Transcription of 052620 Interisland (22569 - Draft, VersiForm)
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052620 Interisland (22569 - Draft, VersiForm)
Race (optional):American Indian/Alaska NativeAsianBlack/African-AmericanNative HawaiianOther Pacific IslanderWhiteOtherMANDATORY STATE OF HAWAI I TRAVEL AND HEALTH FORMFOR ALL PASSENGERS AND CREW MEMBERSThe State of Hawai i actively screens and monitors travelers for public health and is required that all travelers provide the information i Revised Statutes Section 127A-12 and 127A-13 Home Address Number and StreetCityStateZip Code-First NameMiddle Initial(s)Last NameContact Telephone in Hawai i - Primary()-Contact Telephone in Hawai i - Secondary()-Birthdate (MM/DD/YYYY)//Gender (optional)MaleFemaleNon-BinaryTRAVELER INFORMATION:ORCountry of Citizenship:What is your occupation?FLIGHT INFORMATION: This information, along with your name and contact information, may be used for contact tracing, as well as quarantine enforcement. AirlineFlight Date (MM/DD/YY)//Departure:AirlineFlight Date (MM/DD/YY)//Return:Destination Address or Hotel NameCityZip Code-StateH ITRAVEL INFORMATION:Country or State:Country or State:Country or State:From (MM/DD/YY)//From (MM/DD/YY)//From (MM/DD/YY)//To (MM/DD/YY)//To (MM/DD/YY)//To (MM/DD/YY)//(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.)
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