MANDATORY STATE OF HAWAI‘I TRAVEL AND HEALTH FORM FOR ALL PASSENGERS AND CREW MEMBERS The State of Hawai‘i actively screens and monitors travelers for public health and safety. It is required that all travelers provide the information below. Hawai‘i Revised Statutes Section 127A-12 and 127A-13 (For children 17 years and younger traveling with a parent/guardian please fill out first name, last name, birthdate, and Health History Parts 1 and 2 only, and sign on behalf of the child.) TRAVELER INFORMATION: First Name Middle Initial(s) Last Name Home Address Number and Street City State Contact Telephone in Hawai‘i - Primary ( ) ( ) Email Address: What industry do you work in? - Contact Telephone in Hawai‘i - Secondary - Birthdate (MM/DD/YYYY) Zip Code / (e.g., health, construction, retail) What is your occupation? - Male Female Race (optional): American Indian/Alaska Native Asian Black/African-American Native Hawaiian Have you signed a 14-day quarantine order that is currently in effect? Yes Country: Country of Citizenship: Gender (optional) / OR Non-Binary Other Pacific Islander White Other No FLIGHT INFORMATION: Airline Flight No. Travel Date (MM/DD/YY) Airline Flight No. Travel Date (MM/DD/YY) / Departure: / / Return: / Destination Address or Hotel Name City State Zip Code HI - TRAVEL INFORMATION: Have you traveled outside the State of Hawai‘i in the last 14 days? Where? Country or State: From (MM/DD/YY) Country or State: From (MM/DD/YY) Country or State: From (MM/DD/YY) Version 06/05/2020 When? Yes / / / No / / / To (MM/DD/YY) To (MM/DD/YY) To (MM/DD/YY) / / / / / / 6105225696 HEALTH HISTORY (PART 1) Do you feel ill now? Yes No (Skip to Health History Part 2) Are you feeling any of these symptoms now? Yes No Yes No Fever Vomiting Chills Diarrhea New cough Skin rash Sore throat Loss of taste or smell Headache Tiredness/fatigue Runny or stuffy nose Muscle ache Shortness of breath Chest pain or pressure Have you taken medicine to bring down fever? (e.g., Tylenol or ibuprofen) Yes No HEALTH HISTORY (PART 2) Were you ever in contact with a person confirmed to have COVID-19? Yes No When? (MM / YY) / Have you ever been tested for COVID-19? Yes No When? (MM / YY) Have you had a flu vaccine in the last year? Yes No Date of vaccination? (MM / YY) / In what country? / ATTESTATION: I declare under penalty of law that all the information provided herein is true and correct to the best of my knowledge and belief. (Signature) (Date) (Print Name) On behalf of a minor, 17 years or younger. Version 06/05/2020 5539225696