Fi$a epidemiologici pentru pasageri ti cilitori

Epidemiological card for passengers and travelers

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Pentru note de serviciu / For service use /

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1. Numele si prcnumele / Name and sumame / @-I{.O.

Virsta/Age/Bo3pacr ani/yers/rsr.3. Sexul / cender / IIon M/M F/X

Pasaporl /Tlacnopf Passpon seritff
4. Domiciliu sau date de contact ln Republica Moldova
Address or contact data in Republic of Moldova
Anpec unrr KoETakrH6re AaHHEte B Pecll}6nlll(b MonAoBa

5. Telefon / Phone number / TereooH

6, Subliniati dac5 aveli: febrd, tuse, eliminfi nazale, respim{ie dificili, mialgii, cefalee
Indicate ifyou have: fever, cough, running nose, heathing difficulties, mplgia, headache
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3aT )yAHemroe abrxaune, 6ons B MEruqax, ronoBHbre 6oJrx

7. A1i contactat cu persoana afectate de boald r€spftatorie in ultimele 7 zile?

Have you been in contact with a person with rcspiratory disease dudng the last 7 days?
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Da /Yes /Aa Nu/Not/Her

8. Indicati lara,/ttuile $i locurile vizitate in ultimele 7 zile
Please speciE the counfy/countries and places you have visited during the last 7 days
yKaxnre crpaEy/crpaHBr r'r Mecra, Koroplre Btr Ilocsrrlnu 3a nocreAHre 7 Asei

9, Mijloc de transpod Means oftransportTpaHcfioprrroe cpencrBo:

Avion/ Plane / CaMoner
Ruta,trlight/Peic
Codul 0G) rutei / Flight Code (Nr.) / Koa (JV!) Peica _,
Nr. locului / Seat number / HoMep Mecra

10, Locul completfuii anchetei / Place of card completion A4ecro 3anorrHeH[rr aHKer6r

Data/Date I IlaJra J 14_ Senndtura/Signature/noAnucE

Prin prezenta, mi oblig str respect recomandiril€ medicului, sd modtorizez la Iocul de

trai termometria de trei ori pe zi iar la aparifia unor semne/simptome de viroze voi ap€la
im€diat mediculde familie.
Declar pe propria raspunderc c[ informalia completatd in fiSI corespunde realitdlii $i datele sunt
veridice.
Numele PreDum€le_
SemnItum
N.B. Fumizarea de date false ori neconfome realitdtii, inducerea ln ercare a organelor de stat
abilitate la completarea prczentei fi$e, atrage rispunderea stabilitd conform legislaliei in vigoare.
 rdspundere cd urmdtoarele 14 zile
. ..., .d.eclar..pe proprie.
md voi afla la autoizolarea pe adriesa indicati in figa .
epidemiologicS. Am fost inforrm?t despr- .rSsbunderea
contrave nlion a 15 sau penalS pentru nerespectarea
semnaTura