OMB Control No.: 0920-1318
Expiration date: 12/31/2022
AS Revision: JUNE2022
Alaska Airlines Flight:___________________ Date of Flight: ___________________
ATTACHMENT A: PROOF OF COVID-19 VACCINATION FOR
NONCITIZEN/NONIMMIGRANTS PASSENGER DISCLOSURE AND ATTESTATION
TO THE UNITED STATES OF AMERICA
As required by United States federal law, all airlines or other aircraft operators must collect the passenger attestation on behalf of the U.S. Government.
This passenger disclosure and attestation fulfills the requirements of U.S. Centers for Disease Control and Prevention (CDC) Amended Order: Implementing Presidential
Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic.1 As directed by the CDC and the Transportation Security Administration (TSA),
through Security Directive 1544-21-03 and Emergency Amendment 1546-21-02, and consistent with CDC’s Order implementing the Proclamation, all airline or other aircraft
operators must provide the following disclosures to all passengers prior to their boarding a flight from a foreign country to the United States.
The information provided below must be accurate and complete to the best of the individual’s knowledge. Under United States federal law, the applicable portion of the attestation
must be completed for each passenger ages 2 years or older and the attestation must be provided to the airline or aircraft operator prior to boarding a flight to the United States
from a foreign country. Failure to complete and present the applicable portion of the attestation, or submitting false or misleading information, could result in delay of travel,
denial of boarding, or denial of boarding on future travel, or put the passenger or other individuals at risk of harm, including serious bodily injury or death. Any passenger who
fails to comply with these requirements may be subject to criminal penalties. Willfully providing false or misleading information may lead to criminal fines and imprisonment
under, among other provisions, 18 U.S.C. §1001. Providing this information can help protect you, your friends and family, your communities, and the United States. CDC appreciates
your cooperation.
One attestation form must be filled out for each passenger age 2 years or older who is not a U.S. citizen, U.S. national, lawful
permanent resident, or an immigrant (“Covered Individual”), and who is seeking to enter the United States by air travel.
The attestation may be filled out by the air passenger or on behalf of the air passenger by a legal representative, such as a parent or
guardian. The passenger must also be able to check all boxes related to and comply with applicable after travel requirements to
board a plane to the United States.
I, ________________________________________ am attesting on (Select one):
My own behalf Behalf of: ________________________________________
A. FULLY VACCINATED
(If you select A, sign the form to complete Attestation.)
I attest that I am (or the person I am attesting on behalf of is)
fully vaccinated
against COVID-19.
B.
NOT FULLY VACCINATED
OR UNWILLING TO PROVIDE PROOF OF VACCINATION
I attest that I am (or the person I am attesting on behalf of is)
excepted
from the requirement to present
Proof of Being
Fully Vaccinated Against COVID-19
based on one of the following
(make one choice, as applicable):
Child ages 2 through 17 years
(complete C only, then sign the form to complete Attestation)
.
Participant in certain COVID-19 vaccine trials, as determined by CDC
(complete C only, then sign the form to
complete Attestation)
.
Diplomatic and Official Foreign Government Travel
(complete D only, then sign the form to complete Attestation)
.
Medical contraindication to an accepted COVID-19 vaccine, as determined by CDC
(complete E only, then sign the
form to complete Attestation)
.
Humanitarian or emergency exception, as determined by CDC and documented by an official U.S. Government
letter
(complete F only, then sign the form to complete Attestation)
Valid nonimmigrant visa holder (excluding B-1 or B-2 visas) and citizen of a Foreign Country with Limited COVID-
19 Vaccine Availability, as determined by CDC
(complete F only, then sign the form to complete Attestation)
.
Member of the U.S. Armed Forces or spouse or child (ages 2 through 17 years) of a member of the U.S. Armed
Forces
(proceed to signature line only, then sign the form to complete Attestation)
.
Sea crewmember traveling pursuant to a C-1 and D nonimmigrant visa
(complete F only, then sign the form to
complete Attestation)
.
Person whose entry is in the U.S. national interest as determined by the Secretary of State, the Secretary of
Transportation, the Secretary of Homeland Security, or their designees
(complete G only, then sign the form to
complete Attestation)
.
Form continues on reverse side
à
Print First and Last Name
Print First and Last Name
C.
EXCEPTIONS:
Child 2 to 17 years of age OR Participant in certain COVID-19 vaccine trials as determined by CDC
I attest that I am (or the person I am attesting on behalf of is)
excepted
from the requirement to present
Proof of Being
Fully Vaccinated Against COVID-19
and made the following arrangements
(must check all boxes in D and then sign
Attestation)
.
To be tested with a COVID-19 viral test 3-5 days after arriving in the United States, unless I have (or the person
has) documentation of having recovered from COVID-19 in the past 90 days;
To self-isolate for a full 5 calendar days and properly wear a well-fitting mask any time I am (or this person is)
around others during my (or this person’s) isolation period and for an additional 5 days after ending isolation,
- if the result of the post-arrival viral test is positive; or
- if I develop (or this person develops) COVID-19 symptoms.
D.
EXCEPTION: Diplomat and Official Foreign Government Travel
See Alaska Airlines Agent for expanded attestation
E.
EXCEPTION: Medical contraindication to an accepted COVID-19 vaccine as determined by CDC
See Alaska Airlines Agent for expanded attestation
F.
EXCEPTIONS:
Humanitarian or emergency exception as determined by CDC; Valid nonimmigrant visa holder (excluding B-1 or B-2 visas) and
citizen of a Foreign Country with Limited COVID-19 Vaccine Availability as determined by CDC; OR Sea crew member traveling pursuant to a
C-1 and D nonimmigrant visa
See Alaska Airlines Agent for expanded attestation
G.
EXCEPTIONS: Person whose entry is in the U.S. National Interest
See Alaska Airlines Agent for expanded attestation
Print Name
Signature
Date
Privacy Act Statement for Travelers Relating to the Requirement to Provide Proof of a Negative COVID-19 Test Result
The United States Centers for Disease Control and Prevention (CDC) requires airlines and other aircraft operators to collect this information pursuant to 42 C.F.R., 71.20 and
71.31(b), as authorized by 42 U.S.C. § 264. Providing this information is mandatory for all passengers arriving by aircraft into the United States. Failure to provide this information
may prevent you from boarding the plane. Additionally, passengers will be required to attest to providing complete and accurate information, and failure to do so may lead to
other consequences, including criminal penalties. CDC will use this information to help prevent the introduction, transmission, and spread of communicable diseases by performing
contact tracing investigations and notifying exposed individuals and public health authorities; and for health education, treatment, prophylaxis, or other appropriate public health
interventions, including the implementation of travel restrictions.
The Privacy Act of 1974, 5 U.S.C. § 552a, governs the collection and use of this information. The information maintained by CDC will be covered by CDC’s System of Records No.
09-20-0171, Quarantine- and Traveler-Related Activities, Including Records for Contact Tracing Investigation and Notification under 42 C.F.R. Parts 70 and 71. See 72 Fed. Reg.
70867 (Dec. 13, 2007), as amended by 76 Fed. Reg. 4485 (Jan. 25, 2011) and 83 Fed. Reg. 6591 (Feb. 14, 2018). CDC will only disclose information from the system outside the CDC
and the U.S. Department of Health and Human Services as the Privacy Act permits, including in accordance with the routine uses published for this system in the Federal Register,
and as authorized by law. Such lawful purposes may include, but are not limited to, sharing identifiable information with state and local public health departments, and other
cooperating authorities. CDC and cooperating authorities will retain, use, delete, or otherwise destroy the designated information in accordance with federal law and the System
of Records Notice (SORN) set forth above. You may contact the system manager at dgm[email protected] or by mailing Policy Office, Division of Global Migration and
Quarantine, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS H16-4, Atlanta, GA 30329, if you have questions about CDC’s use of your data.
3 Any passenger who is not a U.S. citizen, U.S. national, lawful permanent resident, or an immigrant is referred to as a Covered Individual because they are covered by the
Presidential Proclamation and CDC’s Amended Order: Implementing Presidential Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic.
This term does not apply to crewmembers of airlines or other aircraft operators if such crewmembers and operators adhere to all industry standard protocols for the prevention
of COVID-19, as set forth in relevant guidance for crewmember health issued by the CDC or by the FAA in coordination with the CDC.
_______________________________________________________________________________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB Control Number. Comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, may be submitted to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333;
ATTN: PRA 0920-1318.
