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DUll vi him hllllh:89 y t~ChLI'Il~lim: 86 l' leNg~\y}y24/0"2/2020 16:39:28H~ thollg VOffice So Y rs

BQYTE CONG HOA xA HOI CHU NGHiA VIET NANI. . .DQc I~p - TV' do - Hanh phuc

Ha N9i, ngayJ3thangOJ..;lClIn 2020S6:~3~IBYT-DPVIv thuc hi~n ap dung to' khaiy t~ d6i voi COVID-19.

iSO~1~~'·1r·H·?i.j1';.'i'rftE~'{lIVE.' I!--,~~;;-,.,;:~~.;~.-~~,;,.;;~;,7~~fr~;,~---J '.'.'. ,.. ~ ~, , :_.I c ~.~~'<l~-"j'1'1. \, ""."',.<' "K11hgu 1. Uy ban nhan dan tinh/thanh pho .

~,,_a'l.~~~3~~L£f~g~~tin illH~ thong giam sit benh truyen nhiem, hien nay dich benhviern duong ho h§p cap do chung moi cua vi rut Corona (COVID-19) dang di@nbi~n phirc tap voi s6 tnrong hop mac tang nhanh tai Him Quoc. 8@n ngay23/02/2020, tai Han Quoc aa ghi nhan 556 truong hop mac, 4 truong hop nr vong,dua Han Quoc thanh quoc gia co s6 tnrong hop mac cao nh~t ngoai Trung Quoc.Cac tnrong hQP m~c t~p trung chu yeu tai thanh pho Daegu va khu B~cGyeongsang. Chinh phil Han Qu6c aa Qua thanh ph6 Daegu va khu B~cGyeongsang 1ahai khu V\ICcan co S\1' quan tam Q?Cbi~t vS dich COVID-19. Hj~nVi~t Nam co s6 lugng 16nchuySn bay th~ng ttl'Han Qu6c, djch b~nh t<;tiHan Qu6edang co xu huang gia tang, co nguy co Ian truySn sang qu6e gia kha.c trong do coVi~t Nam. Nh&mngan Ch?ll dich b~nh xam nh?p VaGVi~t Nam, can eu Nghj dinhs6 89/20 18/N8-CP ngay 25/6/2018 cua Chinh phu quy dinh chi tiSt thi ha11hm¢ts6 di@uCllaLu~t phong, ch6ng b~nh truySn nhi@mvS ki~m dich y t6 bien g10i, B¢Y tS dS nghi Uy ban nhfm dan tinhlthanh. ph6 chi a(,lGca.c co quan lien qual1th~rchi~n ap d\lng ta khai y tS d6i v6i COVID-19, C\l th~:

1. 86i tugng phai khai baa y tS: khach nh~p canh dSn ttl' ho?c ai qua Han Qu6c.

2. 8ia diSm ap dl,mg: t(,lit§t ca cae eil:akh§u.

3. Thai gian ap dVng: k~ ttl' 15gia, ngay 23 thang 02 nam 2020.

4. N9i dung ta khai y tS: ap d\mg "M~u s6 01: TO'khai y t@ d6i voi nguai"t(,liPh\ll\lc ban hanh kem theo Nghi dinh s6 89/20 18/ND-CP ngay 25/06/2018 cuaChinh phll (ban tiSng Vi~t, Anh, Han Qu6c kem thea Van ban nay). 8S nghj lAym~u to' khai y tS t(,liwebsite co aia chi: http://baocaokdyt.eom.

5. B6 tri phien dich tiSng Han Qu6c lam vi~c tSlicU'akh§u dS h6 trg vi~c khaibao y tS va sang lQc ta khai y tS.

6. Quy trinh thvc hi~n:

- KiSm dich vien y tS lam thil t\ICnh~p c3.nhchi d~n hanh khach dSn bQph~nkiSm dich y tS as khai ta khai y tS khi lam thu t\lc nh~p c3.nhd6i voi h£1nhkhaeha6n ttl' hoi;icoi qua Han Qu6c. T?i day kiSm dich vien y t6 va can b9 phien dichc6 trach nhi~m hu6ng din han11khach khai bao y t~ va dong dAu xac nh~n theoquy dinh.

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

7. 86i voi cac Trung tam Ki~m dich y tS quoc tS, Trung tam Y tS duphong/Trung tam Ki~m soat benh t~t co hoat d9ng kiem dich y tS:

- T6 chuc in va cap phat to khai y tS baa dam chfrt lUQUgva du v~ s6 luongcho hanh khach thirc hien khai baa y tS

- Cung cfrpmi~n phi to khai baa y tS tai cac cira khau.

- Tri~n khai khu V~l'Cdanh cho khai baa y tS tai khu vue cira khau d@n(b6 tribi~n chi d~n, ban, ghS, but, ta khai, nguoi hirong d~n...).

- Trang bi can dfruli~n l11IJCcho kiem dich vien y tS d~ xac nhan VaGto khaiy tS (can dfrunhay diroc ngay, thang, nam; co dong chi! 8A KIEM TRA).

- Thong baa cho cac ben lien quan tai cira kh~u d~ ph6i hop trong qua trinhtri~n khai ap dung to khai y tS d6i voi hanh khach nh~p canh.

- KSt th6c ngay lam vi~c, l~p danh sach ca.c truang hQ'Pphai khai bao y tSgLrid~n Trung tam Y tS dv phong/Trung tam Ki~l11saM b~nh t~t clh cac diaphuung nui cac t1'uang hQ'Pnay dSn cu tm, tC;lmtru ho~c luu t1'udS theo doi suckhoe hang ngay (trong vong 14 ngay kS tu ngay nh~p canh VaGVi~t Nam) theahuang d~n cua B9 Y tS.

8. 86i v6i ki~m dich vien y tS:

- Ki~l11 tra vi~c khai bao y tS cua hanh khach thea quy dinh.

- 80ng dfruxac nh~n VaGta khai y tS.

- Luu tru ta khai y tS thea quy dinh.

- Khi phat hi~n hanh khach khai baa co tri~u chUng s6t, ho, kho tho, viemlong duang ho http th1yeu cfruhanh khach VaGkhu V\IC cach ly dS kham sang lQcva.baa cao kip thai thea quy dinh.

Trong qua trinh tri~n khai th\}'chi~n, nSu co kho khan, vuang m~c d~ nghi cacdO'nvi lien h~ v~ B9 Y tS (el,lC Y tS dt,!'phong, di~n thoC;li:0989671115 ho~c0963 851919) d~ duqc huong d~n giai quySt.

No'i nhij.n:- NhLf Kfnh giri (danh saeh kem theo);- PTT. VU DlJ'cDam (dS bao do)- Van phong Chinh pht'L(dS bao do);- Cac d6ng chi Thlf tmc)'ng;- Bo Ngo<;li giao, Bo C6ng an, BO Giao thong V~n tai,BQ Qu6c phOng, BQ LD TB XH;- Olc V\l, C\le: DP, KCB, KH-TC, TT-KT;- Oie Yi~n YSDT/Pasteur;- SO' Y t& va Cac TTKDYTQT, TTYTDP/CDCtinhJthanh ph6 co ho~t dQng KDYT;- Luu: YT, DP,

KT. ~<) TRl[6N~..~""",J;;!(J' TRUONG - /

Y fm!

2

DANH SACH GIn CONGVAN(Kern theo Cong van s5&.S5/BYT-DP ngay-Sthang J. nam 2020)

Uy Ban nhan dan tinh, thanh ph5 co heat d<)ngki~m dich y t~: Ha Noi, Hai Phorig, UlOCai, Lang San, 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,Tien Giang, Quang Binh, Quang Narn, C~n ThO',Quang Ngai, Binh Dinh, Thanh H6a,Long An, Die N6ng, Lam D6ng, Ba Ria- Vung tau, Phu Yen, Kien Giang, Lai Chau,Nghe An, D6ng Thap, NamDinh, Binh Plnnrc, San La, Ca Mau, Cao Bang, Ha Giang,TheiiBinh, Ninh Binh, Ha TInh, Gia Lai, D~c L~e, Binh Duong, Tnl Vinh, Vinh Long.

3

MEDICAL DECLARATION FORMThis is important document, your information is vital to allow health

authorities contact you to prevent communicable diseases

· Full name (BLOCK LETTETZS): .· 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 .1 Immigation date: 1 .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": ..Co~tact information in Viet Nam· Staying address: , .· Tel./Mob.: Email: ..If you 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 [ ] [ .I • Vomiting [ ] [ ]II

• Diarrhea [ ]r , Cough [ ] [ .I [ ]· 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 Hum/ living animal market! slaughter house/ contact to animal Yes [ ] No [ ]-_..._--_.._.._._--!Yes [ ] No [ ]· Care for a sick person ofcornmunicables diseases

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

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

Dale 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: '"

M~u s& 01(Kich thurrc 297 x 105 mm, co gon trong mot trang giay)

(m~ t trurrc)TO KHAI Y TE DOl VO'!NGU'OI

Day lit hH li~u qU,an trQng,.thong tin cua Anh/Ch] se giup co' quan y t~lien lac khi can thi~t elephong chBng djch b~nh truyen nhi~lll.

• Hq ten (viet chtt in hoa): ,., .• Nam sinh: Gioi tlnh: Quoc tich: .• S{\h9 chieu ho~c.gi~y thong hanh hop phap khac: .Thong tin eli lai: Tau bay 0 Tau thuyen 0 6 to 0 Khac (ghi ro): .S6 hieu phuong tien: S6 ghe (n@uco): .Ngay khoi hanh: 1 .1 Ngay nhap canh: 1 .1 .D' 1" ..,'. . i. .]a ( iern khoi hanh (tmh/quoe gia): .D' d';' . i.. i..'!a rem not den (tinh/quoc gia): .Trang vong 14 ngay qua, Anh/Chi co d@nquae gia/vung lanh th5 nao khong? (Il~U c6 ghi ro): .Din chi lien Il}ctl}i Vi~t Narn• Dia chi noi 0 tai Vi~t Nam ..• Di~n thoai: Email: .Trong yong 14 ngay (Hnh d~n th(ri di~m laIn thu tl,lc xu~t canh, nh~p canh, qua dnh) Anh/Chl e6 th5yxufit hi~n d§u hi~u nao sau day khong?

" SEi. H,i. Klj. '0,l__

Li~t ke ten y~C xiu ho~c sinh phfim y t~ dli su' dl,lng: ..Lich suopho'i nhi~m: Trong Yong 14 ngay qua, Anh/Chj c6:

i-D(~11trang tfl,liehan nuoil chq buon ban d9ng v~t s6ng/ co sa gi~t m5 d~ng ~~;!ti~p [C6-[] Khong-[---]------- ',1

: XLle d9ng v~t

I • Tnlc ti@pcham soe nguoi b~nh truySn nhi€m IC6 [ 1 Khong [ ]

T6i cam k&t IIhu'ng thOng tiu tren la dung s\I' th~t, toi hi~u r~ng n~u cung dp sai thong tin e6 th~ d~nd~n nhu'ng h~u qua nghiem tr'.)I1g.

Tri~u ch(mg C6 Khong Tri~u chung C6 Khan"b._--,t [ ] [ ) • Non/bu6n non [ ] [ J) [ ] [] • Tieu dUlY [ ] [ ]

16 thO' [ ] [] • Xu~t huy~t ngoai da [ ] [ ]

'mhQng [ ] [ ] • N5i ban ngoai da [ ] [ ]--

Ngay thclng nam 202.. Ky ten

HU'ONG DAN--_. __._----------------------------1-£anhkhach mang theo phAn nay o~lam (hu t\lC nh~p canh, xu~t canh, qua duh vii biio v¢ sU'c khiie

cua Anhl Chi

lNgay tMng nam 202... Di$n tho\\i ouong day n6ng eua BQY t@: ...

! . -. .:. -' I )! • Hy ten (vlctclmll1 loa: " .• Hn tiuh ho?c thanh ph6 ho?e vung lanh th5 ho?e qu6c gia xu~t phat: .

Vi suc kh6e Clla Anhl Chi va ella c(>ngd6ng n€u Anhl Chi thAy Xll~t hi~nb~t elr d~u hi~u b~t thuOng vS Slre kh6e, dt nghi lien h~ ngay voi CO' qUemkiem dicb y te bien giai t?i Clra kh§u ho?c w quan y t~ nm g~1l IlhAt ho~ctheo dia chi e-mail: , ho(i,es6 fa.x: .Di~n tho\\i ouong day n6ng cua tinh/th[ltlh ph6 (ncri e6 ella khiiu):

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TO' KHAI Y TIt DOl VO] NGUO'I

Day Iil ari li~u quan trong, thong tin cua Anh/Ch] se giup CO' quan y tBlien lac khi dn thi~t d~phong ch6ng djch b~nh truyen uhj~ll1.

• Ho ten (viet chu in boa):· Nam sinh: Giai tinh: Quoc tich: . . . .. ..• s6 h<)chieu hoac gi~y thong hanh hop phapkhac: .Thong tin di lai: Tim bay 0 Tau thuyen 0 6 to 0 Khac (ghi ro): ..S6 hieu phuong tien: s6 gh6 (nSu co): .Ngay khoi hanh: 1 .1 Ngay nhap canh: 1 ..1. ..Diu cr~ choi h rti :.....' lenl k Ihan (tinh/quoc gJa).................................................. . .. .~ .:.... I :.. .Dja diem noi den (tlnh quoc gia): ..

Trong yang 14 ngay qua, Anh/Ch] c6 d~n qu6c gia/vung lanh th6 nao khong? (n&u co ghi ro): ..

Dja chi lien lac tai Vi~t Nam· Dja chi noi a tai Viet Nam ..· Dl~n thoai: " Email: .Trong vong 14 ngay (Huh d~n thot di&rn lam thu tuc xUl1tciinh, uh~p canh, qua dnh) Anh/Chj co th~yxufit hi~n d:1u hi~u nao sau day khOng?

Tri~u chirng C6 Khong Tri~u chirng C6 Khong

. Sft [ ] [ ] • Non/bu6n non [ 1 ! [ ]

. Ho [ ] [ ] · Tieu chuy [ 1 I [ ]

Klt6 th6'

I[ ] [ ] • Xufit huy6r ngoai da [ 1 r ]

Dau h<;lllg [ J [ J • N6i ban ngoai da [ 1 [ ]

Li~t ke ten v~c xin ho~c sinh phfirn y t8 d§ SUo dVng: .

Ljch SUo pho'i nhi~m: Trongvong 14 ngay qua, Anh/Chj co:.----. . ., .! • Dt:n trang tr~i chan nuoil ehq buon ban d9ng v~t song! co sa giet m6 dOng v~t! tiep C6 [ ] Khong [ ]! xuc dong vat

I • Tr~rc tj~p cham soc nguai b~nh truy~n nhi6m C6 [ 1 Khong [ JI . _L ~

T6i cam 1,8tnhirng thong tin tren la dung SIr thgt, toi hi~u r~llg n~u cung dp sai th6ng tin co th~ dftflc1~nlIhU'llg hgu qua nghiem trQng.

Ngay thang nam 202.. K)' tell

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HUaNG DAN

!H:lnh khach mang theo phftn nay d~ Hun thu tl,lc nh~p canh, xufit canh, qua callh vii bao v~ sirc khoei CUll Anhl Chi• H(,Jten (vi~t ehu in hoa): ...Hn tinh ho(i.e thanh ph6 ho~e vlll1g Hinh th6 ho~c qu6c gia xuAt phat: .

XACNH~COA KIEM DlCH VIEN Y TE

VI sue khOe eua Anhl Chj va cua cQng d6ng n~uAnhl Chi thAy xuAthi~nb~t ell' dAu hj~u bitt thlTl'mgv~ sue khee, d~ nghj lien h~ ngay vai co quanki~m djch y t~bien gim t~i clra kh§u ho?c co quan y t~ nm gk nbAtho~cthee dia chi e-mail: ~_,,_,_,_, ho?e s6 fa.'I:: ..Di~n tho~i duemg day nong Clla tinh/thanh phb (noi c6 CLra kh5u):

L_' Ngdy fhcmg niim 202... Di~n thwi Gucmgday n6ng cua B<) Y t~: ...

---------------------------- ----------------IJ