STATE OF ALASKA
Department of Health & Social Services
TRAVEL DECLARATION FORM
FOR ALL 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.
MANDATORY 14-DAY QUARANTINE FOR
ALL INCOMING PASSENGERS
Travelers 18 years of age and over must complete and sign their own form.
PLEASE LIST THE SPECIFIC PLACES TRAVELED WITHIN THE PREVIOUS 14 DAYS.
______________________________________________ 2. ________________________________________
______________________________________________ 4. ________________________________________
FULL NAME (PRINT)
HOME ADDRESS _______________________________________________________________________________
CITY __________________________________ STATE _________________________ ZIP ____________________
QUARANTINE ADDRESS: _______________________________________________________________________
CITY __________________________________ STATE __________________________ ZIP ____________________
PHONE NUMBER _____________________________ DATE OF ARRIVAL _______________________________
Certicate: 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.
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