person is unable to attest on his or her own behalf (e.g., because of physical or mental impairment).

The information provided must be accurate and complete to the best of the individual’s knowledge.

Under United States federal law, each passenger must provide this attestation. Failure to provide this attestation, or submitting false or misleading information, could result in delay of travel, denial of boarding, denial of boarding on future travel, or put the passenger or other individuals at risk of harm, including serious bodily injury or death. Any passenger who fails to comply with these requirements may be subject to criminal penalties under, among others, 42 U.S.C. § 271 and 42 C.F.R. § 71.2, in conjunction with 18 U.S.C. §§ 3559 and 3571. Willfully providing false or misleading information may lead to criminal fines and imprisonment under, among others, 18 U.S.C. § 1001. Providing this information can help protect you, your friends and family, your communities, and the United States. CDC appreciates your cooperation.

PASSENGER ATTESTATION REQUIREMENT:

I [name of passenger or authorized representative] have read the disclosure pertaining to my obligation to obtain a negative pre-departure test result for COVID-19 in order to board an aircraft departing from the UK and arriving in the United States.

[ ] I attest that I have received a negative pre-departure test result for COVID-19. The test was a viral test that was conducted on a specimen collected from me during the 3 calendar days preceding the flight’s departure.

[ ] On behalf of [___________], I attest that such person has received a negative pre-departure test result for COVID-19. The test was a viral test that was conducted on a specimen collected from that person during the 3 calendar days preceding the flight’s departure .

___________________________________________

____________________­­­­_____Date

Privacy Act Statement

The United States (U.S.) Centers for Disease Control and Prevention (CDC) requires airlines to collect this information pursuant to 42 C.F.R. §§ 71.20, 71.31, and 71.32, as authorized by 42 U.S.C. § 264.  Providing this information is mandatory for all passengers arriving by air into the United States. Failure to provide this information may prevent you from boarding the plane. Additionally, passengers will be required to attest to providing complete and accurate information, and failure to do so may lead to other consequences, including criminal penalties. CDC will use this information to help prevent the introduction, transmission, and spread of communicable diseases by performing contact tracing investigations and notifying exposed individuals and public health authorities; and for health education, treatment, prophylaxis, or other appropriate public health interventions, including the implementation of travel restrictions.

The collection and use of this information is governed by The Privacy Act of 1974, 5 U.S.C. § 552a.  The information maintained by CDC will be covered by CDC’s System of Records No. 09-20-0171, Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation and Notification under 42 C.F.R. Parts 70 and 71.  See 72 Fed. Reg. 70867 (Dec. 13, 2007), as amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018). CDC will only disclose information from the system outside the CDC and the U.S. Department of Health and Human Services as the Privacy Act permits, including in accordance with the routine uses published for this system in the Federal Register, and as authorized by law. Such lawful purposes may include but are not limited to sharing identifiable information with state and local public health departments, and other cooperating authorities. CDC and cooperating authorities will retain, use, delete, or otherwise destroy the designated information in accordance with federal law and the System of Records Notice (SORN) set forth above. You may contact the system manager at dgmqpolicyoffice@cdc.gov; Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H16-4, Atlanta, GA 30329, if you have questions about CDC’s use of your data.