Đăng ký về TP - Khai Báo Y Tế

MEDICAL REPORT

In case the registrant returns to the City
Declaring false information is a violation of Vietnamese law and may result in criminal prosecution.

If you have made a declare please: Khai báo lại, dùng thông tin khai trước đây

Thông tin người khai hộ, họ và tên:

Full name*:

Gender*:

Male Female

Nationality*:

Your phone number*:

Passport Number/ID Card*:

Date of birth*:

Health insurance card number:

Email:

Place of residence (Please specify address, group, village, hamlet, commune, ward, district, city)*:

Where have you been in the last 14 days ?:

Do you go (depart) from or go through these places?

Within the past 14 days, have you been in contact with?

	Yes	No
Patients with or suspected of having COVID-19*
People from countries with COVID-19*
Symptoms (fever, cough, difficulty breathing, sore throat)*

In the past 14 days, have you experienced at least 1 of the following signs: fever, cough, shortness of breath, pneumonia, sore throat, fatigue?* No Yes

Address of residence (temporary and permanent residence) in Da Nang*:

Departure place:

Place to stop and stay on the way to Da Nang:

Date and time in Da Nang*:

Date and time of leaving Da Nang:

Type of transportation*:

License plate/vehicle number*:

Driver's phone number:

On the vehicle being carried (number of people, what goods):

Organizations and individuals You come to contact and work in Da Nang:

Destination contact phone:

Attached information:

Hình ảnh xác nhận là F0 khỏi bệnh:

Photo of test results or proof of permanent/temporary residence:

Image of vaccination confirmation:

Case from Quang Nam to/from Da Nang: Commitment within the past 14 days not to travel to other localities besides Da Nang and Quang Nam; In the process of going to/from Da Nang: commit to going and returning on a fixed route; minimize contact with the community, strictly comply with 5K regulations.

Commitment to truthfully and accurately declare the place of stay and the place of passing before returning to Da Nang; take full responsibility before the law if false declaration affects the work of epidemic prevention and control; When returning to the place of residence in Da Nang city, make a medical declaration with the health agency or the police or the local government for management and monitoring.

If you have any questions, please contact Hotline of 7 districts

Please enter the security code*:

* Hotline support: (0236) 1022 * Electronic declarations can replace paper slip declarations * The data you provide is completely confidential and is for epidemic prevention only

Please enter the security code*:

Đăng ký về TP - Khai Báo Y Tế

MEDICAL REPORT

YOU ARE NOT ALLOWED IN THE CITY