1

Repatriation Form 001

Cooperative Republic of Guyana

Repatriation Form

Part 1 Contact information

1.1 First Name 1.2 Last Name

1.3 Middle Name(s)

Female

1.5 Date of Birth

1.6 Country of Birth

1.7 Nationality 1

1.9 Home Address

1.10 - Telehone Number1.13 Email Address

Part 2 Passport Information

2.1 Current Passport Number 2.2 Place of Issue

2.3 Issuing Authority 2.4 Date of Issue

2.5 Date of Expiry

1.8 Nationality 2

1.11 - Mobile Number(s)

1.12 - Work Telephone Number

1.4 Gender at birth

Male

Part 3 Travel History

3.1 Address (Abroad) 3.2 When did you leave Guyana?

3.4 Purpose of stay outside of Guyana Work Study

Health Business

Tourism

Government

Other

3.3 Mobile Number (Abroad)

3.5 Places visited in the last 21 days

2

Repatriation Form 001

Part 4 Medical History

4.1 Have you done a Polymerise Chain Reaction (PCR) test for COVID-19?

Yes No

4.5. Have you had COVID-19?

Yes No Don’t know

4.7.

4.10 Do you have any of the following symptoms?

4.11 If yes to 4.10, when did the symptoms start?

Fever Cough Chills

Headache Fatigue

Muscle Ache Shortness of breath

Loss of smelland / or taste Sore Throat Abdominal pain

Other (please state below)

None of the above

Did you have contact with anyone who is underinvestigation for COVID-19 in the last 14 days?

3.6 Countries visited in the last 21 days

4.3. If yes to 4.1, where?

4.4. If yes to 4.1, state results 4.8 Do you currently have COVID-19?

4.9 If yes to 4.8, in what setting?

Healthcare

Transport

Other(state below)

Vomiting

Diarrhea

General weakness

Part 3 Travel History

3.7 Contact / Next of Kin (Abroad)

Name

Address

Mobile Number

Email Address

Relationship

Place of work

Work Number

Yes No

4.2. If yes to 4.1, when? 4.6 Has anyone in your household been diagnosed with COVID-19?

No Yes Don’t know

Home/Family

Workplace

Yes No

3

Repatriation Form 001

Accommodation

A quarantine facility is any public and/or private facility designated by the Ministry of Public Health to be used for quarantine of COVID-19 cases. The Ministry of Public Health has given consideration to persons who may wish to spend their time at a private place rather than a public quarantine facility and has designated two private places for quarantine – Bacanas Hotel and Brandsville Apartments. Please indicate where you would like to be quarantine from the options below.

Facility Amenities Cost

MOPH Facility

Bacanas Guest House

Bed, meals, Wi-Fi, Security

1st Floor Rooms with AC, and Fans

2nd and 3rd Floors Lower Flat including 3 meals

Free

$5,000 GYD per night $8,000 GYD per night $7,800 per night

Meals : Breakfast Lunch

Dinner

$800 GYD $1,000 GYD $1,000 GYD

For reservations please contact the Manager: Ms. Donna Prefero, telephone (592) 699-2885; Email: incprefero@gmail.com

Brandsville Apartments Each room is equipped with a single bed, refrigerator and laundry service included Breakfast, lunch, Dinner

$15,000 GYD per night Additional guest will be charged $5,500 GYD per night $5,500 GYD per person

For reservations please contact the Manager: Mr. Brandsford, telephone (592) 227-0989; Email: joanb@brandsvillegy.com

Part 5 Declaration (Please check all boxes next to each declaration)

Signature of Applicant Date

Signature of Guardian Date

Y Y Y Y

Y Y YY

I ACKNOWLEDGE and ACCEPT that I am required to undergo at least 14 days of quarantine, if I have not done a PCR COVID-19 test.

I ACKNOWLEDGE and ACCEPT that a negative PCR test result does not necessarily exempt me from the Ministry of Public Health quarantine programme.

I ACKNOWLEDGE and AGREE that, if my PCR COVID-19 test result is negative and I am approved by the Ministry of Public Health, I am required

to undergo one week (7 days) home quarantine upon arrival.

I ACKNOWLEDGE

and

ACCEPT

that

I am

fully

responsible

for

the

cost

of

my

travel

ticket

back

to

Guyana

once

the

Government

of

Guyana

has approved

an

air

operator

to

conduct

the

repatriation

flight.

I ACKNOWLEDGE

and

ACCEPT

that

I will

comply

with

the

quarantine

rules

issued

under

the

State

of

Emergency

by

the

Ministry

of

Public

Health.

I

ACKNOWLEDGE

and

ACCEPT

that

Failure

to

observe

the

quarantine

measures

puts

me

and

those

around

me

at

risk.

I ACKNOWLEDGE

and

ACCEPT

that

I will

fully

cooperate

with

the

facilitator,

caretaker,

health

care

professional

and/or

other

Ministry

of

Public

Health Officials

who

are

responsible

for

my

well-being

during

quarantine.

I ACKNOWLEDGE

and

ACCEPT

that

No

visitors

are

allowed

(however,

they

can

utilise

the

Civil

Defence

Commission

(CDC)

for

collection

of

items

from

family

members).

I WILL,

if asked,

wear

a

mask

or

other

Personal

Protective

Equipment

(PPE)

of

the

specifications

recommended

by

the

Ministry

of

Public

Health at all

times

during

quarantine.

I CONSENT

to

provide

truthful

information

at

all

times

during

my

stay

in

quarantine.

I ACKNOWLEDGE

and

ACCEPT

that

this

DECLARATION

will

be

considered

my

consent

to

the

Ministry

of

Foreign

Affairs

and

the

Ministry

of Public

Health

to

disclose,

share,

record

and

store

the

information

contained

in

this

application

with

the

relevant

authority

or

service

provider

for

the

purposes of ensuring

the

safety

and

security

of

any

and

all

third

parties

that

may

come

into

contact

with

me, prior,

during

and

after

my

time

in quarantine.

I CERTIFY that the information provided above is true and accurate at the time of submission.

WARNING:

IT

IS

AN

OFFENCE

UNDER

THE

LAWS

OF

GUYANA

TO

MAKE

ANY

FALSE

STATEMENT,

REPRESENTATION

OR

DECLARATION.

Select one