Combined passenger disclosure and attestation to the united states of america


Participant in certain COVID-19 vaccine trials as determined by CDC



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CDC Attestation


Participant in certain COVID-19 vaccine trials as determined by CDC 
(proceed to and complete D
only and then sign the form to complete the Attestation
).
Medical contraindication to an accepted COVID-19 vaccine as determined by CDC (
proceed to and
complete E only and then sign the form to complete the Attestation
).
Humanitarian or emergency exception as determined by CDC and documented by an official
U.S. Government letter (
proceed to and complete F only and then sign the form to complete the Attestation
).
Valid nonimmigrant visa holder (excluding B-1 or B-2 visas) and citizen of a

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