Ministry of Health and Family Welfare
Government of India
SELF REPORTING FORM TO BE FILLED BY ALL INTERNATIONAL PASSENGERS
(TO BE PRESENTED AT THE HEALTH & IMMIGRATION COUNTER)
All persons coming to India are required to fill-up this Proforma in duplicate & submitting a copy each to Health
and Immigration Counter.
Personal Information Contact Address in India for All Travelers:
1
Name of
the
passenger
2
Seat No.
3. Flight
No.
4
Passport
No.
5
Nationality
6
Age
7
Date of
Arrival
8
Port of
origin of
Journey
9
Port of
final
destination
(PART-A)
a. Details of the cities / countries visited in last 14 days? ____________________________
b. Are you suffering from any of the following symptoms
Fever Yes No
Cough Yes No
Respiratory distress Yes No
Are you suffering from (Please Indicate) – (Hypertension, Diabetes , Bronchial Asthma, Cancer, Under
Immunosuppresive therapy, Post Transplant patients) - _____________________________________
The above information is correct and in case of any wrong information and non-cooperation, I will be liable for
action under the law.
Signature of the passenger
In case you develop symptoms such as fever and cough within 28 days of leaving this airport, restrict your outdoor movement and
contact MoHFW’s24 hours helpline number 011-23978046. Call operator will tell you whom to contact further. In the meanwhile,
keep yourself isolated in your house/room.
1
House Number
2
Street/ Village
3
Tehsil
4
District/ City
5
State
6
Pin
7
Residence Number
8
Mobile Number *
(mandatory field)
9
E mail ID
