Fillable Repatriation- Form Final

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Repatriation- Form Final

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Cooperative Republic of Guyana
Repatriation Form
Section 1. Biodata
Last Name
First Name
Middle Name
Home Address (Guyana)
Gender Male Female
Date of Birth
Place of Birth
Nationality
Passport Number
Issued Date
Place of Issue
Expiration Date
Telephone Number Cell Cell
Landline
Email Address
Section 2. Travel history
When did you leave Guyana?
DD/MM/YYYY
Purpose of stay outside of Guyana Work
Study
Health
Tourism
Business
Government
Other
Current Address (Abroad)
Telephone Number (abroad) Landline Mobile
Places visited in the last 21 days
Are you travelling with family
members?
Adults Yes No
Children
Yes No
Next of Kin in Guyana
Name
Relationship
Address
Telephone
Email
Section 1. Biodata
Section 2. Travel history
Section 3. Medical History
Have you been tested for
COVID-19?
Yes No
If yes, when
Where
Type of Test done:
Polymerise Chain Reaction (PCR)
Test
Rapid COVID-19 Test
Have you been diagnosed
as having COVID-19? Yes No
Have you had COVID-19? Yes No Don’t Know
In the last 14 days did you
have contact with any
person who is under
investigation for COVID-19?
Yes No Don’t Know
Do you presently have any of the following symptoms?
Fever Muscle Ache
Cough Vomiting
Respiratory Distress Abdominal Pain
Sore Throat Diarrhea
Shortness of breath Fatigue
Chills Other (please State)
Headache None of the above
If yes to any of the above,
when did the symptoms
started:
What is your intended route
of return to Guyana?
Barbados Panama City, Panama
Cuba Triniad and Tobago
Miami Suriname
New York
dd/mm/
yyyy
dd/mm/yyyy
Section 4. Accommodation
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 will give consideration to persons who
may wish to spend their time at a private facility rather than a public
quarantine facility and has designated two private places for this
purpose – Baracara Hotel and Bransville Apartments.
MOPH Facility
Bed, meals, Wi-Fi, security (free of cost).
BARACARA HOTEL
(cost be borne by
citizen)
2
nd
& 3
rd
Floors $8,000 GYD per night
1
st
Floor $5,000 GYD per night (4 with AC, 4 with Fans)
All rooms are equipped with a small refrigerator and 2 beds.
Meals:
Breakfast $800 GYD.
Lunch $1,000 GYD
Dinner $1,000 GYD
OR
Lower Flat $7,800 GYD per night inclusive of 3 meals
BRANSVILLE
APARTMENTS
(cost be borne by
citizen)
$15,000 GYD per night.
Each room is equipped with a single bed, refrigerator (laundry
included);
Additional person in the room will be charged $5,500 GYD per night.
Meals:
Breakfast/Lunch/Dinner $5,500 GYD per person.
ALL persons being
repatriated to Guyana are
required to undergo at
least 14 days of
quarantine. Please
indicate where would you
like to be quarantined?
Ministry of Public Health
(MOPH) Facility Free
Baracara Hotel Proof of reservation and payment
Brandsville Apartments Proof of reservation and payment
Section 5. Declaration
I ACKNOWLEDGE and ACCEPT that I am required to undergo at least 14 days of
quarantine.
I acknowledge that a negative PCR test does not necessarily exempt me from quarantine.
I AGREE to comply with the quarantine rules issued under the State of Emergency by the
Ministry of Health
I ACKNOWLEDGE that failure to observe quarantine puts me and those around me at
risk.
I AGREE to fully cooperate with the facilitator, caretaker, health care professional or other
MoPH officials who are responsible for my well-being during quarantine.
I ACCEPT that No Visitors are allowed (however, they can utilize the 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 MoPH) 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 as my consent
to Ministry of Foreign Affairs and Ministry of Public Health to disclose, share, record and
store the information contained in this application with any relevant authority or service
provider for the purposes of ensuring the safety and security of any and all third parties
that may come in 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.
________________________________ _________________________
Name Signature
Date: dd/mm/yyyy
WARNING: IT IS AN OFFENCE UNDER THE LAWS OF GUYANA TO MAKE ANY
FALSE STATEMENT, REPRESENTATION OR DECLARATION.
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Repatriation- Form Final

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Completed 16 July 2020

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