DHS&EM | Travel Declaration Form

MANDATORY 14-DAY QUARANTINE FOR ALL INCOMING PASSENGERS

Due to the rapid spread of COVID-19 and the high incidence of travel-related infection, the State of Alaska has instituted a mandatory 14-day quarantine for all incoming passengers. The potential for widespread transmission of COVID-19 by infected individuals entering Alaska threatens the health and well-being of Alaskans, as well as the infrastructure and security of the state. In an abundance of caution and to assist in flattening the curve regarding the spread of COVID-19 in Alaska, the State of Alaska, under its authority to protect the public health, is implementing advanced protocols to ensure all travelers arriving in Alaska participate in 14 consecutive days of self-quarantine to begin immediately upon arrival, allowing for travel from an airport or portage to the designated quarantine location.

Travelers 18 years of age and over must complete and sign their own form.

* indicates a required field or selection.

PLEASE LIST THE SPECIFIC PLACES TRAVELED WITHIN THE PREVIOUS 14 DAYS.*

First Name:*

Middle Initial:

Last Name:*

HOME ADDRESS:*

CITY:*

STATE:*

ZIP: (5 digits only)*

QUARANTINE ADDRESS:*

CITY:*

STATE:*

ZIP: (5 digits only)*

PHONE NUMBER: (10 digits, no spaces.)*

EMAIL: (Confirmation email address.)*

DATE OF ARRIVAL:*

Certificate: Read and Sign:
I swear or affirm, under penalty of perjury, that: the above information I provided on this document is true and correct. I swear I will comply with the self-quarantine regulations as set out in Health Mandate* .

WARNING: If you provide false information on this form, you may be convicted of a Class B felony under AS 11.56.200 and/or a Class A misdemeanor under AS 11.56.210. Additionally, due to the imminent danger to the public by the spread of Coronavirus, if you violate the self-quarantine regulations set forth in the mandate, you may also be convicted of a class A misdemeanor which is punishable by a fine of up to $25,000, or imprisonment of not more than one year, or both pursuant to Alaska Statute 12.55.035 and Alaska Statute 12.55.135.

SIGNATURE: (Please type your full name.)*

DATE:*

Alaska Department of Military and Veterans Affairs Division of Homeland Security & Emergency Management

MANDATORY 14-DAY QUARANTINE FOR ALL INCOMING PASSENGERS

Travelers 18 years of age and over must complete and sign their own form.

Accessibility

Mike Sutton
Director

Division of Homeland Security &
Emergency Management

MANDATORY 14-DAY QUARANTINE FOR ALL INCOMING PASSENGERS

Travelers 18 years of age and over must complete and sign their own form.

Accessibility

Mike Sutton Director

Division of Homeland Security & Emergency Management

Mike Sutton
Director

Division of Homeland Security &
Emergency Management