MINISTRY OF HEALTH

International Travelers Health Surveillance Form

Providing the following information to a Port Health Officer is required under the Public Health Act CAP 242 of the laws of Kenya, and is being collected as part of public health response to the Corona Virus pandemic.

Kindly note that fields marked with * are required, they must be filled before submitting the form.

First name: *

Middle name:

Last name: *

Gender : *

Date of Birth : *

Nationality : *

Country of Origin : *

Date of Arrival in Kenya: *

ID / Passport Number : *

Phone Number : * Select the correct country code first.

Email address * Confirmation QR Code will be sent to this email.

Airline : *

Flight Number : *

Seat Number : *

Destination City :

Countries Visited :

Fever (37.5°C or higher): *

Feverish : *

Negative Covid19 PCR : *

Chills : *

Cough : *

Difficulty in breathing : *

Name of Contact Person (Next of Kin):

Phone Number of Contact Person :

Village/House Number/Hotel :

Sublocation/Estate :

Postal Address :

Travellers QR Code

MINISTRY OF HEALTH
COVID-19 TRAVELERS HEALTH SURVEILLANCE FORM QR CODE

This QR Code should be displayed to the Port health Official upon arrival at the airport.