健康状態自己申告書（HEALTH DECLARATION FORM ON ENTRY SCREENING）
令和2年3月19日
HEALTH DECLARATION FORM ENTRY SCREENING
For the health of you and others, please fill out the Health Declaration form truthfully
We ask your help and accountable according to the order of task Force for the Control to COVID-19 of Lao PDR
5. ນ້ຳເບີຂອງທ່ຽວບິນ/ລົດໄຟ/ລົດ (Flight/Train/Car) No:………………………………………………………………….
6. Have you been to affected city during the past 14 days, prior entering to Lao PDR: € Yes, € No
ໃນ 14 ວັນຜ່ານມາ ກ່ອນເຂົ້າມາ ສປປ ລາວ ທ່ານໄດ້ໄປປະເທດ ຫຼື ເຂດທີ່ມີການລະບາດບໍ່? € ໄປ, € ບໍ່ໄດ້ໄປ
7. ໃນ 14 ວັນກ່ອນໜ້ານີ້, ທ່ານມີອາການດັ່ງລູ່ມນີ້ບໍ່? ກະລຸນາໝາຍ “ü” ໃສ່ບ່ອນສີ່ລ່ຽມນີ້
Do you have one or more of the following symptoms/ please mark “ü” in the corresponding “€”
□ມີ, □ບໍ່ມີ, □ ໄຂ້, □ ໜາວສັ່ນ, □ ໄອ, □ເຈັບນ້າເອີກ, □ ຫັນໃຈຝຶດ
□Yes, □ No, □ Fever, □ Chill, □Cough, □Chest tightness, □Difficulty
8. ເບີໂທທີ່ສາມາດຕິດຕໍ່ໄດ້ (Contact Number):
........................................................................................................................................................
ຂ້າພະເຈົ້າ ຂໍຢັ້ນຢືນວ່າ ຂໍ້ມູນຂ້າງເທີງນີ້ ແມ່ນຖືກຕ້ອງຕາມຄວາມເປັນຈິງ
I hereby declare that the above information provided is complete and true
For more information please contact the hotline 166 or 202 5406 6777 for English
ລາຍເຊັນ
(Signature)
Thank you for your kind cooperation and please drop this form to health staff
For the health of you and others, please fill out the Health Declaration form truthfully
We ask your help and accountable according to the order of task Force for the Control to COVID-19 of Lao PDR
- ຊື່ ແລະ ນາມສະກຸນ (Name and Surname):…………………………………………………………………………
- ເລກໜັງສືເດີນທາງ (passport number):………………………………………………………….……………...........
- ວັນທີ ມາຮອດ (Date of Arrival):………………………………………………………………………………………
- ສະຖານທີ່ພັກເຊົາ ຢູ່ລາວ (Address in Lao PDR):……………………………………………………………………
5. ນ້ຳເບີຂອງທ່ຽວບິນ/ລົດໄຟ/ລົດ (Flight/Train/Car) No:………………………………………………………………….
6. Have you been to affected city during the past 14 days, prior entering to Lao PDR: € Yes, € No
ໃນ 14 ວັນຜ່ານມາ ກ່ອນເຂົ້າມາ ສປປ ລາວ ທ່ານໄດ້ໄປປະເທດ ຫຼື ເຂດທີ່ມີການລະບາດບໍ່? € ໄປ, € ບໍ່ໄດ້ໄປ
7. ໃນ 14 ວັນກ່ອນໜ້ານີ້, ທ່ານມີອາການດັ່ງລູ່ມນີ້ບໍ່? ກະລຸນາໝາຍ “ü” ໃສ່ບ່ອນສີ່ລ່ຽມນີ້
Do you have one or more of the following symptoms/ please mark “ü” in the corresponding “€”
□ມີ, □ບໍ່ມີ, □ ໄຂ້, □ ໜາວສັ່ນ, □ ໄອ, □ເຈັບນ້າເອີກ, □ ຫັນໃຈຝຶດ
□Yes, □ No, □ Fever, □ Chill, □Cough, □Chest tightness, □Difficulty
8. ເບີໂທທີ່ສາມາດຕິດຕໍ່ໄດ້ (Contact Number):
........................................................................................................................................................
ຂ້າພະເຈົ້າ ຂໍຢັ້ນຢືນວ່າ ຂໍ້ມູນຂ້າງເທີງນີ້ ແມ່ນຖືກຕ້ອງຕາມຄວາມເປັນຈິງ
I hereby declare that the above information provided is complete and true
For more information please contact the hotline 166 or 202 5406 6777 for English
ລາຍເຊັນ
(Signature)
Thank you for your kind cooperation and please drop this form to health staff