DEPARTURES

1. MEDICAL INFORMATION (PLEASE SELECT YES OR NO) *

Yes

Are you feeling well today?

Do you have a respiratory infection?

Do you have a fever?

Do you have a new or worsening cough?

Do you have a sore throat?

Do you have difficulty breathing?

Do you have coryza - head cold e.g. runny nose, sneezing, post-natal drip?

Do you have anosmia - loss of sense of smell?

2. HISTORY OF EXPOSURE (PLEASE SELECT YES OR NO) *

Yes

Comment

In the last 14 days have you had contact with anyone diagnosed with COVID-19?

Have you ever been diagnosed with COVID-19?

If yes, date of diagnosis

In the last 14 days have you been in any country other than the Cook Islands?

In the last 14 days have you worked at an International Airport, Maritime Port or at a Quarantine or Managed Isolation Facility?

In the last 14 days have you worked on an international aircraft or shipping vessel?

Have you ever been diagnosed with COVID-19? *

Yes No
If yes, date of diagnosis:

Day Month Year
Date
In the last 14 days have you been to any islands in the Cook Islands? *

Yes No
Please state which islands visited *
I declare that the information I have given is true, correct and complete. *

Clear
Should be Empty:

DOMESTIC DEPARTURES