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: [email protected]
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: [email protected]
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