Traveller's Health Surveillance Form
Traveller Information

Note: Write surname and other names as appear in your passport.

Contact while in Tanzania
Countries visited/transit in last 21 days (3 weeks)
Have you experienced the following conditions during the last 7 days (1 week)? *

Please, mark/tick all the clinical manifestations that you have experienced during the last 7 days (1 week)

Exposure Questions
Declarations of filled information *
I declare that the information provided is complete and correct to the best of my knowledge. I understand that any false information filled could lead to denial or prosecution in accordance to law.