BQYTE CQNG HOA xA HQI CHU NGHiA VI¢T NAMDQc l~p - TV do - H~nh plnic

HaN(>i, ngayJ3thangObam 2020S6:~3~IBYT-DPVIv thuc hien ap dung to khaiy t~ d6i voi COVID-19.

Kinh giri: Uy ban nhan dan tinh/thanh pho: .

Theo thong tin nr H~ thong giam sat benh truyen nhiem, hien nay dich benhviem duong ho h~p c~p do chung moi cua vi rut Corona (COVID-19) dang diSnbien phirc tap voi s6 tnrong hop mac tang nhanh tai Han Quoc. DSn ngay23/02/2020, tai Han Quoc da:ghi nhan 556 tnrong hop mac, 4 tnrong hop tir vong,dira Han Quoc thanh quoc gia co s6 tnrong hop mac cao nh~t ngoai Trung Quoc.Cac tnrong hop mac tap trung chu ySu tai thanh pho Daegu va khu B~cGyeongsang. Chinh phu Han Quoc da: dira thanh ph6 Daegu va khu B~cGyeongsang la hai khu V\ICc~n co S\Iquan tam dac biet vS dich COVID-19. HienViet Nam co s6lm;mg Ian chuyen bay thang tir Han Quoc, dich b~nh t~i Han Qu6cdang co xu huang gia tang, co nguy co Ian truySn sang qu6c gia khac trong do coVi~t Nam. Nh~m ngan ch~n dich b~nh xam nh~p vao Vi~t Nam, can cu Nghi dinhs6 89/20 18/ND-CP ngay 25/6/2018 cua Chinh phu quy dinh chi tiSt thi hanh mQts6 diSu cua Lu~t phong, ch6ng b~nh truySn nhiSm vS kiSm dich y tS bien giai, BQY tS dS nghi Uy ban nhan dan tinhlthanh ph6 chi d~o cac co quan lien quan th\Ichi~n ap d\mg ta khai y tS d6i vai COVID-19, cv thS:

1.D6i tugng phai khai bao y tS: khach nh~p canh dSn illho~c di qua Han Qu6c.

2. Dia diSm ap dVng: t~i t~t ca cac cua kh~u.

3. Thai gian ap dvng: kS tu 15gia, ngay 23 thang 02 nam 2020.

4. NQi dung ta khai y tS: ap dVng "M~u s6 01: Ta khai y tS d6i vai nguai"t~i PhVlvc ban hanh kern thea Nghi dinh s6 89/2018/ND-CP ngay 25/06/2018 cuaChinh phu (ban tiSng Vi~t, Anh, Han Qu6c kern thea Van ban nay). DS nghi l~ym~u ta khai y tS t~i website co dia chi: http://baocaokdyt.com.

5. B6 tri phien dich tiSng Han Qu6c lam vi~c t~i cua kh~u dS h6 trQ'vi~c khaibao y ts va sang lQc ta khai y tS.

6. Quy trinh th\Ic hi~n:

- KiSm dich vien y tS lam thu tvc nh~p canh chi d~n hanh khach dSn bQph~nkiSm dich y tS dS khai ta khai y tS khi lam thu tvc nh~p canh d6i vai hanh khachdSn tu ho~c di qua Han Qu6c. T~i day kiSm dich vien y tS va can bQphien dichco trach nhi~m huang d~n hanh khach khai bao y ts va dong d~u xac nh~n theaquy dinh.

- Khi phat hi~n hanh khach co biSu hi~n nghi nga m~c b~nh do COVID-19,kiSm dich vien y tS ap d\mg cac bi~n phap kiSm dich y tS thea quy dinh.

7. D6i voi cac Trung Him KiSm dich y tS quoc tS, Trung tim Y tS duphong/Trung tam KiSm soat benh t~t co hoat dong kiem dich y tS:

- T6 clnrc in va c~p phat to khai y tS bao dam ch~t lUQ11gva du vS s6 hrongcho hanh khach thuc hien khai bao y tS

- Cung c~p mi~n phi ta khai bao y tS tai cac cira kh~u.

- TriSn khai khu V\ICdanh cho khai bao y tS tai khu vue cira kh~u dSn (b6 tribiSn chi dfin, ban, ghe, but, ta khai, nguoi huang dfin...).

- Trang bi con d~u liSn mire cho kiSm dich vien y tS dS xac nhan van to khaiy tS (con d~u nhay diroc ngay, thang, nam; co dong chir DA KIEM TRA).

- Thong bao cho cac ben lien quan tai cira kh~u dS phoi hQ'Ptrong qua trinhtrien khai ap dung to khai y tS d6i voi hanh khach nh~p canh.

- KSt thuc ngay lam vi~c, l~p danh sach cac truang hQ'Pphai khai bao y tSgui dSn Trung tam Y tS dv phong/Trung tam KiSm soat b~nh t~t cua cac diaphuong nai cac twang hQ'Pnay dSn cu tru, t<;lmtru ho~c luu tru dS thea d6i suckhoe hang ngay (trong vong 14 ngay kS tu ngay nh~p canh van Vi~t Nam) theahuang dfin cua B9 Y tS.

8. D6i v6i kiSm dich vien y tS:

- KiSm tra vi~c khai bao y tS cua hanh khach thea quy dinh.

- Dong d~u xac nh~n van ta khai y tS.

- Luu trfr ta khai y tS thea quy dinh.

- Khi phat hi~n hanh khach khai bao co tri~u chUng s6t, ho, kho tho, viemlong duang ho h~p thi yeu c~u hanh khach van khu vvc cach ly dS kham sang 19Cva bao cao kip thai thea quy dinh.

Trong qua trinh triSn khai thvc hi~n, nSu co kho khan, vuang m~c dS nghi cacdon vi lien h~ vS B9 Y tS (C\lC Y tS dv phong, di~n tho<;li:0989671115 ho~c0963851919) dS duQ'chuang dfin giai quySt.

Noi nh~n:-Nhu Kinh gui (danh saeh kern theo);- PTT. va Due Dam (de bao cao)- Van phong Chinh phU (de bao eao);- Cae d6ng ehi Thu tmong;- BQNgo;;ti giao, BQ Cong an, BQ Giao thong V~n tai,BQQu6e phOng, BQLD TB XH;- Cae Vl,l, Cl,le:DP, KCB, KH-TC, TT-KT;- Cae Vi~n VSDTlPasteur;- So' Y tS va Cae TTKDYTQT, TTYTDP/CDCtinhlthanh ph6 e6 ho;;ttdQng KDYT;- Luu: VT, DP.

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DANH SACH GU1 CONG VAN(Kern theo Cong van s6&$5/BYT-DPngayzsthang ct. nam 2020)

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Uy Ban nhan dan tinh, thanh ph6 c6 hoat dong kiem dich y t€: Ha NQi,Hai Phong, LaoCai, Lang Son, Quang Ninh, Quang Tri, Da N~ng, Kon Tum, Khanh hoa, D6ng Nai,TP. H6 Chi Minh, An Giang, Tay Ninh, Binh Thuan, Thira Thien Hu€, Di~n Bien,Ti~nGiang, Quang Binh, Quang Nam, CfrnThO',Quang Ngai, Binh Dinh, Thanh H6a,Long An, D~cNang, Lam Dong, Ba Ria-Vfing tau, Phu Yen, Kien Giang, Lai Chau,Ngh~An, D6ng Thap, Nam Dinh, Binh Phuoc, Son La, Ca Mau, Cao B~ng,Ha Giang,Thai Binh, Ninh Binh, Ha 11nh,Gia Lai, Dac Lac, Binh Duong, Tra Vinh, Vlnh Long.

3

(m~t sau)MEDICAL DECLARATION FORM

This is important document, your information is vital to allow healthauthorities contact you to prevent communicable diseases

• Full name (BLOCK LETTERS): .• Date of Birth: Gender: Nationality: ..• Passport number or other legal document: .Travel information: Plane 0 Ship 0 Automobile 0 Other (clarify): .Transportation No.: Seat No.: .Departure date: / .1 Immigation date: / .1 .Place of departure (province/country): .Place of destination (province/country): .In the past 14 days, have you been to any province/city/territory/country? If yes, where?: .Contact information in Viet Nam• Staying address: .• Tel.lMob.: Email: .Ifyou have any of the followings at present or during the past 14 days (until the date ofentry/exit/transit)?

Symptoms Yes No Symptoms Yes No

• Fever [ ] [ ] • Vomiting [ ] [ ]• Cough [ ] [ ] • Diarrhea [ ] [ ]• Difficulty of breathing [ ] [ ] • Rash [ ] [ ]• Sore throat [ ] [ ] • Skin haemorrhage [ ] [ ]

List of vaccines or biologicals used: .History of exposure: During the last 14 days, did you:

• Visit any poultry farm/ living animal market! slaughter house/ contact to animal Yes [ ] No [ ]

• Care for a sick person of communicables diseases Yes [ ] No [ ]

The information I have given is true, correct and complete. I understand failure to answerany question may have serious consequences.

Day: Month: Year: 202.. Signature of Passenger/ Crew

GUIDANCE

Date Month Year 202...

For your own heath and that of the community, ifyou experience any of the above-mentionedsymptoms, please contact heath quarantine units atpoints entry or the nearest health care centre or emailto Email: or Fax: .Hotline of province/city of point of entry: .Hotline of the Ministry of Health: ...

Passenger uses this part for entry/exit/transit clearance and for protection of your health• Full name (BLOCK LETTERS): .• Province/City/Territory/Country of departure: .

VERIFICATION BYHEALTH QUARANTINE OFFICER

Mftu sa 01(Kich thuoc 297 x 105 mm, co gon trong mot trang giay)

(m~t trmrc)TO KHAI Y TE DOl vor NGUOI

Day lit tai li~u quan trong, thong tin cua Anh/Ch] Sf giup CO'quan y t~lien lgc khi cin thi~t d~ phong ch6ng djch b~nh truyen nhi~m.

• H9 ten (viet chtr in hoa): .• Nam sinh: Gi&i tinh: Quoc tich: .• s6 hi) chieu hoac gi§y thong hanh hQ'Pphap khac: .Thong tin di lai: Tau bay D Tau thuyen D 6 to D Khac (ghi ro): '" .s6 hieu phuong tien: se gh~ (neu co): '" .Ngay khoi hanh: / .1 Ngay nhap canh: / .1. .Dia diem khoi hanh (tinh/quoc gia): .Dia diem noi d~n (tinh/quoc gia): .Trong vong 14 ngay qua, Anh/Chi co d~n quoc gia/vung lanh th6 nao khong? (neu co ghi ro): .

Bia chi lien lac t~i Vi~t Nam• Dia chi noi a tai Viet Nam .• Di~n thoai: Email: .Trong vong 14 ngay (tinh d@nthci di@mlam thu tl}CxuM dnh, nMp canh, qua canh) Anh/Chi co thAyxuAt hi~n diu hi~u nao sau day khong?

Tri~u chUng Co Khong Tri~u chUng Co Khong

• S6t [ ] [ ] • Nonlbu6n non [ ] [ ]• Ho [ ] [ ] • Tieu chay [ ] [ ]• KhotM [ ] [ ] • Xu§t huy~t ngoai da [ ] [ ]

• Dauh9ng [ ] [ ] • N6i ban ngmli da [ ] [ ]

Li~t ke ten v~c xin ho~c sinh phftm y t@dli suodl}ng: .Ljch suophoi nhi~m: Trong vong 14 ngay qua, Anh/Chi co:

• D~n trang trc;tichan nuoil chq buon ban di)ng v~t s6ng/ cO'sa gi~t m6 di)ng vW ti~p Co [ ] Khong [ ]xuc di)ng v~t

• Tr\fc ti~p cham soc nguai b~nh truy~n nhi~m Co [ ] Khong [ ]

Toi cam k@tnhfrng thOng tin tren la dung sl}'th~t, toi hi@u rling n@ucung dp sai thOng tin co th@d~nd@nnhu'ng h~u qua nghiem trQng.

Ngiry thimg niim 202.. Kyten

mfONGDAN

Hanh khach mang theo ph§n nay d@lam thu tl}Cnh~p canh, xu At dnh, qua dnh va bao v~ suc khOecua Anh/ Chi

• HQ ten (vi~t cM in hoa): .

• Ten tinh ho~c thanh ph6 ho~c vimg lfulh th6 ho~c qu6c gia xu§t phat: .

XACNHANeVA KfEM DICH 'VIEN Y TE

Vi suc khoe CllaAnh/ Chj va Cllaci)ng d6ng n~u Anh/ chj th§y xucithi~nb§t cu d§u hi~u b§t thuang v~ suc khoe, d~ nghj lien h~ ngay v&icO'quankiSm djch y t~ bien gi&itc;tiCllakh~u ho~c CO' quan y t~ nm goinnh§t ho~cthea dja chi e-mail: ho~c s6 fax: .Di~n thoc;tiduang day nong Clla tinhltMnh ph6 (nO'ico clra kh~u):

Ngiry thimg niim 202... Di~n thoc;tiduang day nong CllaBi) Y t~: ...

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• ~;AJ ClJ~ I %~ Al;AJ ClJ~ I %~ s:.~ Al~ ClJ~ I %~ 1.] ~ o:j[ ] -¥- [ ]

• ~~ -'8. ~A} ~ 1.] n~ o:j[ ] -¥- [ ]

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TO KHAI Y TE DOl vrn NGUOI

Day la tai li~uquan trong, thong tin cua Anh/Ch] Sf giup CO'quan y t~lien lac khi dn thi~t d~phong chang djch b~nh truyen nhi~m.

• H9 ten (viet chtr in hoa): ; " "." " " " " .• Nam sinh: Gioi tinh: Quoc tich: .S A h' hiA h - ·A h' hanh h ha kha• 0 9 c eu oac gray tong a op p ap~ ac: .

Thong tin di lai: Tau bay D Tau thuyen D 6 to D Khac (ghi ro): .s6 hieu phuong tien: se gh@(neu c6): .Ngay khoi hanh: I ..!. Ngay nhap canh: I ..!. " .Dia diem khoi hanh (tinh/quoc gia): .Dia di~m noi d@n(tinh/qudc gia): .Trong yang 14 ngay qua, Anh/Chi co d@nqu6c gia/vung lanh th6 nao khong? (neu co ghi ro): .." .Dja chi lien lac t~i Vi~t Nam• Dia chi noi a tai Vi~t Nam .• Di~n thoai: Email: .Trong vong 14 ngay (tinh d~n thOi di@m lam tho t1}Cxuftt canh, nh~p canh, qua canh) Anh/Ch] co thftyxu§t hi~n d§u hi~u nao sau day khong?

Tri~u chUng C6 Khong Tri~u chUng C6 Khong

• S6t [ ] [ ] • Nonlbu6n non [ ] [ ]

·Ho [ ] [ ] • Tieu chay [ ] [ ]

· Kh6 tM [ ] [ ] • Xu~t huy@tngoai da [ ] [ ]

· Dauh9ng [ ] [ ] • N 6i ban ngoai da [ ] [ ]"' 'A ~ • -' ;. J. d- ? dLu;t ke ten vac xln ho~c sinh pham y te a suo 1}ng: .

Ljch sir phoi nhi~m: Trong vong 14 ngay qua, Anh/Chj co:

• D€n trang tr~i chan nuoil chq buon ban d(ing v~t s6ngl CO' sa gi€t m6 d(ing vW ti@p C6 [ ] Khong [ ]xuc d(ing v~t

• Tr\fc ti@pcham s6c nguai b~nh truy~n nhi~m C6 [ ] Khong [ ]

Toi cam k~t nhu'ng thOng tin tren la dung Sl! th~t, toi hi@ur~ng n~u cung cftp sai thOng tin co th@d§nd~n nhfrng h~u qua nghiem trQng.

Ngay thang niim 202.. Krten

HUONGDAN

Hanh khach mang theo ph§n nay d@lam tho t1}Cnh~p ciinh, xuftt ciinh, qua canh va bao v~ su'c khoecoa Anhl Chj

• H9 ten (vi€t cM in hoa): .• Ten tinh ho~c thanh ph6 ho~c vting lanh th6 ho~c qu6c gia xu~t phat: .

XACNHANeVA KIEM DJCH 'VIEN Y TE

Vi suc kh6e cUaAnh/ Chi va clla c(ing d6ng n@uAnh/ chi th~y xu~t hi~nb~t cu d~u hi~u b~t thuang v~ suc kh6e, d~ nghj lienM ngay vai cO'quanki~m djch y t€ bien giai t~i Clmkh~u ho~c cO'quan y t@nol gftn nh~t ho~cthea dia chi e-mail: ho~c s6 fax: " .Di~n tho~i duang day n6ng clla tinhlthanh ph6 (nO'ic6 cua kh~u):

Ngay thang nam 202...Di~n tho~i duang day n6ng CllaB(i Y t€: ...