DEPARTURES

DOMESTIC DEPARTURES

HEALTH DECLARATION
MANDATORY TO COMPLETE
Pursuant to section 20 of the COVID-19 Act 2020, the following health enquiries will be made on your depature from Rarotonga by a duly authorised official.

Please answer these questions in advance by filling in this form and handing it over when requested to do so. A responsible adult should fill in this form for a child (under 18 years).

You are required to answer the health questions truthfully and it is an offence to intentionally or recklessly provide false or misleading information which may result in a term of imprisonment not exceeding 12 months or to a fine not exceeding $10,000.

If you refuse to answer these questions, you may be required to undergo a test for COVID-19 and may be placed in quarantine (at your expense) until such time as those test results are known.
PASSENGER IDENTITY (AS SHOWN ON PASSPORT)
First Name(s)*
Family Name*
Date of Birth (DD/MM/YYYY)*

DayMonthYear
Gender M/F*
Passport Number
TRAVEL INFORMATION
Date of Arrival into the Cook Islands*

DayMonthYear
Date
Date of Departure from Rarotonga*

DayMonthYear
Date
Flight Number*
Seat Number

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

	Yes	No
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	No	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?*

YesNo
If yes, date of diagnosis:

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

YesNo
Please state which islands visited*
I declare that the information I have given is true, correct and complete.*

Clear
Should be Empty: